HISTORICALLY

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THE MAJORITY OF DIAGNOSTIC CLASSIFICATION SYSTEM HAVE BEEN BASED

UPON HISTOPATHOLOGICAL FINDINGS RATHER THAN CLINICAL FINDINGS,
OFTEN LEADING TO CONFUSION, MISLEADING TERMINOLOGY, AND
INCORRECT DIAGNOSES .

A KEY PURPOSE OF ESTABLISHING A PROPER PULPAL AND PERIAPICAL

DIAGNOSIS IS TO DETERMINE WHAT CLINICAL TREATMENT IS NEEDED.

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The American Association of Endodontists held a consensus conference
to standardize diagnostic terms used in endodontics .
The goals were to propose universal recommendations regarding
endodontic diagnoses; develop a standardized definition of key
diagnostic terms that will be generally accepted by endodontists and all
collages.
Each of the following diagnostic terms will be defined with typical
respective clinical and radiographic characteristics along with
representative case examples when appropriate. However, clinicians
must recognize that diseases of the pulp and periapical tissues are
dynamic and progressive and as such, signs and symptoms will vary
depending on the stage of the disease and the patient status.

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EXAMINATION AND
DIAGNOSTIC PROCEDURES

Endodontic diagnosis is similar to a

jigsaw puzzle—diagnosis cannot be
made from a single isolated piece of
information.

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 DIAGNOSTIC TERMINOLOGY APPROVED BY THE
AMERICAN ASSOCIATION OF ENDODONTISTS AND
THE AMERICAN BOARD OF ENDODONTICS

(1) Pulpal Diagnoses

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NORMAL PULP

• It is a clinical diagnostic category in which the pulp is

symptom-free and normally responsive to pulp
testing.
• Although the pulp may not be histologically normal, a
“clinically” normal pulp results in a mild or transient
response to thermal cold testing, lasting no more than
one to two seconds after the stimulus is removed.
• One cannot arrive at a probable diagnosis without
comparing the tooth in question with adjacent and
contralateral teeth. It is best to test the adjacent teeth
and contralateral teeth first so that the patient is
familiar with the experience of a normal response to
cold.
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 • It is based upon subjective and objective findings
REVERSIBLE indicating that the inflammation should resolve
PULPITIS and the pulp return to normal following
appropriate management of the etiology.
• Discomfort is experienced when a stimulus such
as cold or sweet is applied and goes away within
a couple of seconds following the removal of the
stimulus.
• There are no significant radiographic changes in
the periapical region of the suspect tooth and
the pain experienced is not spontaneous.
• Following the management of the etiology (e.g.
caries removal plus restoration; covering the
exposed dentin), the tooth requires further
evaluation to determine whether the “reversible
pulpitis” has returned to a normal status. 7
 • It is based on subjective and objective findings that the
SYMPTOMATIC vital inflamed pulp is incapable of healing and that root
IRREVERSIBLE PULPITIS canal treatment is indicated.
• Characteristics may include sharp pain upon thermal
stimulus, lingering pain (often 30 seconds or longer
after stimulus removal), spontaneity (unprovoked pain)
and referred pain. Sometimes the pain may be
accentuated by postural changes such as lying down or
bending over and over-the-counter analgesics are
typically ineffective.
• Teeth with symptomatic irreversible pulpitis 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, dental history and thermal testing are the
primary tools for assessing pulpal status. 8
ASYMPTOMATIC
IRREVERSIBLE PULPITIS

• It is a clinical diagnosis based on

subjective and objective findings
indicating that the vital inflamed pulp is
incapable of healing and that root canal
treatment is indicated.
• These cases have no clinical symptoms
and usually respond normally to thermal
testing but may have had trauma or deep
caries that would likely result in exposure
following removal.
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 • It is a clinical diagnostic category indicating
death of the dental pulp, necessitating root
PULP NECROSIS canal treatment.
• The pulp is non-responsive to pulp testing and is
asymptomatic.
• Pulp necrosis by itself does not cause apical
periodontitis (pain to percussion or radiographic
evidence of osseous breakdown) unless the
canal is infected.
• Some teeth may be non-responsive to pulp
testing because of calcification, recent history of
trauma, or simply the tooth is just not
responding. As stated previously, this is why all
testing must be of a comparative nature (e.g.
patient may not respond to thermal testing on
any teeth). 10
 DIAGNOSTIC TERMINOLOGY APPROVED BY THE
AMERICAN ASSOCIATION OF ENDODONTISTS AND
THE AMERICAN BOARD OF ENDODONTICS

(2) Apical Diagnoses

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

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SYMPTOMATIC APICAL
PERIODONTITIS
• It represents inflammation, usually of the apical
periodontium, producing clinical symptoms
involving 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.
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ASYMPTOMATIC
APICAL PERIODONTITIS
• It is inflammation and destruction of
the apical periodontium that is of
pulpal origin. It appears as an apical
radiolucency and does not present
clinical symptoms (no pain on
percussion or palpation).

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CHRONIC APICAL
ABSCESS • It 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 typically signs
of osseous destruction such as a
radiolucency. To identify the source of a
draining sinus tract when present, a gutta-
percha cone is carefully placed through
the stoma or opening until it stops and a
radiograph is taken.
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ACUTE APICAL
ABSCESS • It is an inflammatory reaction to pulpal infection
and necrosis characterized by rapid onset,
spontaneous pain, extreme tenderness of the
tooth to pressure, pus formation and swelling of
associated tissues.
• There may be no radiographic signs of
destruction and the patient often experiences
malaise, fever and lymphadenopathy.

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CONDENSING
OSTEITIS

• It is a diffuse radiopaque lesion

representing a localized bony reaction
to a low-grade inflammatory stimulus
usually seen at the apex of the tooth.
• May it is symptomatic or not and ttt is
based on that .

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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; symptomatic apical periodontitis

with condensing osteitis.
Non-surgical endodontic treatment is indicated followed by
a build-up and crown. Over time the condensing osteitis
should regress partially or totally .
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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.
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• Diagnosis: Symptomatic irreversible pulpitis;
normal apical tissues.
• Non-surgical endodontic treatment is
indicated; access is to be repaired with a
permanent restoration.
• Note that the maxillary second premolar has
severe distal caries; following evaluation, the
tooth was diagnosed with symptomatic
irreversible pulpitis (hypersensitive to cold,
lingering eight seconds); symptomatic apical
periodontitis (pain to percussion).

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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.
Treatment would be excavation of the caries followed by placement
of a permanent restoration. If the pulp is exposed, treatment would
be non-surgical endodontic treatment followed by a permanent
restoration such as a crown.

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CASE 4

Mandibular right lateral incisor has an apical radiolucency

that was discovered during a routine examination. There was
a history of trauma more than 10 years ago and the tooth
was slightly discolored. The tooth did not respond to Endo-
Ice® or to the EPT; the adjacent teeth responded normally to
pulp testing. There was no tenderness to percussion or
palpation in the region.
Diagnosis: pulp necrosis; asymptomatic apical periodontitis.
Treatment is non-surgical endodontic treatment followed by
bleaching and permanent restoration.
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CASE 5
Mandibular left first molar demonstrates a
relatively large apical radiolucency encompassing
both the mesial and distal roots along with
furcation involvement. Periodontal probing depths
were all within normal limits. The tooth did not
respond to thermal (cold) testing and both
percussion and palpation elicited normal
responses. There was a draining sinus tract on the
mid-facial of the attached gingiva which was traced
with a gutta-percha cone. There was recurrent
caries around the distal margin of the crown.
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• Diagnosis: pulp necrosis; chronic
apical abscess.
• Treatment is crown removal,
non-surgical endodontic
treatment and placement of a
new crown.

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CASE 6

Maxillary left first molar was endodontically treated more

than 10 years ago. The patient is complaining of pain to
biting over the past three months. There appear to be
apical radiolucencies around all three roots. The tooth was
tender to both percussion and to the Tooth Slooth®.
Diagnosis: previously treated; symptomatic apical
periodontitis.
Treatment is nonsurgical endodontic retreatment followed
by permanent restoration of the access cavity

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CASE 7

Maxillary left lateral incisor exhibits an apical

radiolucency. There is no history of pain and the
tooth is asymptomatic. There is no response to Endo-
Ice® or to the EPT, whereas the adjacent teeth
respond normally to both tests. There is no
tenderness to percussion or palpation.
Diagnosis: pulp necrosis; asymptomatic apical
periodontitis.
Treatment is nonsurgical endodontic treatment and
placement of a permanent restoration
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