Review Article

Identify and Define All Diagnostic Terms for Pulpal Health
and Disease States
Linda G. Levin, DDS, PhD,* Alan S. Law, DDS, PhD,† G.R. Holland, BSc, BDS, PhD, Cert Endo, CRSE,‡
Paul V. Abbott, BDSc, MDS, FRACDS(Endo),§ and Robert S. Roda, DDS, MSjj

Introduction: Consensus Conference Subcommittee 2
was charged with the identification and definition of
all diagnostic terms for pulpal health and disease states
A n evidence-based practice centers on the integration of the best clinically relevant
scientific information with the patient’s desires and the individual practitioner’s clin-
ical practice abilities. Its ultimate goal is to enhance patient care through the development
by using a systematic review of the literature. Methods: of appropriate treatment modalities for specific clinical presentations. The development
Eight databases were searched, and numerous widely of standard terminology is at the center of patient care in that it facilitates communication
recognized endodontic texts were consulted. For each between the patient and doctor as well as between dental health professionals. Presently
reference the level of evidence was determined, and in endodontics there is no standard diagnostic nomenclature consensus for pulpal status
the findings were summarized by members of the in health or disease. The objective of this analysis was the establishment of evidence-
subcommittee. Highest levels of evidence were always based diagnostic nomenclature for clinically encountered pulpal conditions.
included when available. Areas of inquiry included
quantification of pulpal pain, the designation of condi-
tions that can be identified in the dental pulp, diagnostic
Materials and Methods
terms that can best represent pulpal health and disease, The following databases were searched for literature pertaining to our charge:
and metrics used to arrive at such designations. Results MEDLINE-Ovid, PubMed, Web of Knowledge, Cochrane Oral Health Group, EMBASE,
and Conclusions: On the basis of the findings of this SCOPUS, Google Scholar, and Medstory. Non–English language citations and
inquiry, specific diagnostic terms for pulpal health and nonhuman studies were excluded in searches for pain and pulpal metrics. Texts re-
disease are suggested. In addition, numerous areas for viewed included the following: Endodontics, 6th ed, Ingle JI, Bakland LK, BC Decker,
further study were identified. (J Endod 2009;35:1645– Hamilton, Ontario, Canada, 2008; Pathways of the Pulp, 9th ed, Cohen S, Hargreaves
1657) KM, Mosby-Elsevier, St Louis, MO, 2006; Principles and Practice of Endodontics, 4th
ed, Torabinejad M, Walton RE, Saunders, Philadelphia, PA, 2008; Encyclopedia of
Key Words Pain, Schmidt RF, Willis WD, Springer, Berlin, Germany, 2006; Essential Endodontol-
Dental pulp, diagnosis, metrics ogy: Prevention and Treatment of Apical Periodontitis, Ørstavik D, Pitt Ford TR,
Blackwell Publishing, Oxford, United Kingdom, 2007. Problems were encountered in
consistency of terminology, a lack of high levels of evidence, and inherent subjectivity
in subject matter (diagnostic terminology). A lack of studies with high levels of evidence
From the *School of Dentistry, University of North Carolina posed the most significant concern.
at Chapel Hill, Chapel Hill, North Carolina; †Private Practice,
Lake Elmo, Minnestoa; ‡School of Dentistry, University of Mich-
igan, Ann Arbor, Michigan; §School of Dentistry, University of
Western Australia, Perth, WA, Australia; and jjBaylor College Subquestion #1: How Should the Degree of Pulpal Pain Be Quantified
of Dentistry, Dallas, Texas. Clinically?
Address correspondence to Linda G. Levin, DDS, PhD, Ste
106, 3624 Shannon Rd, Durham, NC 27707-3772. E-mail address:
The absolute measurement of pain on a scale common to all patients is not possible as a result of the individual subjectivity of the pain response (1, 2). As a result,
0099-2399/$0 - see front matter initial evaluations as well as the effectiveness of interventions must be assessed by using
Copyright ª 2009 American Association of Endodontists. vague descriptors relative to the individual pain experience such as ‘‘severe,’’ ‘‘sponta-
doi:10.1016/j.joen.2009.09.032 neous,’’ and ‘‘continuous’’ or a subjective determination of the increase or decrease in
intensity. More precise forms of pain measurement are available, but their value in
endodontic diagnosis and treatment has not been determined.
Several techniques for pain measurement in human subjects have been described.
They include verbal rating scales (3–15), numeric rating scales (8, 16), visual analog
scales (12, 17–27), color analog scales (28–32), finger span expression (9, 33, 34),
calibrated questionnaires (8, 35–39), and cortical evoked potentials (6, 7, 16, 21, 40–
43). A brief description of each is presented.
Verbal rating scales are a list of verbal pain descriptors such as no pain, mild pain,
moderate pain, and severe pain. The patient chooses the word that best describes their
pain, and a number is assigned to this, depending on its ranking in terms of intensity.
Numeric rating scales are a list of numbers, for example, 0–100, with 0 being no
pain and 100 the most intense pain imaginable. The patient selects a number that corre-
sponds to their pain intensity.

JOE — Volume 35, Number 12, December 2009 Diagnostic Terms for Pulpal Health and Disease States 1645

Because histopathologic diagnosis is not truly available approach in multiple studies. One such systematic format is given the name S. The intensity colors are anchored at each end by the terms ‘‘no pain’’ and visual analog scale has achieved wide acceptance in the experimental ‘‘worst pain. 22–29. which is an dontic tooth movement on the perception of pain was determined by acronym for Subjective findings. types. having the important attributes of simplicity and a facile conver- Calibrated questionnaires should really be calibrated question. the table. JOE — Volume 35. This health and disease was by Morse et al (51). assess pulpal pain is an informal verbal descriptor scale. or are evaluative describing but they would be less appropriate and more time-consuming in the the overall intensity of the experience. Use of Dolorimetry Technique in Observations of Pulpal Pain Verbal rating Numeric rating Visual analog Color analog Calibrated Finger Span Cortical evoked scales scales scales scales questionnaires Scale potentials 16 3 16 2 2 3 5 Visual analog scales consist of a line with 2 end points of ‘‘no pain’’ ined the efficacy of the various scales in describing pulpal pain.’’ The patient marks a point on the line that relates represents a significant deficit of knowledge in the area of pulpal to the intensity of their pain. Several studies have shown that there is little or no correlation been used in observations of pulpal pain. then the various disease states of the pulp individually. Clinically.’’ this system that we use today (50. 44. The use of finger span and color analog scales is generally mined on the rank values of the words. These are displayed on a form setting of the dental office than either verbal descriptor or visual analog that includes diagrams used for localization.Review Article TABLE 1. The information collected is the patient’s chief complaint. the affective qualities of the pain. by holding the thumb and forefinger of one hand together. the list of conditions that can be identified and described with level in that they were randomized. 18.’’ field. local anesthetic.P. Number 12. Because pulpal inflammatory disease is a progressive this is ‘‘most possible hurt. The finger span concept is first demonstrated Various states of pulpal health and disease exist. resulting in some reports being counted more than once in must be described by using a clinical classification scheme. respect to the dental pulp becomes manageable. a disease state that changes through time.’’ The span in each instance is measured. Its in the dental office. Although electroencephalography would be an advantage is that it allows measurement of the different components of exciting extension to endodontic practice. the pain experience individually. temporal continuum. A series of graded in such as severe. or spontaneous being widely used. and it is a variation of is not quantification but the reporting of an ‘‘all or none response.. or ortho. New systems of classification These reports were not included in this survey. particularly with long- naire because there is only one that has gained widespread acceptance. nology that relates to the clinically inaccessible histopathologic state of Although some of the studies reviewed for this article are of high the pulp. Clinical classification is based on the use of a diagnostic method- ology to produce data that can be interpreted to develop a pulpal diag- Measurement of Pulpal Pain nosis. 45). histopathologic classification systems and clinical classification sent a ‘‘tiny’’ hurt. 20.A. providing a 3-dimensional measure of rendering the use of cortical evoked potentials a distant possibility.O. It reports resulted from experimental settings in which the effect of is usually helpful to format the process to increase efficiency and consis- some variable such an analgesic. The numbers are numbers between clinical diagnostic findings and the histopathologic state of the of reports and thus biased by investigators who have used the same pulp (54–63). The scale is clinically useful. and a somewhat wider distance is ‘‘medium’’ hurt. yet most have used a combination of the 2 types of terminology When the forefinger and thumb are moved as far apart as possible. whereas the other scales are predominantly 1-dimen- sional. systems. term pain. The of quantifying pulpal pain in a truly clinical situation. 38. exist a large number of potential histopathologic descriptors of pulpal logram taken while applying a noxious stimulus and can be used with an disease states. its acceptance is unlikely. December 2009 . only a limited number of pulpal unconscious subject. Calibrated questionnaires (essentially the selected from the medical literature that describe the sensory qualities McGill Pain Questionnaire) have very broad acceptance in many areas. scales. 36. By eliminating termi- (8–16. sion to numbers. and Plan of treatment (49). Subquestion #2: What Are the Conditions That Can Be Finger span scaling has largely been used in children because it Identified and Described with Respect to the Dental overcomes the complexities of other scales that children might have Pulp? difficulty understanding. There are many reports Appraisal). there Cortical evoked potentials are components of an electroencepha. clinical trials. (46–53). A pain rating index is deter. the experience. Objective tests. The patient is many classification systems have been used to designate them. This consists of 20 groups of descriptors ment of clinical interventions. Some studies of local continue to arise as attempts are made to enhance the accuracy and anesthetic solutions do use pain scales. The diag- told that the fingers in this position represent ‘‘no hurt’’ (or ‘‘no pain’’). and serves as a valuable tool for the monitoring and assess- the McGill Pain Questionnaire. intermittent. of the pain. The McGill Pain Questionnaire confined to very young subjects and would be of limited application has been translated into at least 16 languages and is very widely used. All available information is used to develop a diagnosis and a plan of treatment. In some studies more than 1 approach to the endodontic clinician and because diagnosis is needed to perform to pain measurement was used. exercises. 1646 Levin et al. 33. and the results of objective testing. of efficacy testing of local anesthetics that use the failure to respond One of the earlier attempts to describe clinical pulpal states of to an electrical pulp tester as an indicator of effective anesthesia. tency. and historically. nostic systems that have been advocated can be combined into 2 main Then a spread of a small distance between the fingers is shown to repre. and they have been included clinical relevance of diagnostic terminology (65). their A systematic review of the literature revealed no published reports medical and dental history. All techniques are included in the count clinical endodontic treatment. The most prevalent approach endodontists use to the measure of pain intensity. however. conditions can be described on the basis of examination findings for Table 1 shows the number of times a dolorimetry technique has a patient. This and ‘‘worst pain ever. 39. The distance of that point from ‘‘no pain’’ is pain assessment. Assessment (or measuring the pain after pulpal stimulation. 64). with terms Color analog scales are used with children. none of them exam.

situation because it relates to the clinical presentation of the pulp. The pain might be sharp or dull. dentinal hypersensitivity can occur in the absence of the typical etiologic 56). pulp exposure. the tooth containing a necrotic pulp can become discolored pain response to stimuli (usually thermal but possibly to biting pressure (46. which might have different pulp states in different Irreversible Pulpitis roots within the same tooth. will result in pulpal necrosis followed by apical periodontitis. 49. fication schemes appear to be mainly the opinions of the various 64) necessitating root canal therapy.’’ this authors. in many cases. Irreversible inflammation of the pulp is produced by clinical diagnostic terminology are generally very low in that the classi. The pulp will generally respond to Pulp Necrosis cold or electrical stimuli. The and the radiographic appearance might be unremarkable except for words vital and healthy are inaccurate because vitality cannot be deter. Number 12. caries excavation. there might or might not be evidence of calcification of the pulp. bite sensitivity. There is no response to percussion or palpa. 50. periodontal ligament space (49. The area of cell Reversible Pulpitis death expands until the entire pulp necroses. pulpal nerve fibers responding to the inflammatory mediators (71) and peptides (72). pain. Occasionally. trauma. The tooth might or might not be percussion or bite sensitive. the presence of the etiologic agent (65). with high correlations between negative pulp tests and necrosis of the agents of pulpitis such as caries or faulty/new restoration. The etiology of irreversible pulpitis might be deep caries is equivalent in meaning to vital asymptomatic (51) or healthy pulp (69) or restorations. 64. removal of the irri. and the second is symptomatic irreversible pulpitis (49. and hyperocclusion (77) of periradicular origin. combined with signs and This descriptor refers to a pulpal state that implies the presence of symptoms of infected necrotic pulp (46. inflammatory pulpal process that. 68. but it will usually not respond to heat (65). The first type is asymptomatic irreversible pulpitis. To decide whether to perform apexogenesis Pulpectomy or extraction is required to alleviate the symptoms and or apexification on these teeth. 49. or trauma (46. Partial pulp for this is exposed root dentin (46. dental trauma (46. The tooth will exhibit pain when exposed to thermal irritants listed in the following section. without treatment. and. however. cracks. 76) mild pulpal inflammation and that the pulp is capable of healing (46. who provide logical arguments for their choices in developing form of pulpitis is expected to progress to pulp necrosis without treat- nomenclature on the basis of studies with levels of evidence rarely ment (63. although this finding is not universally supported (58). suddenly (except for cases of dental trauma). 64. respond to heat application (49). The term normal pulp appears to be more relevant to the clinical tants. Despite being ‘‘painless. and the radiographic appearance the pulp tissue (47. if the inflamma- mined through clinical examination or vitality testing. The one thing that usually distinguishes pulp normal. 65) or condensing osteitis (chronic This descriptor indicates that all clinical signs are within normal limits focal sclerosing osteomyelitis) (75) might be visible. the removal of the stimulus. with C fibers medi- Clinically Normal Pulp ating dull throbbing pain (53. Occasionally. which is a phenomenon of fluid movement in thermal or electrical pulp tests. 47. Because this event rarely occurs is normal. The distinction between a more severe degenerative process that will not heal and that. 78) as a result of altered translucency of the tooth structure or hemo- in a cracked tooth) (65–67). and there might be pulpal fibrosis. 53) is necrosis of palpation. Reversible pulpitis should be distinguished clinically from necrosis from the other pulpal states is the absence of sensitivity to dentin hypersensitivity. 47. The JOE — Volume 35. and the response will not linger for more than The end result of irreversible pulpitis (asymptomatic or symptom- a few seconds. 53. Review Article Levels of evidence in the literature supporting the use of specific symptoms or pain. pulp will present with variable symptoms ranging from none to severe tant) is performed. They are usually related to clinical examination find. 65). tion. exceeding Level 4. if left untreated. or any other pulpal irri- (53). and the radiographic appearance is generally dicular radiolucency. 74). It implies a more severe degenerative patient (53). will result in pulpal The conditions of the pulp that can be identified and described are necrosis. 70). More clinical study is needed in this area. both of these is the requirement for endodontic therapy to treat the tooth. if left partial and full necrosis becomes important when dealing with immature untreated. The clinical manifestations of these (heat and/or cold) (53) that are prolonged well beyond the removal of conditions and the objective findings relating to them accompany the stimulus. thickening of the be decidedly unhealthy and yet respond in a clinically normal manner. the necrotic pulp might the dentinal tubules and is not necessarily related to pulpal inflamma. carious exposure (47. depending on the type of each descriptor. and it might be localized or referred This descriptor is mentioned in several classifications (8. This can occasionally give rise to positive responses to thermal and electric pulp tests. The etiology pulp. 50–52). 64. and bite tests elicit no pain. 79–82). appearance can vary from apparently normal to exhibiting a large perira- tion of the alveolus. there occurs a variable period of time when the pulp will be partially necrotic. 49–53. The pain resolves within seconds of lysis of red blood cells during pulp decomposition. apical periodontitis. Subsequent bacterial inva- This descriptor refers to a pulpal state that implies the presence of sion will ultimately result in an infected root canal system (46. December 2009 Diagnostic Terms for Pulpal Health and Disease States 1647 . Percussion. one must decide whether the entire pulp is prevent apical periodontitis (46. Radiographically. Symptomatic irreversible pulpitis is a pulpal state characterized by ings. 73). Reversible pulpitis is a result of caries. 47. The treatment (59). Of all the histopathologic pulpal states. there is much uncertainty as to the specific correlations mild to severe pain that lingers after removal of a stimulus (53) or that between diagnostic information and the actual treatment needs of the might be spontaneous (49). Several classifica- necrotic. and that the tooth is asymptomatic. Teeth with necrosis of the 47. 65). The definitive test for this is to enter the pulp chamber and tions have broken this entity down into 2 types. 49. 65). tooth. 68. The common factor in remove necrotic tissue until a vital pulp stump is reached (53). and pulps might tory process has extended into the periapical area. defective or new restorations and is characterized by a mild to severe Occasionally. 65). 65) if appropriate therapy (ie. 69). 20) and (1. necrosis (necrobiosis) (65) is very difficult to diagnose especially in multi-rooted teeth. atic) (49) and. 48. A-delta fibers mediate sharp pain. Depending on the age of the for irreversible pulpitis is root canal therapy or extraction of the tooth. teeth that have an open apex. Hyperplastic Pulpitis (Pulp Polyp) Asymptomatic irreversible pulpitis is a pulpal state characterized This rarely found entity occurs when caries invades the pulp in an by evidence of the need for endodontic therapy in the absence of clinical immature tooth with open apices (46. 50–53. 49. The presentation of these 2 entities is very similar except that necrosis is the one that is most reliably predicted from clinical testing (54.

85). whether the root canal space is infected (65). however. Free-floating Previously Initiated Treatment cells of the oral mucosa are ‘‘seeded’’ onto the proliferating granuloma. and the started but not completed will present for diagnosis (64). 85). is usually clinically detect. calcified pulps (94). this terminology is perhaps not specific enough proposed (84. It is based on the able before treatment and can directly affect the prognosis of treatment. this might also be due to undermining. and the possible presence of radiopaque interappointment medicaments versible (47). The lesion stays associ- previous endodontic therapy. and by whether other considerations chronic irritation to the pulp. which is an entity that should during the search for canals (90). This entity is also referred to as previously pulp cells into clastic ones is unknown. pulp necrosis is found in less than 7% of traumatically induced establishes a pathway for drainage of pulpal inflammatory exudates. and the root or might not present with signs and symptoms of pulpal or periradicular ends are immature. and the opening through the carious lesion into the oral cavity In fact. of these that starts the resorptive process. Generally. that progressive inflammation of the pulp or pulp necrosis will occur. Several hypotheses have been treated (64). the mineral content of the tertiary dentin Acute inflammation then subsides. and it is possible that it might be a combination to endodontics to make it an appropriate term for this condition. 92). 84. ingress from the coronal aspect is likely to have occurred (100. Internal root resorption is considered a form such as perforation of the root or a separated instrument. 96) or with mineral trioxide screening. per se. graph because this will only show a 2-dimensional representation of the however. and the tissue is frequently epithelialized. 85. and chronic inflammatory tissue represents more than just calcium hence the term pulp canal mineral- proliferates through the opening (68). and much tertiary) resulting in radiographically apparent shrinkage of the pulp legitimate debate will now ensue. progression of pulp diseases through the various stages discussed in that severely calcified teeth are predisposed to tooth perforation above. 87). 1648 Levin et al. Radiographically. the important question to be answered is whether might respond to pulp sensibility tests. this appears as a fleshy ization would be a more accurate term. fying (88. The previously described clinical pulpal diagnoses are those that but both terms appear to be inaccurate because the canal is rarely can be described and differentiated by using the diagnostic methods completely obliterated (93). and so completion of endodontic therapy would be necessary. It is a simple yet the initial phases of root canal therapy. (such as restorative needs) require that treatment be instituted (103). and therapeutic pulpotomy with calcium painless and is usually found clinically through routine radiographic hydroxide (the Cvek pulpotomy) (85. a tooth that has had endodontic therapy previously tous tissue. December 2009 . and apical periodontitis would be expected to ensue Internal resorption of the tooth structure is a pathologic state of (65).Review Article enhanced blood supply created by the open apices allows the immature canal space (46). The assessed of irreversible pulpitis and requires root canal therapy to halt the technical quality of the root filling alone cannot give any indication as to process (47). Occasionally. Internal resorption is generally surgical root canal therapy. subepithelial external obturation and perhaps the presence of an iatrogenic complication root resorption (84. given time. Calcification. The tooth pulp (pulpotomy). al- sessed. does not necessarily imply pulp to better resist bacterial invasion than a more mature pulp (81. The author realizes that universal agreement of the tooth. 95. JOE — Volume 35. 89). growth in the size of the lesion (47). Pulp calcification. 85). It also includes normal pulp tissue. the pulp in which multinucleated clastic cells within the pulp tissue Previous Endodontic Therapy begin to remove the dentinal walls of the pulp space. In these cases as with any necrotic pulp or pulpless tooth. the decision as to whether to treat the tooth with this diagnosis (nonsurgical/surgical Pulp Calcification retreatment or extraction) will be determined by diagnosing the pres- Degenerative changes to the pulp such as pulp calcification or pulp ence or absence of apical periodontitis. and for teeth with completed full be negative if there is partial necrosis with the advancing resorptive endodontic therapy. Clinically. and the irritation and bleeding (68). This will usually be determined by the response of the periradic- necrotic tissue (65. resulting in a stratified squamous epithelium (47). to as pulp canal obliteration (65) or calcific metamorphosis (91. 101). lined above and relating to the clinical findings. 85). The history and both the clinical pulp space (86) in which the original borders of the pulp space become and radiographic examinations should indicate the existence of distorted or disappear altogether (84. If perforation of the tooth structure has ular tissues (99) and the clinical determination as to whether bacterial occurred and the tissue in the pulp space is exposed to oral fluids. but this cannot be completely addressed by inspecting the radio- lowing the color of the underlying granulomatous tissue to be visible. but occasionally the tests might the treated pulp remains healthy. This entity is also sometimes referred be diagnosed and given recognition when there are no signs of disease. 85). Number 12. These teeth resultant lesion is rarely painful except when masticatory forces cause would have undergone previous pulpotomy or pulpectomy. The pulp responds by fibrosing or calci. just a progressive deposition of dentin (secondary or on the terminology presented here will not be easily obtained. 83). the pulp space will Internal Resorption become infected. For treatment designed to preserve the ated with the root canal on angled radiographs (84. it is whether the pulp spaces are infected (85. when it appears generally as an ovoid enlargement of the aggregate (97) to induce apexogenesis. pain might occur (84. such as calcium hydroxide paste would be found. lesion within the living portion of the pulp tissue subjacent to the 98). The crown of the tooth might appear The technical quality of the root canal filling will also need to be as- pink in color (47. and there is actually no ‘‘metamorphosis’’ routinely available today. however. Treatment for this entity is either endodontic disease (65). However. The resorption sometimes Various treatment modalities would fall under this diagnostic category moves swiftly and then might be followed by a time of slower or no including teeth that have undergone nonsurgical root canal therapy. 87) as a result of thinning of the tooth structure. so its value as a diagnostic term comprehensive clinical diagnostic system that uses terminology out- is questionable. These teeth might a deep carious lesion connecting to the pulp space. there appears to be history and clinical examination should reveal this. by a thorough knowledge of atrophy/fibrosis are related to aging or sublethal injury resulting in outcomes assessments (102). and radiographic evidence of access into the pulp space therapy or extraction because this condition is considered to be irre. Lastly. pulp fibrosis or atrophy is a histologic change The classification presented in Table 2 has been proposed previ- that is not clinically discernible unless the pulp space is entered during ously by Abbott and Yu (65) and Abbott (104–106). mass of tissue connected to the pulp space that appears to be growing out of the tooth. It is generally idio- Many times teeth that have had previous endodontic therapy are pathic in that the trigger for the metaplastic transformation of normal examined by dentists (65).

although the exact nature of the healing There might come a time when diagnostic methods will arise that response cannot be predicted). ie. pulp sensibility). Review Article TABLE 2. No sign of infection Infected Pulpitis Pulpless. there is no undisputed evidence to support or refute the use of these 2 terms. The most ical practice when a rational treatment plan needs to be established to important aspect of this assessment is to determine whether the root target a specific pathologic entity. that is. Atrophy Hence. that is. This is Many different classification systems have been advocated for pulp usually confirmed clinically during treatment and is significant in terms diseases over the years. and therefore the pulp or tooth will be removed. Subquestion #3: On the Basis of the Highest Level of The term necrosis is defined as ‘‘death of cells or tissues through injury Available Evidence. then it will die at some stage. Teeth with more severe symptoms are usually diagnosed as having dimensional imaging will allow practitioners to correlate better between irreversible pulpitis. 108). This Technical standard (based on the radiographic appearance) implies that subcategories of classification are required for teeth with Adequate pulpitis. also proposed a classification system of their own that varies from those in Table 2. although some dispute exists as to the applicability of instrument these terms. It is also not known whether pulps in patient treatment. the rest is irreversibly inflamed) pulp as being a clinically normal pulp when there is an absence of any Pulp necrosis signs or symptoms of pulp disease being present (65). Number 12. the routine clinical and radiographic examination of a patient. At this time. canal system is infected because an infected canal will cause apical JOE — Volume 35. Hence. resulting in many misleading terms and diagnoses for the Teeth with existing root canal fillings need to be assessed as part of same clinical condition. and this does not provide much information about Chronic whether the pulp is healthy. the more pressing need at this time is to develop a more reliable body of scientific evidence to validate or correct the current mation recover if conservative treatment strategies were used? This question requires further research to establish an answer. Necrosis If an inflamed dental pulp is not treated and continues to be subject to the irritant or injurious factor. fractured versible pulpitis. It is recog- Disease? nized that in the disease continuum. Table 3 (65) has been reproduced as a summary of many of finding with either partial or full necrosis that endodontic therapy is still these classifications. mild symptoms will have reversible pulpitis. Our patients deserve at least that much. The generally accepted terms are reversible pulpitis and irre- Inadequate Other problems: eg. the pulp (107. It is for the most part a histologic findings. What Diagnostic Terms Best or disease. This could lead to an expansion of this terminology and to greater accuracy Currently. Perhaps advances in areas such as measuring pulpal blood flow or high-resolution. that is. the most appropriate term to use is pulpitis. it is recog- will have greater specificity and sensitivity and that are so inexpensive nized that it is not possible to accurately determine this state of pulpitis and efficient that future clinicians will be able to discriminate other in all cases. it is essential that clinicians differentially diagnose which pulps Infected can be managed conservatively and which ones require removal. This creates confusion and uncertainty in clin. 3. the pulp will heal after treatment with either normal or fibrous tissue. Comprehensive Clinical Diagnostic System Clinically Normal Pulp Clinically normal pulp: based on clinical examination and All classifications of tissue conditions should include tissue that has test results not been harmed in any way. diagnostic process and thus help us to enhance clinical care. because the suffix Pulpal canal mineralization -itis is defined in dictionaries as indicating inflammation of the tissue Partial whose name it is attached to. partial necrosis can exist. infected root canal system Degenerative changes The first response of a dental pulp to a stimulus is inflammation. and efforts must continue in that direction. Abbott (104–106) and Abbott and Yu (65) have indicated. However. although most of them are based on histologic of the extent of possible canal infection. Total Hyperplasia Some teeth with pulpitis can be clinically managed via conservative Internal resorption means (such as a simple restoration or a sedative dressing followed by Surface a restoration). its Represent Pulpal Health and the Various Forms of Pulpal use in a classification of pulp diseases is entirely appropriate. whereas others require more radical treatment. (Note that both forms of responses result in clinically normal pulp tissue. normal or healthy tissue (65). These tests are not entirely reliable because they are Irreversible pulpitis usually only testing the ability of the pulp to respond to a stimulus Acute (ie. especially in a localized area of the body’’ (109). pulpal histopathologic states and clinically detectable phenomena. perforation. it is generally accepted that teeth with relatively pulpal conditions more accurately than we can today. which Inflammatory implies removal of the pulp either as part of endodontic treatment or Replacement via extraction of the tooth. Because these clinical treatments vary so Previous root canal treatment No sign of infection greatly. differentiating between reversible and irreversible pulpitis is largely done on an empirical basis. Reversible pulpitis implies that the inflammation within the pulp can be reversed. these classifications mix clinical and histologic Teeth with Previous Root Fillings terms. Typically. could all pulps with inflam- However. Hence. From a clinical perspective. missed canals. The Reversible pulpitis clinical tests available to dentists to assess the state of the dental pulp are Acute Chronic relatively crude. are ever truly irreversibly inflamed. December 2009 Diagnostic Terms for Pulpal Health and Disease States 1649 . it is more appropriate to classify the Necrobiosis (part of pulp necrotic and infected.

chronic internal resorption. acute chronic partial irreversible pulpitis. painful pulpitis. chronic hyperplastic pulpitis (pulp polyp) Necrosis of the pulp Pulp necrosis Pulp necrosis. Concussed pulp. irreversible pulpitis. December 2009 pulpitis pulpitis. irreversible. symptomatic suppurative (pulpal hypersensitive hypersensitivity. hyperemia. pulpitides. necrosis. Reproduced with permission from the Australian Dental Journal. incipient. Yu C. . pulpitis abscess). Pulpitis pulpitis. pulpalgia. (Note: Normal pulp not (Note: Normal pulp not Healthy pulp (Note: Normal pulp not Within normal limits. atrophic. secondary or irregular dentin American Association of Walton and EndodontistsGlossary8 Harty9 Torabinejad10 Grossman11 Castellucci12 Stock13 Bergenholtz14 Normal pulp Normal pulp (Note: Normal pulp not (Note: Normal pulp not Healthy pulp Normal pulp Pulpa sana mentioned) mentioned) Pulpitis: reversible Pulpitis: reversible Pulpitis: reversible Hyperemia. Pulp necrosis Necrosis: partial. Comparative Terminology and Classifications of Pulp Diseases Used by Various Authors and Organizations (2–14) 1650 Review Article World Health Cohen and Organization2 Weine3 Ingle4 Seltzer and Bender5 Burns6 Tronstad7 Levin et al. Number 12. asymptomatic. internal resorption From Abbott PV. other (acute pulpitis). Pulp degeneration. irreversible acute pulpitis. partial pulpitis chronic ulcerative (hyperplastic form) pulpitis. denticles.52:(1 Suppl):S17–S31. pulpalgia. dentin. pulpitis pulpitis pulpitis. Healthy pulp mentioned) mentioned) mentioned) normal pulp. Pulp degeneration. of chronic pulpitis. Necrotic pulp liquefaction. Pulpitis: Hyperemia. acute pulpitis. unspecified pulpitis. chronic. chronic pulpalgia hyperplastic pulposis partial liquefaction symptomatic pulpitis unspecified (subacute pulpitis). necrosis. chronic irreversible pulpitis nonpainful pulpitis. Internal resorption (intracanal) resorption calcific. irreversible pulpitis. chronic hyperplastic pulpitis Pulp necrosis Necrosis Pulpal necrosis Necrosis Necrosis Pulpal necrosis Necrosis pulpae Pulp calcification. pulpitis irreversible reversible pulpitis. hyperemia. (pulpal polyp). chronic ulcerative. Aust Dent J 2007. pulpal calcification calcific pulposis dystrophic stones mineralization Abnormal hard tissue Internal resorption Internal resorption formation in pulp. acute. pulpitis. Pulpitis: asymptomatic (hyperemia). (reversible pulpitis). TABLE 3. advanced. Pulp degeneration. sicca complete Pulp degenerations. chronic hyperplastic acute pulpalgia moderate. chronic pulpalgia. hyperplastic chronic ulcerative irreversible pulpitis JOE — Volume 35. A clinical classification of the status of the pulp and the root canal system. atrophic pulp. chronic pulpitis (no caries). pulpal atrophy. calcific metamorphosis Pulpitis: initial Pulpitis: hyperalgesia Pulpitis: hyper-reactive Pulpitis: incipient form Pulpitis: reversible. calcification. dystrophic atrophic pulposis. fibrous. pulpitis with partial hyperplastic pulpitis. internal Pulp degeneration. total pulpitis with canal calcification.

or it can be left untreated and simply reviewed until extraction is required. Diagnoses? graphic manifestations of the degeneration. This condition tion. response within the pulp (ie.’’ gorize vital pulp status according to the severity of inflammation and. specific diagnostic terms are required for these situations. the tooth can be extracted. Others have elected to further cate- Root Canal System. before further restoration of the tooth. untreated canal) should be listed as part of the diagnosis (65). supply to the apical part of the pulp. it is important to distinguish between active and completed and there are signs of the root canal system being infected. resulting in apical periodontitis. some pulps might Provides the Maximal Accuracy for Establishing Pulpal undergo degenerative changes over time. This root canal filling because this might determine whether further treat. It is important to distinguish these cases diagnosis. term is required. either part of the particular. Number 12. The proposed terminology is internal surface resorp- Teeth that have root canal fillings might become infected at any tion. There are a wide variety of the resorptive area (113). If the condition is defined a specialist for further treatment). when just minor areas of the root canal wall have been resorbed time once a pathway of entry for microorganisms becomes available. Hence. If this blood supply is lost. Review Article periodontitis. a tooth with active internal inflamma- possible reasons why the treatment might not have been completed tory resorption will have some necrotic and infected pulp tissue as well (eg. and the entire canal will become pulpless (as infection does not necessarily imply that the root canal system is not described above). The proposed term is ‘‘infected root canal system in Internal inflammatory resorption occurs when an inflammatory a root-filled tooth’’ (65). Such determination is usually based tissue originating from the pulp. and then that would complicate further management of the tooth (eg. normal aging process or it can be an indication of long-standing irrita. Once apical perio- infected. In an effort to interpret research findings in a meaningful way. the term judged as being technically unsatisfactory and requiring replacement should be hyperplastic pulpitis. the necrotic apical pulp tissue is then digested and removed treatment with no signs of infection’’ (65). from one another. patient was referred to as some pulp tissue with irreversible pulpitis. and Subquestion #4: Which Combination(s) of Metrics they might be difficult to diagnose clinically. It is also important to assess the technical standard of the tion. Likewise. then the If a tooth has had endodontic treatment commenced but not apical part of the pulp will necrose. whereby the bulk of the tissue or organ is increased’’ (111).’’ Any other findings the dental pulp in which the pulp first is replaced by bone. but merely that there is different forms of internal resorption require different clinical manage- no clinical or radiographic evidence of it being infected at the time of ment. Thus. The phrase no signs of by the microorganisms. which resorb the dentin walls of the root canal and then prog- Teeth with Incomplete Endodontic Treatment ress through the dentin toward the cementum (113). then there is no need to mention each of these conditions in the to the diagnosis in all cases. in Typical conditions are pulp canal calcification. completed and it has no signs of the root canal system being infected. perfora. Hyperplasia is defined as ‘‘an (1) vital versus nonvital pulp and (2) normal pulp versus reversible pul- abnormal increase in cells in a tissue or organ. Calcification is defined as ‘‘abnormal deposition of attempts to address the evidence for metrics for establishing diagnoses of calcium salts within tissue’’ (110). term can be used when there has been an overgrowth of granulation ment is required and/or feasible. the internal inflammatory resorption will no longer be active. In other cases. which will make clinical management somewhat easier and If a tooth has had endodontic treatment commenced but not less involved. (112). The dentinoclasts present in internal inflammatory resorp- from other conditions outlined above and below because their clinical tion will only remain alive and active as long as there is a viable blood management might be different. coronal part of the root canal that cause pulpitis in the pulp apical to but the treatment was not completed. It has been suggested that the inflammation might be If there are no signs or symptoms to suggest that a root-filled tooth limited to the pulp chamber and that the apical pulp tissues might be is infected. and the dentinoclasts will also die. Because the tooth is not infected. this review tion to the pulp. the root filling might be tion. it Teeth with Internal Resorption would be appropriate to say it is ‘‘a root-filled tooth with no signs of Three forms of internal root resorption have been reported. This resorption might be self-limiting and might repair if the The management of such a tooth requires specific considerations pulp is relatively healthy and if the irritating stimulus has been removed and treatment techniques. nonactive states of internal inflammatory resorption. subsequently the dentin is replaced by bone (113). The phrase no signs of infection does not necessarily although varying terminology has been used to describe them. whether the inflammation is reversible or irreversible (115). Hence. active. Hence. but merely that there is no clinical or radiographic evidence dontitis is evident. This resorption is Patients might present to dentists and/or endodontists with a tooth believed to be a result of the presence of microorganisms within the that has had endodontic treatment commenced at some time in the past. and it might result in the development on the radiographic appearance of the root canal filling. these might or might not be relevant as such. then the management of such a tooth might be simply one of normal. Teeth with Degenerative and/or Physiologic Changes to ie. it is important to consider Inconsistent definitions of pulpal disease have led many these conditions as part of the diagnostic process and therefore to researchers to dichotomize pulpal status into general categories that include them in a classification of the ‘‘Status of the Pulp and the are defined as vital or nonvital (114). must be distinguished from the other 2 types of internal resorption mentioned above because its clinical management is quite different. a specific diagnostic category or from the tooth. patient did not return for treatment. then the tooth could be classified as having ‘‘an infected root canal Internal replacement resorption is a metaplastic type of change to system and incomplete endodontic treatment. infection’’ (65). then the tooth could be classified as having ‘‘incomplete endodontic Typically. it is highly likely that the resorption is no longer of it being infected at the time of examination (65). of a pulp polyp. The imply that the root canal system is not infected. and therefore it is essential that they be differentially diagnosed examination. Such changes are not pathologic in nature. If there are clinical or radio. except for some vasodilatation and minimal chronic inflamma- observation and reassessment. the Pulp Dental pulps undergo physiologic changes just like all other tissues in the body. The best method for arriving at the JOE — Volume 35. pulpitis) leads to activation of dentinoclas- tic cells. Because this condition is associated with inflammation. pitis versus irreversible pulpitis. Hence. December 2009 Diagnostic Terms for Pulpal Health and Disease States 1651 . excluding tumor forma.

there is relatively more evidence related to determination of vital ificity than cold.83 0.92 0. agreed on definition for pulpal disease. The limitations would include stimulus). The results from such a gold stan. In addition. vitality that does not rely on intact and functioning innervations. rather they are a measure of intrapulpal blood flow. Thus. when used in the absence of other of necrotic tissue on accessing a tooth would indicate that the tooth was tests.91 Petersson et al (133) Clinicala 0. One can conclude from the information dard test for pulp diagnosis is used to compare with the diagnostic presented in these tables that there is considerable variability in the test being evaluated for the determination of testing accuracy. and cotton roll. laser Doppler flowmetry response versus no response) (114). vital pulp) (117. definition of response.’’ b In Evans et al (1999).78 0.90 Evans et al (121) Clinicalb 0. can reliably determine the presence of diseased (ie. teeth undergoing calcific changes.81 0. 115). tooth variables (eg.2 tetrafluoroethane. For example. it other factors have been used in an attempt to determine pulp status. and pulse oximetry (53). ethyl chloride. more readily discernible (ie.81 0.93 0. electric. December 2009 .33 0. Thus they appear to be more versus nonvital pulp.86 0. Number 12.92 0. might be misdiagnosed as being nonvital by these tests. it ular changes. native to assessing the responsiveness of pulpal innervations is assessing pretation of the findings from the pulp tests can be dichotomized (ie. and electric tests. as opposed to the vitality of the pulp tissue. gold standard was determined by ‘‘direct pulp inspection. of the cold test. and patient variables (eg.48 0. is termed the findings from the selected studies related to the accuracy of these tests gold standard test or reference test. metrics used to establish a periradicular diagnosis might appears that heat tests have lower positive predictive values than cold aid in the determination of a pulpal diagnosis.’’ 1652 Levin et al.94 Dummer et al (132) Histology 0. As a result.Review Article TABLE 4. on extracted teeth for pulp or for cold. but Comparison of studies that address pulp testing methods is chal.1.89 — — Gopikrishna et al (120) Clinicalc 0. which might or might not be is not surprising to find considerable variability between studies. caries. blood circulation of the tissue. Given the inherent challenges. systemic diseases). tions of these tests include any condition that limits the ability of the stimulus type. However. 118). Accuracy of Heat Testing Reference Gold standard Sensitivity Specificity Positive predictive value Negative predictive value Seltzer et al (128) Histology 0.47 0. sensitivity and specificity of cold and heat tests and in the sensitivity sessing diagnostic accuracy for pulpal disease testing have used 2 of electric pulp tests. There is less variability in findings for specificity pulp tests have been performed) (114. are summarized in Tables 4–8. It must be recognized of electric pulp tests. tooth type).91 Petersson et al (133) Clinicala 0. but with severed or compromised when compared with determining a diagnosis of normal pulp versus nerves.70 0. cotton In addition to tests for pulp responsiveness and pulpal blood flow. In addition. nonvital) nonvital) and a histologically derived measure (eg. gender.41 0. Furthermore. heat. heat. pulpal status was ‘‘confirmed by pulpectomy. the gold standards and pulse oximetry. oral trauma. the studies suggest that there is no agreement different gold standard tests: a clinically derived measure (eg. vital pulp) (116). if one arrives or electric tests. have been included in this article because the for studies on metrics for determining vital versus nonvital pulp are results of these tests have been referenced to a gold standard (121). a lack of response to a heat test appears to be at an endodontic diagnosis of apical periodontitis.’’ c In Gopikrishna et al (2007). Materials used as a coolant include CO2 snow. This challenge is especially apparent when associated with aging. swab. Accuracy of Cold Testing Reference Gold standard Sensitivity Specificity Positive predictive value Negative predictive value Seltzer et al (128) Histology 0.81 0. The tests for which some level of accuracy for likely to identify nonvital pulp and vital pulp. Application methods include direct application. This is because the inter. A diagnosis of vital versus nonvital pulp is relatively straightforward a pulp with vascularity and vital cells. This is most likely because determining pulp status has been determined are cold. past trauma. The impractical or desirable to use within clinical practice. or physiologic conditions habits. after trauma) (120). Other Clinical Measures of Pulp Disease methane. They are. method of application. heat. laser Doppler flowmetry and pulse oximetry provide a measure of laser Doppler flowmetry. gold standard was determined by ‘‘direct pulp inspection. Two such tests. suggesting that this test is more consistent at iden- that because the progression of pulpal disease might result in periradic. the implication is that less likely to be predictive of a vital pulp (119).83 a In Petersson et al (1999).68 0.33 0.92 0.81 a In Petersson et al (1999). and electric tests assess the responsiveness of the of the pulp or necrotic pulp space. full coverage or deep restorations. and dichlorodifluoro. age. presence as to whether cold and heat tests. reces. cotton pellet. determination of necrotic pulp tissue on The findings summarized in Tables 7 and 8 show that both laser endodontic access or on histologic examination after extraction). ice stick. of less value in conditions in which the innervation of Metrics for Diagnosis of Vital versus Nonvital Pulp the pulp tissue is compromised (eg.70 0. Doppler flowmetry and pulse oximetry have higher sensitivity and spec- Thus. tifying teeth without disease (ie. TABLE 5.89 0. anxiety. Thus.78 0. such as in teeth with a history of sion. restorations.1. pulpal innervation. Studies as.68 0. JOE — Volume 35. care must be taken to avoid false- one attempts to interpret the findings of studies that address the use positive findings that might occur if the adjacent gingiva is not masked. location of test to distinguish the vascular blood flow. there is an inflammation of the periodontal ligament caused by infection Cold. An alter- reversible pulpitis versus irreversible pulpitis. given the variations in factors such as testing methodology (eg. therefore. pulpal status was evaluated by direct visual inspection. heat. and electric tests to identify teeth without disease which the history of symptoms has been established and/or on which (ie.94 Dummer et al (132) Histology 0. limita- lenging.47 0. 1.

the determination of reversible Identified Deficiencies in Available Evidence versus irreversible pulpitis by using cold has relatively lower sensitivity. procedures. although a history of presenting symptoms would.93 0.71 0.’’ and the gold standard was histologic evidence symptoms. was not used.72 0.’’ the goal of pulp testing should be to prevent apical perio- determined that self-reports of toothache pain seem to be valid predic. or negative enough information in the report to establish accuracy) of metrics predictive value of the symptoms. The methodology used (131).95 0. has shown that ‘‘the preoperative presence of apical periodontitis has mining pulp status. 130). Other authors have addressed the However. ted to correlate the results of diagnostic tests with categories of pulpal aid in determining the pulpal diagnosis. Number 12. endodontic access or extraction and histology. some researchers have attempted to evaluate whether the mation. Studies have not been con.84 Evans et al (121) Clinicalb 0.88 0. Given that an extensive review of the highest levels of evidence history of presenting symptoms could be used as a metric for deter. the more likely it is been reported in endodontic textbooks as indicating an irreversible pul. of pulpal inflammation (Table 9). Table 10 illustrates the challenges of of 4 articles that histologically evaluated teeth after pulp tests. Some researchers have attemp.98 — — — Petersson et al (133) Clinicala 0. gold standard was determined by ‘‘direct pulp inspection. a history of being spontaneous.00 a In Gopikrishna et al (2007). JOE — Volume 35.49 or lower) for nonvitality.95 1. would result in a definitive been used to differentiate between reversible and irreversible pulpitis. racy of metrics used for diagnosis. 122–124). Accuracy of Electric Pulp Testing Reference Gold standard Sensitivity Specificity Positive predictive value Negative predictive value Seltzer et al (128) Histology 0. such as pulp status upon periapical radiolucency. No arti.92 0. Review Article TABLE 6. diagnosis that would lead to known outcome. For example. and they treatment. the statistical analysis does not allow for determination of the accu- (0. on histologic factor for determining whether pulpal inflammation is irreversible is evaluation of extracted teeth with deep carious lesions (125). There are several areas in which there is a lack of knowledge con- specificity. Hyman and Cohen (116) summarized the results would not yield predictive value. cerning the accuracy of metrics for determining pulp diagnoses. specificity. A clinical finding of carious pulp exposure has pulpal pain is and the longer it had been present. and history of pain were all found to have a high specificity tion. The metric developing metrics for pulpal diagnosis (and specifically reversible that was evaluated in this table was from teeth that had an ‘‘abnormal versus irreversible pulpitis) on the basis of history of the presenting reaction to cold test.00 0. resulting in the likelihood of apical periodontitis) but also to TABLE 7.’’ c In Gopikrishna et al (2007). making it impossible to nosis. December 2009 Diagnostic Terms for Pulpal Health and Disease States 1653 . and positive predictive values. Another predictive pitis (53. In addition.’’ Thus. the goal of pulp testing should be not only by Grushkas and Sessle for determining reversible versus irreversible to determine when the pulp has become nonvital (and most likely in- pulpitis was only defined as the use of ‘‘standard dental diagnostic fected. as compared with determining the severity of pulpal inflam- inflammation. Evans et al (121) reported that the presence of external root resorption.87 0. In some cases the spontaneous pain cles were found that used (1) a standardized method for determining was so severe as to wake the patient from sleep (128). tenderness to percus.74 a In Petersson et al (1999). Bender (127) has reported that the more severe validate their findings. studies that have assessed for determining diagnoses of reversible versus irreversible pulpitis the history of symptoms for teeth with necrotic pulps have shown that are less common than studies that determine accuracy of metrics for 26%–60% of the cases had no history of pain (129. pulp History of the Presenting Symptoms tests are more sensitive and specific when used to determine vitality of In addition to using pulp tests to determine the severity of pulpal pulp tissue. When compared with the determina- tion of vital versus nonvital pulp tissue. In addi- sion. Alternately stated. An ducted in which pulse oximetry and laser Doppler flowmetry have ideal metric.96 Gopikrishna et al (120) Clinicalc 0. determining vital versus nonvital pulp. pulpal status was evaluated by direct visual inspection. or combination of metrics. for some patients. a gold standard. Thus. dontitis and thereby optimize the outcomes of endodontic treatment tors of whether pulp inflammation is reversible.91 0. thereby suggesting treat- ment options if the predicted outcome is undesirable. for many patients the history inflammation (119). Accuracy of Pulse Oximetry and Pulpal Vitality Reference Gold standard Sensitivity Specificity Positive predictive value Negative predictive value a Gopikrishna et al (120) Clinical 1. In general. it is worth noting that none of the Identification of Reversible versus Irreversible Pulpitis studies that have addressed the history of presenting symptoms have re- Studies that have attempted to determine accuracy (or have sulted in sensitivity. along with (2) a gold standard for determination of accuracy of caries excavation as a metric Limitations of Using History of Presenting Symptoms for determining reversible versus irreversible pulpitis.97 or better) but low sensitivity (0. This has been based.’’ b In Evans et al (1999). Although the history of presenting symptoms might be useful as an aid in determining a pulpal diagnosis. when pulp was exposed during caries removal. the authors failed to disclose the clinical criteria that were history of presenting symptoms as a metric for determining a pulp diag- used for assessment of these characteristics. positive predictive value. Grushka and Sessle (126) have used the McGill a dominant. crown discoloration. negative effect on the outcome of nonsurgical endodontic Pain Questionnaire to differentiate types of toothache pain. pulpal status was ‘‘confirmed by pulpectomy. in large part. pulpal status was evaluated by direct visual inspection. that irreversible inflammation has been present.

versible pulpitis. infection. clinical examination findings. however.81 Dummer et al (132) Histology 0. will be of immense value in determining the need for endodontic inter- tive changes in the dental pulp.58:343–6. with exuberant dentinogenesis as a result vention and the prevention of apical periodontitis. Cohen M.Review Article TABLE 8. This is odontal disease has asymptomatic reversible pulpitis.88 Garfunkle et al (119) Histology 0. It should be emphasized that levels of evidence in the literature because of time and resource constraints. best represent pulpal health and disease are the following: Discussion  Clinically normal pulp Subquestion #5: What Gaps in Knowledge Remain for  Reversible and irreversible pulpitis  Pulp necrosis Developing and Validating Metrics and the Resulting  Root-filled tooth without signs of infection Pulpal Diagnoses?  Root-filled tooth with signs of infection In the area of clinical quantification of pulpal pain. December 2009 . calibrated questionnaires. For opinions of the various authors who provide logical arguments for their the purposes of the development of an evidence-based diagnostic termi. in that the classification schemes appear to be mainly the dental pulp are divided into histologic and clinical classifications. visual analog  Internal surface resorption scales. Internal opment of sensitivity. or peri. there is much uncertainty as mation of the pulp or pulpitis is a broad category that can be further to the specific correlations between diagnostic information and the divided into reversible or irreversible. whereas partial necrosis for pulp diagnoses that incorporate the history of presenting symptoms. predictive values by establishing a gold standard. it was observed  Incomplete endodontic treatment without signs of infection that the majority of studies were performed in experimental settings in  Incomplete endodontic treatment with signs of infection which the effects of a variable on pain perception were measured. therefore.80 0. it can threaten tooth biologic markers for reversible and irreversible pulpal inflammation retention if left unchecked. (ie. for pulpal diagnosis. 1654 Levin et al. numeric rating scales. Pulp calcification is the result of degenera. depending on the degree and actual treatment needs of the patient. Verbal rating scales. Hyperplastic pulpitis is a rare condition usually results of pulpal tests.  Internal inflammatory resorption (active or inactive) ical setting.’’ determine when the pulpal inflammation is irreversible. TABLE 9. can be the most difficult.48 0. JOE — Volume 35. choices in developing nomenclature on the basis of studies with levels of nology. It is recom- visual analog scale and the calibrated questionnaire have been used mended as a point of discussion in terms of adopting it as part of termi- in experimental settings.57 — — — From Hyman JJ. developing algorithms necrosis is the most easily diagnosed entity.0 — — a In Evans et al (1999). As a result of the lack of evidence that supports the metrics thereof.41 0. Total for obtaining a history of presenting symptoms. Future studies should focus on standardized methods Pulp necrosis is characterized by necrosis of the pulp tissue. Minor symptoms particularly important when discriminating between reversible and irre- of sweet or thermal sensitivity represent symptomatic reversible pulpitis. supporting the use of specific clinical diagnostic terminology are gener- Conditions that can be identified and described with regard to the ally very low. and finger span scaling were reviewed in the context of pulpal pain assessment. Inflam. On the basis of pulp pathophysiology. because endodontic intervention is recommended for the latter.63 0. provides the best accuracy for determining pulpal diagnoses. and negative resorption is the result of clastic cells that are stimulated by inflamma. and apical periodontitis. This will facilitate the devel- described in immature teeth with gross pulpal exposures. More clinical study is needed in character of presenting symptoms. their utility in practice is limited nology. These Metrics for establishing pulpal diagnoses were reviewed by our 2 categories can be further divided on the basis of symptoms or the lack committee. The identification of tory mediators to resorb dentin. The categories of previously initiated determine when inflammation of the pulp has become irreversible treatment (incomplete) and previously treated pertain to those teeth would. outcome.76 0. Accuracy of Laser Doppler Flowmetry Reference Gold standard Sensitivity Specificity Positive predictive value Negative predictive value Evans et al (121) Clinicala 1. the diagnostic terms that quent necrosis. or combination with other metrics or history responses. necrotic pulp with most commonly used by endodontists in patient assessment. Presumably every tooth with decay. Abnormal Response to Cold Testing and Irreversible Pulpitis Reference Gold standard’’ Sensitivity Specificity Positive predictive value Negative predictive value Seltzer et al (128) Histology 0. color analog scales.34 0. and clinical findings. The clinically evidence rarely exceeding the lowest level. specificity. Although painless. The predictive value of endodontic diagnostic tests. Oral Surg Oral Med Oral Pathol 1984. positive predictive values. The subcommittee recognizes that there are other qualifiers such Of these. minor trauma. however. an informal verbal descriptor scale was found to be the as the perceived presence or absence of infection (ie. The  Pulp canal mineralization applicability therefore to endodontic patient populations is limited  Hyperplastic pulpitis because the predictive value for pulpal pathology was not tested in a clin. Asymptomatic irreversible pulpitis and symptomatic irrevers. guide the practitioner and patient in treatment choices that have had endodontic treatment either initiated or completed. The ability to of chronic irritation of the pulp. clinical classifications are the most appropriate. nonsurgical root canal treatment vs extraction) and preempt subse. This is not always easily determined clinically.0 1. The demarcation is significant this area. Both the infection). pulpal status was ‘‘confirmed by pulpectomy. it is not possible at this time to determine which ible pulpitis have different presentations but the same therapeutic metric. They are usually related to normal pulp is that pulp that is free from symptoms and vital. Number 12.

J from posterior composites. Correlation of clinical pain symptoms with histopathological changes Pain 1993. The incidence Weine FS. Ulusu T. J Endod 2007. Umino M. ed. J Endod 2007. GangarosaSr LP. Lin LM. neck and muscle afferents onto nociceptive and non-nociceptive neurons 7. The wand in pulp therapy: an alternative to inferior alveolar nerve block.110:e33. Sadiq W. Snowden JD. Pediatrics 2002. Oztas N. Ranali J. Number 12. 3rd ed. Dorman ML. Fujii Y. Suri A.33:552–6. Keiser K. Inflammation and dental pain in man. Post-operative sensitivity in glass-ionomer versus adhesive 33. McConahay T. Sensitivity to mild discomfort Pain might be absent or 19. Rosenberg PA.93:179–83. Donaldson G. J Am Dent Assoc 2000. An experimental system for a heterotopic pain gels into cavities of teeth with pulpitis. Problem solving blind study in adult volunteers.14:34–8. Burke LB. Metrics for pulpal diagnosis (and specifically reversible versus 17. 46. eds. Endod Dent Trauma 1994. Naidu S. stimulation of the teeth: differential reflection of A delta and C fiber activity? 44.5:29–37. Pain 1986. Heft MW. removed 24. McCreary B. 9. Lier BB.102:55–6. Individual responder analyses for pain: 31. Kniffki KD. Pertovaara A. Pain assessment in infants and young children: the Finger Span Scale. Franzen O. Munshi AK. Buck DJ. restoration is loose and point of being continuous 22. J Clin Pharmacol 1996. Clinic Ped Dent 2001. Intl Endod J 2005. Hu JW. Brain Res 2002. Kononen M. Kennedy S. Endod Dent 12. Schaffer RL. Could result in irreversible Pain usually lingers. 18. Tanaka A. Rosing CK. Problems in managing the effectiveness of incisive/mental nerve block: a randomized. Ulusoy O. Motohashi K. et al. Hargreaves KM. 47. Ramacciato JC. Pain and tooth pulp evoked potentials. Bulloch B. J Endod 1994. J Endod 2007. Al-Negrish ARS. Clin Electroencephalogr 13. Review Article TABLE 10. Zibari Y. J Endod 2007. Dworkin RH. Bowles WR.25:215–9. tooth also fractured or frequency.29:501–6.48:269–74. et al. Ahlquist ML. Hsiao-Wu GW. Ahlquist ML. Bulletin of Tokyo Dental College 1998. of mechanical allodynia in patients with irreversible pulpitis. 2. Am J Dent 2006. King GJ. stimulation study in humans. blinded. Pashley D. Waltimo T. Turk DC.10:201–9. painful tooth pulp stimulation in man. placebo-controlled severe clinical trial. Anesth Prog 2004. Hydromorphone 35. Pharmacodynamic evaluation of as predictors of expected and experienced pain in stressful dental procedures. Chapman CR. Enhance. Use of verbal descriptors. J Orofac Pain 1996. J Clinic Perio 2002. Reader A. quality. Noonan CJ. Wehrbein H. Schwartz SA. Amano N. sity. 6. Infrequent episodes of Pain is often spontaneous 21. Susarla SM.33:1–11. Ciarlone AE. Jacobson RC. Newton JT. Arndt JO. often to the J Dent Res 1997. Coffey J. Cenic D. St Louis: Mosby.112:477–83. E African Med J 1996. Franzen OG. Aass AM. Reid K. Behav Brain Res 1989. 29. Anesthetic efficacy of the 45. McGrath PA. Effect of bonding systems on post-operative sensitivity 32. Nusstein J. gency department. Chapman CR. Medert HA. Coldwell SE. Gjermo P. evoked by tooth pulp stimulation. asymptomatic pulpally necrotic central incisor teeth in patients attending a mili. Zhong G. reduction in orthodontic treatment. Dowden WE. Pain 1983. Kianifard S. 42. 3. Bodur H. Inc. Mogil J.29:724–8. infusions. Differential discomfort effects of noxious conditioning stimulation of the cheek by capsaicin on human Seldom hurts to bite unless Pain is increasing in sensory and inhibitory masseter reflex responses evoked by tooth pulp stimulation. Sieraski SM. testing as predictors of tooth pain before and after application of benzocaine 40. Gutmann JL. Harazaki M. Smulson MH. Clark RM. Lovdahl PE. The influence of deep (odontogenic) pain inten. A longitudinal evaluation of pulpal pulpitis if source not with increasing episodes pain during orthodontic tooth movement. Merkel S.000 epinephrine when might be localized used as a supplemental anesthetic. Non-pain and pain sensations Trauma 1994. J Dent 2006. Anxiety and pain measures in dentistry: a guide to their quality intradental A-delta system in man: a psychophysiological analysis of sharp dental and application.38:789–92. Girdler NM. 39. Ahlquist M. Influence of injection speed on Modified from Clinical characteristics of pulpitis.76:1561–8. 1996:84–165. Fusobacterium nucleatum in endodontic flare-ups. analgesia after intravenous bolus administration. J Oral Sci 2004. 14.23:37–46. Messer HH. Neaverth EJ.52:85–91. Waltimo A. controlled. Akpata ES. Lekic D.55:159–69. tooth pulp. Pain 2006. Bryson M. discussion Might be able to identify 33. Articaine and lignocaine effi- if cause ciency in infiltration anesthesia: a pilot study. Validation of 2 pain scales for use in the pediatric emer- from posterior composites. double- endodontic emergencies. Developing patient-reported outcome nitrous oxide-oxygen sedation.197:45–6. Stiefenhofer AE. Ortho Craniofac Res 2002. Treatment of dentin hypersensitivity by Symptoms usually subside Patient often requires some Nd:YAG laser. Walton RE. Flare-ups in endodontics and their relation- present ship to various medicaments. Kanaa MD. Kemppainen P. Volpato MC. Amin KG. Beck M. Rayens MK. a pediatric ED using the Color Analog Scale.25:739–42.19:151–4. J Nurs 2002. Habahbeh R. Convergence of cutaneous. 1997:229–52. Coda BA. measures for pain clinical trials: IMMPACT recommendations. 27.33:403–5. Ito A. Hargreaves KM. Endodontics. 37. Am J Dent 2001. Owatz CB. Br Dent J 2004. Schindler WG. Derendorf H. Akpata ES. in endodontics.15:377–88. Latha R. Bakland LK. Doroschak AM.19:151–4. Khan AA. Pain sensation during cold 1992. Behbehani J. Klages U. Dental pain evoked by hydrostatic pres- resin-lined posterior composites.36:559–64.25: 660–3. Johnston CA. Am J Emerg Med 2007. Franzen OG. Ramsay DS. Akpata ES. immediately after removal type of analgesic 25. A randomized controlled References trial comparing mandibular local anesthesia techniques in children receiving 1.71:41–8. Baltimore: Williams & Wilkins. Effect of bonding systems on post-operative sensitivity supplemental X-tip intraosseous injection in patients with irreversible pulpitis. Bulloch B. Dumsha TC. Pulpal pathology. facial pain. 4. J Endod 1999. Weaver J. de Paz Villanueva LEC.10:153–66. December 2009 Diagnostic Terms for Pulpal Health and Disease States 1655 . 1994:419–38.34:635–40. Coda B. Owatz CB. Oliveira PC. Pain 1993. Isshiki Y. White RR. JOE — Volume 35. sures applied to exposed dentin in man: a test of the hydrodynamic theory of dentin 5. Milgrom P. Nalbuphine does not act analgetically in electrical Ingle JI. Mengel MK. Use of the cold test as a measure of pulpal Not severe Pain is often moderate to anesthesia during endodontic therapy: a randomized. The intensive aspect of information processing in the 38. In: 16. Luger TJ. Gracely RH. visceral.33:406–10. Bakland LK. and duration on the incidence and characteristics of referred oro. Comparison of 4% articaine with Pain radiates or is diffuse or 1:100. Simon JHS. eds.10:31–40. 43.26:125–30. Histophysiology and diseases of the dental pulp. Quint Int 2005. Soft laser irradiation induced pain 10. 11.10:232–9. Hovland EJ. Dogan C.73:779–81. J Endod 2007. Corbett IP. Loughlin P. Franzen OG. pain.33:119–30. Falace DA. Short duration or shooting History of pain is usually sensation given 20. 4th ed.131:1449–57. Mellor AC. Eur codeine using tooth pulp evoked potentials. Use of EMLA: is it an injection free alternative? J 208–15. Endodontic therapy. Dental trait anxiety and pain sensitivity 41.33:1149–54. Endod 2003. Behbehani J. Sessle BJ. The use of an intra-oral injection of ketorolac 8.33:663–6. 28.36:1126–31. Whitworth JM. In: 15. Tenenbein M. Ehrmann EH.. Khan AA. especially 23. Leavitt AH. The development of a diagnostic instrument occlusion is affected for the measurement of mechanical allodynia. Ahlquist ML. Bartoshuk L. 5th ed. Meechan JG. Pain 1997. thermal scores and electrical pulp 95–101. in the treatment of irreversible pulpitis.000 epinephrine and 2% lidocaine with 1:100. St Louis: Mosby-Year Book. Evaluation of the combination of flur- Reversible pulpitis Irreversible pulpitis biprofen and tramadol for management of endodontic pain.36:272–5. Dubner R. Aus Endod J 2007. in trigeminal subnucleus caudalis (medullary dorsal horn) and its implications for ment of morphine analgesia by fenfluramine in subjects receiving tailored opioid referred pain. Jacobson RC.39: Thompson WO. Flare up rate related to root canal treatment of sensitivity.125: 30. Kaltenbach ML. Am J Dent 2006. 34. Oral irreversible pulpitis) on the basis of history of the presenting symptoms Surg Oral Med Oral Pathol Oral Radiol Endod 2002. 36. Hegde AM. Dionne RA. Pashley DH. Witter J. Takahashi H. In: Dumsha TC.27:219–35. Ngassapa D. Jackson DL. Hill HF. specific or multiple stimuli 26. Jyvasjarvi E. Am tary hospital.51:19–23. In: Gutmann JL. Pain 1992. Clinically significant changes in acute pain in does one pain scale fit all? Trends Pharmacol Sc 2005. Grundy BL. of the dental pulp: a review.20:130–4. Encoding of the subjective intensity of sharp dental pain. Klement W. Anesth Prog 1989.

96. The dynamics of pulp inflammation: correlations lence of reactive and physiologic sclerotic dentin. Repair potential of the pulp. Root resorption. Caliskan MK. Bender IB. Kuyk JK. JOE — Volume 35. Goodis HE. J Can Dent Assoc 2002.reference. 1604–7.8:36–54. Treatment of non-vital permanent incisors with calcium hydroxide: I— 1969. J Endod 2007. between diagnostic data and actual histologic findings in the pulp (part I). Bakland LK. Calcific metamorphosis: a treatment dilemma. eds. J Endod 65. Michaelson PL. Perth: The University of Western Australia.29:787–93. Peach R.27:187–201. Int Endod J 1995. Avery DR.33:1405–7. Sundqvist G. kinin-evoked iCGRP release in bovine dental pulp. Diagnosis and treatment planning. Levin LG. Langeland K. Abbott PV. 297–301. Oral Surg Oral Med Oral Pathol 1967. Broom C. cessed: May 04. Clinical signs and symptoms in pulp disease. beneath various types of dental lesions according to tooth surface and age. El-Meligy OA. 2007. 108. and Bender’s dental pulp. Cohen S. 82. Persson S. Abbott PV. Oztop F. Surg Oral Med Oral Pathol Oral Radiol Endod 1999. In: Weine FS. St Louis: Mosby-Elsevier.28:399–404. eds. Trope M.54:441–4. 2008. eds. Levin LG. Berman LH. Endodontics and dental traumatology: an overview of modern endodon- 76. In: histologic data from 706 teeth. -itis. Baume LJ. Spiegel E. J Endod 1981. Essential endodontology. Cvek M.29:265–7. Newton CW. Baltimore: Williams & Wilkins. Sundqvist G. Comparison of mineral trioxide aggregate and calcium 66. Oxford: Blackwell Munksgaard.14:408–12. 2006:460–513. 97. 1996:28–83. The periapical space: a dynamic interface. Hargreaves KM.81:671–7. 2003. 80. Abitbol S. Walton RE. J Dent Res 2000. Inc. Lepinski AM. In: Ørstavik D. human teeth subjected to experimental irritation. Sigurdsson A. hydroxide in permanent incisors with complicated crown fracture. Reeves R. Non-surgical retreatment. Odontologisk 63. Hargreaves KM. The dynamics of pulp inflammation: correlations 87. Dictionary. Histology of pulpal inflammation. 9th ed. the pulp. Path- 58. 3rd ed. Copenhagen and St Louis: Munksgaard. Johnson WT. Torabinejad M. Webster. Influence of infection at the time of ible pulpitis: treatment and prognosis. Abbott P. Is pulpitis painful? Int Endod J 2002. Rivera EM. Glossary of endodontic Hargreaves KM.81:108–17. Dictionary.Review Article 48. In: Cohen S.87:256–63. Pereira JC. Int Endod J 1997. Suda H. Bowles WR. eds. Merriam- 79. Mickel AK. Andreasen FM. Diagnosis. endodontically treated teeth.10:71–81. Essential endodontology. 7th ed. Baumgartner JC.4:232–7.68: hydroxide as pulpotomy agents in young permanent teeth (apexogenesis). Available at: http://dictionary. Caplan DJ. Hargreaves KM. Goodis HE. Huws D. Ac- Goodis HE. Surg Oral Med Oral Pathol 1963. Dachi SF. tomatology of acute dental pain.16:846–71.15: Surg 2000. eds. Messer HH. Pediatr 470–5. 53. Klausen B. 1977. Chicago: Quintessence. Locating referred pulpal pains. J Endod 2003. Helbo M. Mosby. Available at: http://dictionary. Walton RE. Weine FS. St Louis: Mosby-Elsevier. 3rd ed. Chivian N. Holcomb JB. J Am Dent Assoc 1970. Hyman 107. Chicago: Quintessence. December 2009 . Management of the inflamed pulp associated with deep carious to its actual diameter. Accessed May 04. The relationship of bacterial penetration and pulpal pathosis root-filled human teeth. Seltzer S. In: Ørstavik D. Sigurdsson A. 105. Figdor 2002:425–47. 1999. Diagnosis of diseases of the pulp. Hargreaves KM.30:297–306. J Endod 1988. Persistent periapical radiolucencies of 69.22:59–65. In: Cohen S. cessed May 04. Krell KV. 84. onto Study—phase 1: initial treatment. Oral in carious teeth. Chicago: Quintessence. Roda RS. eds. Pathways of the pulp. Gettleman BH. Mitchell DF. In: Cohen S. 514–40. Sinai I. Immunopathological aspects of pulpal and periapical dures. Dummer PM. correlations based on 109 cases.87:617–27. In: Hargreaves KM. 2006:944–1010. system. Pulpal hyperemia: a correlation of clinical and 89. Hargreaves KM. J Am Dent Assoc 1970. Stanley HR. Hargreaves KM. Necrosis. St Louis: Mosby-Elsevier. Caliskan G. Ziontz M. ier.59: 2008. follow-up of periapical repair and apical closure of immature roots. The role of endodontics after dental 2002:34–7. Inc. In: Cohen S. eds. Aquilino SA. Oral Surg Oral Med Oral 60.16:969–77. 181–203. Pitt-Ford TR. 100. inflammations.13:27–35.24:825–30. Dent 2006. 2006: terms. 9th ed. Chi. Inc. Austral Dent J 2007. Friedman S. 1994:439– 2008:44–80. In: Hargreaves KM. In: Hargreaves KM. 2008: 86. Merriam-Webster’s medical Histological evaluation of teeth with 110. ed. Chicago: American Association of Endodontists.35:110–7.36:64–70. Oral Surg Oral Med Oral Pathol 1970. Fouad AF. Holland GR. Merriam-Webster’s medical dictionary. 2006:610–49. St Louis: Mosby-Elsev- 57.reference. Relationship between crown placement and the survival of 72. Ulmansky M. Dixon AD. failed endodontic treatments. eds. 106. Avery J. 2nd ed. 2006:883–917. and periapical scars. Philadelphia: Lippincott. Houghton Mifflin Company. lesion. Available at: http://dictionary. Prostaglandin E2 enhances brady. Bender IB. Fine structure of epithelial and connective tissue elements in Webster. eds. Abbott PV. Biron G. Trope M. eds. Pathol 1983. Endodontic therapy. Merriam-Webster. Pain mechanisms of the pulpodentin complex. Rationale for the management of calcific metamor- 59. 51. Arch Oral Biol 1965.7:205–12. Pitt-Ford TR. titis. In: Cohen S. 4th ed. 29:102–16. Int ways of the pulp. Pulpal reactions to caries and dental procedures. Principles and practice of endodontics. 9th ed. A clinical classification of the status of the pulp and the root canal 1978. Goodis HE. 1994. eds. Smith JW. 3rd ed. McConnell RJ.79: 28:12–8.35:829–32. A clinical report on partial pulpotomy and capping with calcium cago: American Board of Endodontics. Pulpal infections including caries. 90. browse/calcification. Endod Topics 2004. Goodis HE. Seltzer and Bender’s dental pulp. Pathways of the pulp. The cracked tooth syndrome. Philadelphia: WB Saunders. J Endod 1990. Accessed May 04. Seltzer S. A six year evaluation of cracked teeth diagnosed with revers. Garfunkel A. Chicago: Quintessence. J Oral Oral Surg Oral Med Oral Pathol 1963. 91. 9th ed. 103. Clinical manifestations and diagnosis. Andreasen JO. reparative dentin and dead tracts between diagnostic data and actual histologic findings in the pulp (part II). Ziontz M. 70. 2006:2–39. 85. 50. Geriatric endodontics. Number 12. 613–23. The American Heritage Stedman’s medical dictio- hyperplastic pulpitis caused by trauma or caries: case reports. Seltzer and Bender’s dental pulp. Correlation of pulpal histopathology and clinical symptoms in treatment. Structure and functions of the dentin-pulp complex. Torabinejad M. Bowles WR. 98. Lawrence HP. St Louis: Mosby Elsevier. Cvek M. 9th ed. 94. 64. Stanley Endodontic classification. Dabelsteen E. Pathways of the pulp. Liewehr FR. Dictionary. The dental pulp: biologic considerations in dental proce.52(Suppl):S17–31. Levin LG. Oral Surg Oral Med Oral Pathol 1966. Tissue levels of immunore. Oral Med Oral Pathol 1984. Pulp and periradicular pathosis.16:528–33. eds. teeth. Hicks R. Revy 1972. Endodontics. Dictionary.12:257–89. The detection and preva- 55. 67. Haley JV. Oral Surg phosis secondary to traumatic injuries. Hargreaves KM. Schultz M. Textbook and color atlas of traumatic injuries to the 235–61. eds. Schindler WG. Calcific metamorphosis of the pulp: its incidence and 62. Pashley DH. Pulpitis. 99. Torabinejad M. Hartwell GR. A differential diagnostic approach to the symp. J Endod 102. J Endod 1981. Ac- human dental polyps. Oxford: Blackwell Munksgaard. Sjogren U. Oral Surg Oral Med Oral Pathol 1962. Lynch CD. Classification.58:343–6. Hasler JE. Glickman GN. Yu C. Merriam-Webster’s medical dictionary. Pulpal & periapical diagnostic terminology. Seltzer and Bender’s dental pulp. St Louis: Mosby. Stanley HR. Dental pulp pathosis: clinicopathologic Pathol 1982. Painless pulpitis. Permanent restorations and the dental pulp. Oral Surg Oral Med Oral Pathol 1973. Periapical status of endodontically treated teeth in relation to the 71. Kawashima N. Coil JM. 81. Pathways of the pulp. Chicago: Quintessence Books. 9th ed. active substance P are increased in patients with irreversible pulpitis. Merriam- 78. traumatic injuries. 2nd 49.23:27–44. Trope M. titis. In: Hargreaves KM. Hargreaves KM. Nair PN. 2002:345–69. 2008. J Am Dent Assoc 83. Oral Surg Oral Med Oral Pathol 95. Seltzer S. American Board of 2003. Withrow JC. 56. Ray HA. In: Walton RE. Int Endod J nary. Seltzer S. 93. Fouad AF.. diagnosis and clinical manifestations of apical periodon- 75. Gullickson Lundy T. Goodis HE. 11–5. Blanco L. In: Ingle JI. 2002:281–307. 54. Oral 5th ed. Sjogren U. 77. Sela J. 2002: eds. Pathways of ed. 104. Figdor D.15:223–34. Calcification. St Louis: Mosby-Elsevier. J Prosthet Dent 2002. root filling on the outcome of endodontic treatment of teeth with apical periodon- 68. Seltzer and Bender’s dental pulp. technical quality of the root filling and the coronal restoration. Comparison of the radiographic appearance of root canal size 61. Seltzer 52. 1984.reference. 2002:227–45. tics—teaching manual.94:685–9. 92. 1656 Levin et al. Endod J 1980. Bender IB. In: Hargreaves KM. Ann R Australas Coll Dent 74. Treatment outcome in endodontics: the Tor- 2003. 73. Oral Surg Oral Med Oral Pathol 1985. Gregory WB Jr. 88. 109.reference. Johnson RH. eds. The predictive value of endodontic diagnostic tests. Glick DH. Available at: http://dictionary. Periradicular lesions.7:169–81. 2008. Morse DR. Cohen ME. Trowbridge HO.

124.35:110–4. periodontitis. 203–58. 4th ed.16:846–71. Hyman JJ.15:127–31.19:49–50. Oral Surg 116. Lorton L.58:343–6. Bhaskar SN. December 2009 Diagnostic Terms for Pulpal Health and Disease States 1657 . Ingle JI. Berman LH. Hartwell GR. J Endod 2007. Oxford: Blackwell. J Am Dent Assoc 128. to the teeth. 118. Ulmansky M. 131. Houghton Mifflin Company. An evaluation of 566 cases of root 117. Nazimov H. Hicks R. Garfunkle A. JOE — Volume 35. Seltzer S. 2007:344–8. Stirrups D. Fuss Z. Cvek M. Soderstrom C. Huws D. St Louis: Mosby-Elsevier. Rickoff B. Bender IB. Reid J. In: Walton RE. Andreasen FM. Evaluation of the ability of 122. Torneck CD.12:301–5. Hargreaves K. Assessment of reliability of canal therapy in general dental practice: 2–postoperative observations. Sessle BJ. Philadelphia: WB Saunders Co. 115. 2005:2–39. eds. Oral Med Oral Pathol 1984. eds. Beveridge Brown. J Endod 1981. 49–71. J Endod electrical and thermal pulp testing agents. In: Ørstavik D. Dental vitality tests and pulp status. Andreasen JO.6:485–9. Essential endodontology: and pulse oximetry methods for assessing pulp vitality in recently traumatized prevention and treatment of apical pathosis. Pathways of thermal and electrical tests to register pulp vitality. Expected outcomes in the prevention and treatment of apical 120. Oral Surg 1973. 113. Reversible and irreversible pulpitides: diagnosis and treatment. Baumgartner JC. Bakland LK. 2008. Torabinejad M. 2002: to the teeth. Kiani-Anaraki M. Tinagupta K. Oral 130. Dummer PMH. Hyperplasia. Root Bender IB. between diagnostic data and actual histologic findings in the pulp. Kandaswamy D. Pitt Ford TR. 121. Heithersay GS.26:10–4. Endodontics. Available at: http://dictionary. 655–8. Endod Dent Traumatol the pulp. Textbook and color atlas of traumatic injuries and practice of endodontics. 2002: browse/hyperplasia. Root fractures. Petersson K. Seltzer S. Friedman D.19:383–91. Barbakow FH. 112.reference. 125. 133. Evans D. Andersson L. 3rd ed. Andreasen JO. et al. Sorin S. Grushka M. Levy G. Accessed May 04. Dent Traumatol 1999.15:284–90. The American Heritage Stedman’s medical dictio. Walton R. The predictive value of endodontic diagnostic tests.19: 119. In: Andreasen JO. Differential diagnosis of pulp conditions. 4th ed. The measurement of human dental intrapulpal pressure Surg 1965. Andersson L. 2007:393. Bender IB. Cohen M. Int with other methods of assessing the vitality of traumatized anterior teeth. Gopikrishna V. Adult pulp diagnosis: I—evaluation of the tiation of toothache pain. eds. A report of studies into changes in the fine structure of the dental pulp Andreasen FM. Application of the McGill pain questionnaire to the differen- 114. 127. Rappaport HN. J Endod 1986. J Endod 1994. Oral Surg 1963. 126. Oxford. eds. 2007: teeth. clinicopathological corre. Dental pulp pathosis. Clinical signs and symptoms in pulp disease. Diagnosis. Aus 20:506–11. Endo Endod J 1980. Comparison of electrical. Number 12. Cleaton-Jones P. A comparison of laser Doppler flowmetry 132. Bender IB. UK: Wiley-Blackwell Publishing. Review Article 111. Friedman S. 1980. Trowbridge H. Torabinejad M. Principles Andreasen FM.33:531–5. 1999. Cvek M. positive and negative responses to cold and electrical pulp tests. Textbook and color atlas of traumatic injuries in human caries pulpitis. Oral Surg Oral Med Oral Pathol 1965. In: Andreasen JO. Ingle JI. thermal.7:8–16. In: Cohen S. The dynamics of pulp inflammation: correlations 1973. Andreasen FM. In: nary. 408–69. Peters DD.13:27–35. Ziontz M.86:409–11. Hartwell GR. 129. Dictionary. UK: Wiley-Blackwell Publishing. eds. Strang R. 123. lations based on 109 cases. Endodontic diagnostic procedures. Endo J 2000. and its response to clinical variables. Oxford. Baltimore: Williams & Wilkins. Pain 1984. Sela J.