1.2.1 History of Chief Complaint

The initial step for an exact endodontic diagnosis involves taking the patient’s past and present medical history and any current medication. The relationship between the medical conditions and endodontic treatment are discussed later in the book. The medical case history is followed by a dental history, with particular emphasis on the current history. This should be clearly structured and suggestive questions must always be avoided.

It is important to recreate the patient’s chief complaint during the clinical examination. This reduces the chance that you will miss an important piece of evidence. Also note that antibiotics and pain medications can make the diagnostic process more challenging and less reliable.

The clinical and radiographic examinations must be always combined with a thorough periodontal evaluation and clinical testing (pulp and periapical tests) before arriving at a preliminary diagnosis. In case the findings are inconclusive and a definitive pulpal and periapical diagnoses cannot be made, it is better that treatment should not be rendered at this stage. The patient may have to wait and be reassessed at a later date.

Endodontic diagnosis is composed of two parts: pulpal diagnosis and the periapical diagnosis. Pulpal diagnosis indicates the status of the pulp (nerve and connective tissue inside the tooth) and can be accomplished by using thermal and electric pulp tests. The periapical diagnosis indicates the status of the periapex (tissues around the root of the tooth) and, according to the American Association of Endodontists, is based upon pain and swelling. Diagnostic terminology used in this chapter is approved by the American Association of Endodontists and the American Board of Endodontics [4–6].

For clarification, the acute classifications refer to recent symptomatology. The chronic classifications refer to a situation that is long standing and can be viewed on a radiograph. Suppurative periradicular periodontitis is used when a sinus tract or drainage area is present. An acute periradicular abscess occurs when there is acute swelling, pus formation, tenderness, and eventual swelling with or without radiographic pathology.

1.2.2 Pulpal Diagnosis [7–12]

1.2.2.1 Normal Pulp

In this case, the pulp is symptom-free and usually responsive to pulp testing normally. A “clinically” normal pulp results in a mild or transient response to thermal and cold testing, lasting for few seconds after the stimulus is removed. The response should always be compared with adjacent and contralateral teeth.

1.2.2.2 Reversible Pulpitis

This is based upon both subjective and objective findings indicating that the pulp will return to normal following appropriate management of the cause. Pain is experienced when a stimulus such as cold or sweet is applied but goes away quickly (within a couple of seconds) following the removal of the stimulus. Etiological factors may include exposed dentin (dentinal sensitivity), caries, or deep restorations. There are no significant radiographic changes in the periapical area of the affected tooth. Pain elicited is not spontaneous but is usually hypersensitive. After the management of the etiology, the tooth requires further evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Symptoms of dentinal sensitivity mimic those of a reversible pulpitis.

1.2.2.3 Symptomatic Irreversible Pulpitis (SIP)

This scenario is based on subjective and objective findings that the vital inflamed pulp is incapable of healing (returning to normal status) and that root canal treatment is indicated. Characteristics may include sharp pain upon thermal stimulus which lingers (often 30 seconds or longer after stimulus removal), spontaneous pain (unprovoked pain), and referred pain. At times, the pain may be accentuated by postural changes such as lying down or bending over, and over-the-counter analgesics are typically ineffective. Common factors include deep caries, extensive restorations, or fractures exposing the pulpal tissues. Such teeth may be difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no pain or discomfort to percussion. In such cases, detailed dental history and careful examination in conjunction with thermal testing are the primary tools for assessing pulpal status (Fig. 1.1).

1.2.2.4 Asymptomatic Irreversible Pulpitis

This is a clinical diagnosis also based on subjective and objective findings and root canal treatment is indicated. These cases have no clinical symptoms and usually respond normally to thermal testing but may have deep caries that would likely result in exposure during removal.

1.2.2.5 Pulp Necrosis

This is a clinical diagnostic category indicating death of the dental pulp, necessitating root canal treatment. The pulp is nonresponsive to pulp testing and is asymptomatic. Pulp necrosis by itself does not cause apical periodontitis (pain to percussion or any radiographic changes) unless the canal is infected. Some teeth may be nonresponsive to pulp testing due of calcification, or recent history of trauma. Therefore, vitality testing must be comparative in nature with the adjacent teeth (Fig. 1.2).

1.2.3 Apical Diagnoses [7–12]

1.2.3.1 Normal Apical Tissues

In teeth which are not sensitive to percussion or palpation during testing and radiographically, the lamina dura surrounding the root is intact with the periodontal ligament space as uniform. As with pulp testing, comparative testing for percussion and palpation should always begin with normal teeth as a baseline for the patient.

1.2.3.2 Symptomatic Apical Periodontitis (SAP)

This represents inflammation, usually of the apical periodontium. Clinical symptoms include a painful response to biting and/or percussion or palpation. This may or may not be accompanied by radiographic changes (i.e., depending upon the stage of the disease, there may be normal width of the periodontal ligament or there may be a periapical radiolucency). Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp, and root canal treatment is needed (Table 1.2) (Fig. 1.3a, b).

Table 1.2

Clinical findings used to differentiate between SIP and SAP

Criteria	Symptomatic irreversible pulpitis (SIP)	Symptomatic apical periodontitis (SAP)
Sensitivity to cold (carbon dioxide snow)	+	−
Radiographically widened ligament space	±	+
Swelling or sinus tract	−	−
Periapical radiolucency	−	±

1.2.3.3 Asymptomatic Apical Periodontitis

In this case, inflammation of the apical periodontium is of pulpal origin. It manifests as an apical radiolucency and does not present clinical symptoms (no pain on percussion or palpation) (Fig. 1.4a–c).

1.2.3.4 Chronic Apical Abscess

This is an inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and an intermittent discharge of pus through an associated sinus tract. Radiographically, there are signs of a radiolucency.

1.2.3.5 Acute Apical Abscess (AAA)

This is necrosis characterized by rapid onset, spontaneous pain, and extreme tenderness of the tooth to pressure, pus formation, and swelling of associated tissues. There may be no radiographic changes, and the patient often experiences malaise, fever, and lymphadenopathy (Fig. 1.5).

1.2.4 Condensing Osteitis

This is a diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus usually seen at the apex of the tooth.

Symptomatic clinical conditions such as symptomatic irreversible pulpitis (SIP), symptomatic apical periodontitis (SAP), and acute apical abscess (AAA) can be extremely painful [13, 14]. Unfortunately, the current diagnostic nomenclature of the American Association of Endodontists (AAE; [15]) does not differentiate between teeth that cause significant enough pain to require the patient to seek emergency care from those that merely show an increased reaction to diagnostic tests [16].

Due to the obvious clinical symptom of edema (swelling) associated with the diagnosis of AAA, this diagnosis poses no challenge. In contrast, clear-cut symptoms have not been identified to differentiate between SAP and SIP. While SIP is merely painful, SAP is the beginning of the spread of infection with a possibility of untoward systemic consequences [17]. The emergency treatment for SIP and SAP differs [18, 19]. With SIP, simply removing the coronal pulp is sufficient for relief [20], while with SAP the disinfection of the entire root canal system is needed.

1.3 Clinical Evaluation

The clinical evaluation consists of several tests including but not limited to palpation, percussion, periodontal probing, thermal/electrical testing, biting and release (Tables 1.3 and 1.4). For a comparative result to help in establishing a diagnosis, all tests should be performed on the tooth in question and the contralateral/adjacent teeth as well.

Table 1.3

Pulpal diagnosis

Clinical classification	Signs and symptoms	Diagnostic tests	Endodontic treatment needed or not
Reversible pulpitis	Pain—no history of pain, pain is non-spontaneous Radiographically—no radiographic evidence of internal resorption or periapical change	EPT—response is normal and within range Thermal tests—moderate to sharp response to thermal, sweet; response subsides when stimulus is removed Percussion and Palpation—negative, no response	NOT needed
Irreversible pulpitis (with or without apical pathosis) Etiology Deep caries and/or restorations, exposed dentin (attrition, abrasion, and erosion), traumatic injuries, orthodontic forces	Pain • May have acute or chronic symptoms, • Pain may be spontaneous/continuous; previous repeated episodes of pain, • Pain with mastication (on biting) Radiology • Radiographic evidence may reveal normal pulp, narrow pulp chamber, “calcified” canals, or condensing osteitis • An enlarged PDL may also be present	EPT Tooth may test within normal limits, but response may be markedly different from control; rapid/delayed onset, may be persistent, and may be of severe intensity Thermal test A key factor in making a diagnosis. Sharp, exaggerated, painful response to thermal stimulus; pain lingers after stimulus is removed Percussion test May or may not be positive Palpation May or may not be positive	IS needed
Necrotic pulp (with or without apical pathosis) Etiology Deep caries and/or restorations, exposed dentin (attrition, abrasion, and erosion), traumatic injuries, orthodontic forces	Pain • May have acute or chronic symptoms • Pain may be spontaneous/continuous; previous repeated episodes of pain, often dull and throbbing • Pain on biting Radiology • May be normal • Enlarged PDL maybe evident • Periapical or lateral lesions maybe evident	EPT No response/may have false positives Thermal test No response Palpation/percussion test May or may not be positive	IS needed

Table 1.4

Periapical diagnosis

Clinical classification	Signs and symptoms	Diagnostic tests	Endodontic treatment needed or not
Acute apical periodontitis Etiology Irreversible pulpitis, traumatic injuries, Periodontal disease, orthodontic forces, restoration in hyperocclusion	Pain Sharp, intermittent pain of pulpal origin (moderate to severe intensity), aggravating factors are usually present	EPT and thermal tests may be normal, or similar to irreversible pulpitis or pulpal necrosis Palpation/percussion Moderate to severe pain Radiology Usually thickening of PDL, may have periapical or lateral radiolucency	MAY need endodontic treatment
Chronic apical periodontitis (etiology—same as above)	Pain • Slight intensity to no pain, pain may be absent or constant • Periapical pain can be spontaneous. • Pain is dull throbbing • Pain can occur with mastication	EPT and thermal tests may be normal, or similar to irreversible pulpitis or pulpal necrosis Percussion Moderate to none Palpation Moderate to none. May be swelling Radiology Periapical or lateral radiolucency	MAY need endodontic treatment
Chronic suppurative apical periodontitis Etiology Irreversible pulpitis, traumatic injuries, periodontal disease, orthodontic forces, restoration in hyperocclusion	Pain • Usually no pain present • A draining sinus tract or other evidence of suppuration is evident	EPT and thermal tests may be normal, or similar to irreversible pulpitis or pulpal necrosis Percussion None to slight pain Palpation Slightly tender Radiology Periapical or lateral radiolucency	IS needed
Acute alveolar abscess (acute apical abscess) Etiology The result of coronal apical progression of pulpal necrosis into the periapical tissues	Pain • Severe pain which is constant and spontaneous • Pain is pulsing and throbbing • Pain can occur with mastication	Pulp tests No response Percussion Moderate to severe Palpation Moderate to severe, swelling probable Radiology PDL thickening, periapical or lateral radiolucency	IS needed

A pulpal diagnosis is required for a definitive determination

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