3. Dental Exam.

At this point, you are looking for things that might be the cause of pulpal problems in the
Sorting Out Endodontic Symptoms area to which your patient pointed, or where referred pain is a reasonable possibility.
Approach each case in the same order- don’t allow yourself to get distracted by chasing down the
 History of carious damage to pulp. Obvious deep caries, deep restorations, large restorations, or
chief complaint too much. Make sure you have their story, then hit the checklist.
crowns.
1. Medical History. As with all patients, review the patient’s medical history, current medications, and take a  History of trauma. Discolored tooth (bleeding inside the pulp leaves stain behind); radiographic
blood pressure if indicated (patients with a history of hypertension). Special concerns about infection? evidence of change in pulp size or different pulp size from contralateral teeth, either larger (pulp
2. Dental History. Ask a series of questions to create a picture of the history of this complaint. necrotic and stopped normal secondary dentin formation) or smaller (trauma can cause excessive
secondary dentin formation, which can strangle the pulp).
Question Leads you to think of… Which tooth?
 Vertical root fracture or crown fracture. Bacteria can enter the pulp through crack, and pulp
 Duration- history. “How long Days- Irreversible pulpitis if worsening and
has it been hurting?” (Prompt severe, reversible pulpitis if less severe. becomes necrotic. Ignore craze lines, however; commonly found in ant. teeth but not significant.
them: “Days, weeks, or Months- Sinus pain, cracked tooth, TMD all Cold test  Evidence of necrotic pulp. Swelling, sinus tract.
months?”) tend towards a cyclical pattern; possibly Percussion
 “Is it getting better, worse, or angina if worse with exertion and history of Palpation 4. Diagnostic Tests. These tests should be done on all suspect teeth as well as normal adjacent teeth and
staying the same? Does it heart disease; others. Periodontal the contralateral tooth for comparison. Usually you do all the teeth in the suspect quadrant, the opposing
come and go?” Weeks- could be either. probing quadrant in the posterior, and the contralateral tooth in any case.
 “Have you ever had pain in Past history of pain- severe pain which then
this area, even if it stopped?” stopped can indicate a necrotic pulp.
 Cold test. Tests pulpal response (A-delta fibers). Skin refrigerant is best (Endo-Ice® is a brand
 Onset. “Does anything bring  If it hurts with every bite, usually name). Normal response is that your patient feels it within a few seconds, you remove the pellet, and
the pain on? How about when periapical or periodontal inflammation
the sensation goes away within 10-30 seconds. An exaggerated response is when your patient thinks
you’re eating? Hot or cold  Dull, aching pain usually early periapical Percussion
food?” inflammation- look for necrotic tooth. Palpation the cold really hurts, and lingering pain to the cold indicates pulpal pathosis, usually irreversible
 If biting makes it worse,  If a sharp, electric, or shooting pain Percussion pulpitis. No response can mean a necrotic pulp or just an old pulp. Always test the contralateral and
“Does it hurt pretty much occasionally, to certain types of food Palpation adjacent teeth as well.
every time you eat, or just (usually dry bread, crackers) with a  Percussion. Tests periapical tissue inflammation. Tap on the crown of the tooth down towards the
sometimes? Is it a sharp, cyclical history- think cracked tooth. Tooth Slooth® root lightly. If there is a tooth that is more tender, that usually indicates periapical inflammation,
electric pain, or a dull, achy  If sensitive to hot or cold, think pulpitis. pathosis or traumatic occlusion.
pain?”  If it still hurts more than 30-60 seconds
Cold test  Palpation. Tests for inflammation just under bone. Firmly roll the pad of your index finger over the
 Onset- duration. “When it after you’ve removed the cold, think
starts hurting, how long does ? Hot test bone just over the apices of the suspect quadrant teeth. Tender areas indicate inflammation.
irreversible pulpitis.
it last?”  Periodontal probing. Tests for an intact periodontal apparatus. Is periodontal disease present? Are
there narrow defects that might indicate a vertical root fractures?
 Character. Describe the pain:  Sharp (A delta fibers), intermittent-
o Sharp or dull? usually means cranky dentin (exposed Cold test 5. Radiographs, if indicated. If a non-pulpal diagnosis or reversible pulpitis has been ruled out, then
o Throbbing? tubules, crack…) but still reasonably periapical radiographs should be taken.
o Constant, or intermittent? healthy pulp- think reversible pulpitis.
o Does it ever wake you up at  Dull (C fibers or pulpal inflammation), 6. Now, pull the information together and diagnose BOTH the pulp and the periapical regions.
night? achy, throbbing, spontaneous- think
irreversible pulpitis. Pulpal Diagnoses Periapical Diagnoses
 Does anything make it  Positional changes- think sinus or Lean over, tap Normal Normal
worse? irreversible pulpitis head Reversible Pulpitis Apical Periodontitis
 Location. “Can you take one Test the Irreversible Pulpitis - Symptomatic
finger and point to where it quadrant + - Symptomatic - Asymptomatic
hurts?” referred area * - Asymptomatic Apical Abscess
* Referred Areas- Pain refers from tooth to tooth… Necrotic Pulp - Symptomatic
 Within a quadrant –frequently Previously Initiated - Chronic
 Maxillary to mandibular- not uncommonly in posterior, rarely in anterior Previously Treated
 Across the midline- rarely

©JK Mitchell, DDS, MEd April 2012

©JK Mitchell, DDS, MEd April 2012