Endodontic diagnosis could be a difficult task in most occasions, but with clinical assessment and careful history taking this task would be easier and clearer.
This lecture assembled by Osama Asadi, B.D.S, concentrating at the basic science of diagnosing pulpal and periapical diseases and their differential diagnosis and treatment plan. also endodontic case sheet and review-cases attached to the lecture at the end to help proper understanding of the subject.
1. Endodontic Diagnosis and
Treatment Planning
Dr. Osama Asadi, B.D.S
Information provided here are collected from several evidence-based
academic textbooks well-known throughout the world like Elsevier
publications and others
4. Clinical Tests
• Cold test
• Heat test
• Electrical pulp test
• Cavity test
Pulp Tests Periapical Tests
• Palpation
• Percussion
5. Cold Test
Apply ice on the cervical third of the
tooth where enamel is thin.
Normal Pulp: response, last for 1-3 seconds
Pulpitis: response, last for minutes
Necrotic pulp: No response
6. Heat Test
Heat Gutta-percha and place it on
cervical third of the tooth where enamel is
thinnest.
Normal Pulp: response, last for 1-3 seconds
Pulpitis: response, last for minutes
Necrotic pulp: No response
7. Palpation
Place the index finger on the periapical area
of the tooth with firm gentle pressure.
Normal Periapical: No response
Inflamed: response with pain at that area
8. Percussion
Place index finger on the incisal edge / occlusal
third of the tooth and push inward with gentle
pressure.
Normal Periapical: No response
Inflamed: response with pain
10. Normal Pulp
• Normal pulp is symptom-free as reported by the patient.
• Response to cold testing and effect lasts only for 1-2 seconds then disappear.
• Response normally to electrical pulp testing.
• Radiographically show normal PDL space and intact lamina dura.
11. Reversible Pulpitis
Symptoms
• Discomfort or pain on sweet /
cold food and beverages
• It last for few seconds then
relieved.
• Pain never spontaneous
Tests
Cold test : response positively,
enough for diagnosis
Electrical pulp test: response
positively.
Radiograph
• Intact lamina dura
• Normal PDL space
• Normal periapical area
12. Irreversible Pulpitis
Symptoms
• Spontaneous Sharp pain
• Last for minutes or hours.
• Poorly localized referred pain
• Interfere with patient sleep
• Aggravated by hot, relieved by
cold.
• Over-the-counter analgesics is
ineffective
Tests
Heat test : response positively,
enough for diagnosis
Cavity test: if open caries,
response positively.
Radiograph
• Slight widening of PDL
space
• Periapical radiolucency
present only if infection has
passed the apical foramen.
13. Necrotic Pulp
Symptoms
• Asymptomatic
• History of pulpitis or trauma
• Discoloration of tooth may
present
Tests
Response negatively to
thermal and electrical pulp
tests.
Response positively to
percussion or palpation if
only apical infection present.
Radiograph
• Intact lamina dura
• Slight widening of PDL
space.
• Periapical radiolucency
present only if infection has
passed the apical foramen.
14. Apical Periodontitis
Symptoms
• Pain on biting and mastication
Tests
Percussion / Palpation:
response positively.
Radiograph
• Slight widening of PDL
space may or may not
present.
• Periapical radiolucency may
or may not present
15. Acute Apical Abscess
Symptoms
• Spontaneous pain
• Tenderness of tooth to biting
• Swelling of apical area and pus
formation
• Fever, malaise, and
lymphadenopathy may be
reported
Tests
Percussion / Palpation:
response positively.
Radiograph
• Slight widening of PDL
space may or may not
present.
• Periapical radiolucency may
or may not present
16. Chronic Apical Abscess
Symptoms
• Little or no discomfort / pain
• Tenderness of tooth to
pressure
• Swelling of apical area and pus
formation
Tests
Percussion / Palpation:
response positively.
Radiograph
• Slight widening of PDL
space may or may not
present.
• Periapical radiolucency.
18. Treatment Plan
• Reversible pulpitis, treated by removing the offending stimulus.
• Irreversible pulpitis, treated by RCT
• Apical Periodontitis, treated by RCT
• Apical Abscess, treated by RCT
• As it seen, reaching a definitive diagnosis could be a challenge but the result
is the same, RCT!
21. Clinical Cases for review
Case 1. Mandibular right first molar had been
hypersensitive to cold and sweets over the
past few months but the symptoms have subsided.
Now there is no response to thermal
testing and there is tenderness to biting and pain to
percussion. Radiographically,
there are diffuse radiopacities around the root
apices.
Diagnosis:
Pulp necrosis; apical periodontitis with condensing
osteitis.
Tx: Root canal treatment (RCT)
22. Case 2. Following the placement of a full
gold crown on the maxillary right second
molar, the patient complained of sensitivity
to both hot and cold liquids; now the
discomfort is spontaneous. Upon application
of Endo-Ice® on this tooth, the patient
experienced pain and upon removal of the
stimulus, the discomfort lingered for 12
seconds. Responses to both percussion and
palpation were normal; radiographically,
there was no evidence of osseous changes.
Diagnosis:
Irreversible pulpitis; normal apical tissues.
Tx: Root canal Treatment (RCT)
23. Case 3. Maxillary left first molar has occlusal-
mesial caries and the patient has been
complaining of sensitivity to sweets and to
cold liquids. There is no discomfort to
biting or percussion. The tooth is hyper-
responsive to Endo-Ice® with no lingering
pain.
Diagnosis:
reversible pulpitis; normal apical tissues.
Tx: Removal of offending stimulus.
Applying dentin desensitizer on exposed
dentinal tubules.
24. References
• Arnaldo Castellucci, MD, DDS. Endodontics, Volume 1, Pulpal diseases
p. 139-156.
• American Association of Endodontics, Endodontics: Colleagues for
Excellence, Endodontic Diagnosis (2013 issue).