Eugene A. Pantera, Jr.

, DDS, MS
Department of Periodontics and Endodontics

Clinical Diagnosis
University at Buffalo

Pulpal Diagnosis
Endodontic Treatment is NOT Needed
CLINICAL CLASSIFICATION

SIGNS AND SYMPTOMS

DIAGNOSTIC TEST RESULTS

Normal
A pulpal condition, usually called normal, in
which the pulp responds to thermal and
electrical tests in a manner similar to that of a
corresponding control tooth.

Pain
No history of pain.
None to mild to moderate intensity
Pain is non-spontaneous
No pain with percussion
Moderate to sharp response to thermal, sweet, or
sour stimuli; response subsides when
stimulus is removed.

EPT
Response is normal and not in extremes. Is
generally in the same range as control
teeth.

Hypersensitive Dentin
A pulpal condition, with no apparent
histologic changes, in which the patient feels
pain when the dentin is exposed to touch
from a dental explorer, fingernail or tooth
brush and to thermal or to other stimuli.
However the pain disappears when the
stimulus is removed.
Reversible Pulpitis
Syn: hyperemia, inflamed-reversible.
A pulpal condition commonly induced by
dental caries and operative procedures, in
which the patient responds to thermal or
osmotic stimuli, but the symptoms disappear
when the etiology is eliminated.

Etiology
Usually caries, defective restoration, restorative
procedures, mechanical pulp exposures,
tooth brush abrasion, tooth fracture,
recent prophylaxis, or subgingival scaling
and curettage.
Radiology
No radiographic evidence of pulp calcifications,
internal resorption, or periapical changes.

Thermal Tests
Usual, normal response, for duration of the
stimulus. Reaction may be severe, but
BRIEF.

Percussion and Palpation

Negative, no response.

Eugene A. Pantera, Jr., DDS, MS

Department of Periodontics and Endodontics

Pulpal Diagnosis
Endodontic Treatment IS Needed

CLINICAL CLASSIFICATION

SIGNS AND SYMPTOMS

DIAGNOSTIC TEST RESULTS

Irreversible Pulpitis

Pain
May have acute or chronic symptoms.
Sharp, exaggerated, painful response to thermal
stimulus; pain lingers after stimulus is
removed.
Pain may be spontaneous; maybe past repeated
episodes of pain, often continuous pain.
Pain with mastication.

EPT
Tooth may test within normal limits.
Response may be markedly different from
control, rapid/delayed onset, persistent, and
may be of severe intensity.

Irreversible pulpitis without periapical pathosis

A pulpal condition, usually caused by deep
dental caries or restorations, in which
spontaneous pain may occur or be
precipitated by thermal or other stimuli.
Radiographs show no periapical changes.
The pain last for several minutes to hours.

Irreversible pulpitis with periapical pathosis

A pulpal condition similar to above, but in
which periapical or lateral radiographic
changes are evident.

Etiology
Deep caries and/or restorations, evidence of
previous pulp cap.
Exposed dentin (attrition, abrasion, and erosion).
Traumatic injuries.
Resorption (especially perforating).
Orthodontic forces.

Radiology
May be normal.
Radiographic evidence may reveal normal pulp,
calcifications, narrow pulp chamber,
"calcified" canals, , or condensing osteitis.
An enlarged PDL may also be present.

Thermal Test
A key factor in making a diagnosis.
May be abnormal, rapid/delayed onset, greater
intensity and longer duration.
Percussion Test
May or may not be positive.
Palpation
May or may not be positive.

Eugene A. Pantera, Jr., DDS, MS

Department of Periodontics and Endodontics

Pulpal Diagnosis
Endodontic Treatment IS Needed

CLINICAL CLASSIFICATION

SIGNS AND SYMPTOMS

DIAGNOSTIC TEST RESULTS

Necrotic Pulp

Pain
May have acute or chronic symptoms.
Pain may be spontaneous; maybe past repeated
episodes of pain, often continuous, dull,
throbbing, pain.
Pain with mastication.

EPT
No response.
May have false positives.

Etiology
Deep caries and/or restorations, evidence of
previous pulp cap.
Carious pulp exposures.
Exposed dentin (attrition, abrasion, and erosion).
Traumatic injuries.
Resorption (especially perforating).
Orthodontic forces.

Percussion Test
May or may not be positive.

Necrotic pulp without periapical pathosis

A pulpal condition in which there may or
may not be spontaneous moderate to severe
pain or pain elicited by various stimuli.
Response to various testing modalities is
usually absent. Radiographic changes are not
evident.

Necrotic pulp with periapical pathosis

A pulpal condition similar to above, except
that in this category periapical or lateral
lesions are evident in radiographs.

Radiology
May be normal.
May be periapical lesions or lateral lesions.
An enlarged PDL may also be present.

Thermal Test
No response.

Palpation
May or may not be positive.

Eugene A. Pantera, Jr., DDS, MS

Department of Periodontics and Endodontics

Periapical Diagnosis
There MAY be Need for Endodontic Treatment
PULPAL DIAGNOSIS IS REQUIRED FOR DEFINITIVE DETERMINATION
CLINICAL CLASSIFICATION

SIGNS AND SYMPTOMS

DIAGNOSTIC TEST RESULTS

Acute Apical Periodontitis

Pain
History of pulpal pain.
Moderate to severe intensity that may be
intermittent.
Periapical pain usually requires stimulus (eg
mastication).
Pain can be sharp.
Aggravating factors are usually present.

Pulp Tests
EPT and Thermal tests may be normal, or
similar to irreversible pulpitis or pulpal
necrosis.

Etiology
Irreversible pulpitis, traumatic injuries,
periodontal disease, orthodontic forces maxillary
sinusitis, pressure from periapical tumors,
restoration in hyperocclusion.
Chronic Apical Periodontitis
A periapical condition characterized by none
to slight pain on mastication but may present
itself with varying degrees of apical swelling.
Radiographs reveal periapical or lateral
radiolucencies.

Pain
History of 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.
Etiology
Same as for Acute apical periodontitis.

Percussion
Moderate to severe pain.
Palpation
Moderate to severe pain.
Radiology
Usually thickening of PDL, also can have
periapical or lateral radiolucency, or normal.
Pulp Tests
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.

Eugene A. Pantera, Jr., DDS, MS

Department of Periodontics and Endodontics

Periapical Diagnosis
There IS a Need for Endodontic Treatment
PULPAL DIAGNOSIS IS REQUIRED FOR DEFINITIVE DETERMINATION
CLINICAL CLASSIFICATION

SIGNS AND SYMPTOMS

DIAGNOSTIC TEST RESULTS

Chronic Suppurative Apical Periodontitis

Pain
History of pain.
Usually no pain present.

Pulp Tests
EPT and Thermal tests may be normal, or
similar to irreversible pulpitis or pulpal
necrosis. (Is this a lesion of endodontic origin?)

Etiology
Irreversible pulpitis, traumatic injuries,
periodontal disease, orthodontic forces,
restoration in hyperocclusion.

Percussion
None to slight pain.

A periapical condition characterized by non

pain on mastication. A draining sinus tract or
other evidence of suppuration is evident.
Radiographs reveal periapical or lateral
radiolucencies.

Palpation
Slightly tender.
Radiology
Periapical or lateral radiolucency.
Visual
Sinus tract present.

Acute Alveolar Abscess

Syn: Acute apical abscess
An acute alveolar abscess is a severe clinical
manifestation of periapical infectious
disease, characterized by severe pain and
swelling.

Pain
History of pain.
Severe intensity.
Constant and spontaneous pain.
Pain is pulsing and throbbing.
Pain can occur with mastication.

Pulp Tests
No response.
Percussion
Moderate to severe.
Palpation
Moderate to severe. Swelling probable.

Etiology
The result of coronal apical progression of pulpal
necrosis with resultant release of antigens into
the periapical tissues.

Radiology
PDL thickening, periapical or lateral
radiolucency.