Table 1 Pulp and periapical diagnosis based on the American Association of Endodontists classification with associated management options25,26
Diagnosis | Descriptor | Symptoms | Signs/further investigations | Management options |
|---|---|---|---|---|
Pulp diagnosis | ||||
‘Normal' pulp | A clinically ‘healthy' pulp | No spontaneous pain or sensitivity reported | Under cold stimulus, pulp usually responds but pain lasts only 1-2 seconds Other sensibility testing is positive with no lingering pain | No treatment indicated |
Reversible pulpitis | Inflammation of the pulp which should resolve following removal of cause (eg caries) | No spontaneous pain Discomfort from cold/sweet but pain lasts ≤2 seconds | Familiar pain following application of cold but resolution in 1-2 seconds No tenderness to percussion and no radiographic changes apically | Remove cause (eg management of caries, sealing exposed dentine). Review to ensure resolution of symptoms and maintenance of vitality |
Symptomatic irreversible pulpitis | A vital inflamed pulp incapable of healing* | Sharp pain on stimulation, lasting >30 seconds (later stages may result in heat stimulus being more severe than cold) Referred pain, may be poorly located Spontaneous pain, sometimes exacerbated by postural change Pain relieving medication use and loss of sleep is frequently reported | Familiar pain lasting >30 seconds following thermal stimulation Usually positive to EPT testing (may have reduced threshold) Pain to percussion in some cases Apical radiographic changes are possible | Partial or complete pulpotomy followed by vital pulp treatment or root canal treatment Pulpectomy followed by root canal treatment Extraction |
Asymptomatic irreversible pulpitis | A vital inflamed pulp incapable of healing* | No symptoms reported | Extremely deep caries and a radiograph which is likely to result in significant bacterial ingress to the pulp and therefore require pulp management | Partial or complete pulpotomy followed by vital pulp treatment or root canal treatment Pulpectomy followed by root canal treatment Extraction |
Pulp necrosis | A necrotic pulp | No pulp symptoms reported but may have associated apical symptoms and diagnosis | Non-responsive to sensibility testing May have associated apical signs and diagnosis | Pulpectomy followed by root canal treatment Extraction |
Previously treated | Previous endodontic treatment | No pulp symptoms reported but may have associated apical symptoms and diagnosis in the case of post-treatment disease | Non-responsive to sensibility testing May have associated apical signs and diagnosis in the case of post-treatment disease | No treatment Endodontic re-treatment Extraction |
Previously initiated therapy | Endodontic treatment commenced (eg pulpotomy or pulpectomy) | Depending on the stage of treatment, symptoms may include those of symptomatic irreversible pulpitis or pulp necrosis | Depending on the stage of treatment, signs may include those of symptomatic irreversible pulpitis or pulp necrosis | Root canal treatment Extraction |
Apical diagnosis | ||||
‘Normal' apical tissues | No inflammatory or infective process | Any symptoms present are likely to be pulpal origin only | No sensitivity to percussion Normal lamina dura radiographically with normal PDL space | No treatment If pulpal symptoms, management aligning to this |
Symptomatic apical periodontitis | Periapical inflammation secondary to pulpitis or infection of the root canal system | Patients may report pain on biting of short duration Pain is well-located Spontaneous pain is possible | Tooth usually tender to percussion Periapical radiolucency or hypoattenuation may be seen on radiographs/CBCT scans | Vital pulp treatment Extirpation and root canal treatment Endodontic re-treatment Extraction |
Asymptomatic apical periodontitis | Periapical inflammation secondary to pulpitis or infection of the root canal system | No additional symptoms to pulp diagnosis May be asymptomatic (eg previously treated, pulp necrosis) | Tooth not tender to percussion Periapical radiolucency or hypoattenuation may be seen on radiographs/CBCT scans | Vital pulp treatment Extirpation and root canal treatment Endodontic re-treatment Extraction |
Chronic apical abscess | Usually gradual onset, pus is produced in response to intra and/or extra radicular infection. Sinus is present | Usually asymptomatic Patients may be aware of sinus/bad taste | Non vital/previously treated tooth Presence of a sinus adjacent to tooth Tooth mobility possible Periapical radiolucency or hypoattenuation may be seen on radiographs/CBCT scans which is well defined and may be corticated Root resorption is possible in long standing cases | Extirpation and root canal treatment Endodontic re-treatment Extraction |
Acute apical abscess | Pus is produced in response to intra and/or extra radicular infection. May be exacerbation of chronic condition (eg chronic abscess, granuloma, cyst) or acute aetiology | No pain to thermal stimuli Usually well-located pain which is spontaneous and is exacerbated by pressure | Non-vital/previously treated tooth Tooth mobility is possible Swelling May be pus discharge from socket/sinus | Extirpation and root canal treatment Endodontic re-treatment Extraction Antibiotics if drainage not possible and/or systemic involvement |
Condensing osteitis | A localised bony reaction to low-grade long-standing inflammation | May be present secondary to other diagnosis, with symptoms aligning to this When present in isolation, often asymptomatic | May be present secondary to other diagnosis, with signs aligning to this Periapical radiograph shows radiopacity around root apices | Extirpation and root canal treatment Endodontic re-treatment Extraction. |
Key: * = Irreversibly inflamed pulp tissue may be confined to part of the pulp, the remainder being amenable to vital pulp treatments EPT = electric pulp test PDL = periodontal ligament CBCT = cone-beam computed tomography | ||||
