Pulpal and Apical Diagnosis Flashcards
• Is unlikely to often present as PURELY
PULPAL
Each tooth needs 2 Diagnoses:
– Pulpal
– Peri-Radicular
(Maybe Perio & Restorative also)
1st Question to ask the patient in pain:
What is your CC = Chief Complaint?
Can you point to the tooth that hurts?
Can you localize the source of your pain?
If Purely PULPAL –
probably NOT (diffuse pain = pulpal)
The CC is what brought the patient here:
The Objective of Clinical Testing is to
find and confirm the etiology of the patient’s CC.
Clinical Testing is performed (based on CC) (5)
thermal
EPT
percussion
palpation
periodontal probing and mobility
– Thermal:
cold, heat (pulp vitality)
EPT: (only if pulpal status is in doubt)
This test is not done
routinely*
– Percussion:
tapping with mirror (PDL sensitivity)
Palpation:
digital touching of gingival (inflammation, redness,
swelling, tenderness)
Radiographs of the suspect area(s) are obtained
– Minimum 3 Diagnostic films:
• Straight-on PA film
• PA Shift Shot (20° change in horizontal angulation) M or D
• Bite-Wing (to determine Restorability & Bone level)
Answering the question of “WHY?” usually leads to
an accurate diagnosis and a more successful treatment
outcome*
It may be helpful to think of the pulp existing
in only 3 basic conditions:
normal
inflammed
infected
- Normal
(should remain normal & healthy)
Inflamed (could recover or deteriorate)
A. Reversible (No Tx or symptomatic TX > recovery)
B. Irreversible (Pain Lingering & often Spontaneous)
a) Symptomatic
b) Asymptomatic (rare)
Infected
(infected pulp will proceed to necrosis)
Normal Pulp=Within Normal Limits (WNL )
(5)
• CC: None (Asymptomatic Currently & Historically)
• Clinical Testing:
- Thermal testing (Hot-Cold WNL)
- EPT responsive (similar to other WNL teeth)
- Percussion Negative (WNL)
• No Radiographic Changes
• Another Clue: Minimal or No Apparent Damage
• No Axial cracks. Leave it ALONE
Always test 2-3 adjacent teeth prior to the tooth in
question-WHY?
(Establish a STANDARD BASE-LINE: 1
st)
Reversible Pulpitis
• CC: Cold Sensitive
• Clinical Testing:
– Cold sensitivity #6 and #8 - pain relieved almost immediately once
stimulus is removed-(does NOT linger)*
– Patient was referred for retreatment of #7,
BUT only #6 & #8 symptomatic (with cold
stimulus, not lingering No spontaneous pain)
– Percussion Negative (all 3 teeth)
–Radiographic Changes?*
What did the referring DDS miss?
• Failure to LISTEN to patient’s CC
• Improper DX due to failure to do Clinical Testing
• No need to do Hot (CC was COLD)
RP may follow 1 of 3 outcomes:
- If properly treated – may revert to normal
- May remain RP symptomatic for extended period
- May deteriorate to SIP or AIP (even if properly treated)
Irreversible Pulpitis
(Symptomatic)
• CC: Cold Sensitive
• Clinical Testing:
– Cold Sensitivity #6 only – LINGERS*** 15-20 sec.
after stimulus is removed.
– Percussion Negative
– Radiographic Changes: None at apex
– Look for etiology
- Early SIP
cold hurts, >10 and lingers
- Late SIP
hot hurts – cold helps
hot sensitivity?
Normal Teeth are NOT sensitive to HOT. Gingiva are more
sensitive to hot than teeth. HOT sensitivity usually indicates a
deteriorating pulp = SIP Normal: HOT coffee hurts soft T. not
tooth !
• Rarely, deep caries will not
produce any symptoms, though
clinically or radiographically,
caries may extend well into the
pulp.
• In such cases, RCT is definitely
indicated in order to prevent a
later exacerbation.
Necrosis of Pulp
• CC: May be currently asymptomatic – usual history
of symptomatic previously)
• Clinical Testing:
– Cold Sensitivity: No Response to hot, or electric pulp
tester.
Irreversible Pulpitis
(asymptomatic)
•CC: May be currently
asymptomatic – usual
history of symptomatic
previously)
•Clinical Testing:
Cold Sensitivity: No
Response to cold hot, or
electric pulp tester.
Previously Treated: P
Obturated with final RC filling materials other than
medicaments which is not healing or requires remedial
treatment of some type. This becomes a Non-Surgical
retreatment or a surgical RETX or simply extraction &
replacement.
Previously Initiated Treatment:
Tooth has been previously treated by partial endodontic
therapy.
This could be a failed pulp cap or pulpotomy or it could
be a pulpectomy
WNL: (Normal Pulp) –
Pulp is symptom free with normal response to pulp tests
RP : (Reversible Pulpitis) –
Inflammation of the pulp based on subjective and objective
findings that should revolve and return the pulp to normal
SIP (Symptomatic Irreversible Pulpitis) -
Vital inflamed pulp that is incapable of healing. i.e.
lingering pain to cold, sensitivity to heat, spontaneous pain.
AAP (Asymptomatic Irreversible Pulpitis) –
Vital inflamed pulp incapable of healing. No
clinical symptoms. Inflamed due to caries (chronic hyperplastic pulpitis) caries excavation (pulp
exposure), trauma (fracture with exposed pulp tissue)
Pulpal Necrosis (Necrosis) –
Death of the dental pulp (No Response to pulp tests)
PT: (Previously Treated) –
Tooth has been endodontically treated with canals obturated with
final root canal filling materials other than medicaments..
PIT (Previously Initiated Treatment) –
Tooth has been previously treated by partial
endodontic therapy, i.e. pulp cap, pulpotomy/pulpectomy. RCT NOT completed
Always remember everything in DX is continually
CHANGING
A pain which is diffuse today may be localized tomorrow
A severe cold sensitivity may abate overnight
The same tooth may become newly sensitive to bite next day as pulp vitality
succumbs to challenge.