Endodontic diagnosis may be tricky, but never skip it! Before you ever open a tooth, you need to know its diagnosis so you can show why you accessed that tooth.
I know, I know, this seems like such a boring part of endo. But let’s face it: it’s SUPER important. This is how you cover your butt and avoid litigation, plus it’s how you make the right treatment decisions for your patients. If you fail to document your diagnosis, you could get into some real legal trouble, and you can leave referring professionals hanging. Let’s break it down.
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You Need a Pulpal AND Periapical Endodontic Diagnosis
It’s essential that you always have a pulpal AND a periapical diagnosis for every tooth that you treat – plus this should be documented clearly in the patient’s chart along with your diagnostic tests. The diagnosis sets the stage for how you treat and manage your patient all along the way.
Pulpal Diagnosis & Symptoms of Pulpitis
Let’s go over the different pulpal diagnosis first. This is what your cold test is testing, it’s testing the status of the pulp.
- The Normal Pulp: Tooth feels cold and heat with no lingering pain.
The tooth has a normal response to cold and heat. It feels the temperature, but then the sensation goes away after a few seconds. A tooth that has a normal pulp could still need a root canal for restorative reasons, like needing a post in order to retain the core. You’ll see this pulpal diagnosis for teeth that need elective endo. - Asymptomatic Irreversible Pulpitis: Decay into the pulp, but no pain.
The tooth needs a root canal and still feels temperature, but there is no real pain associated with the hot or cold stimulus. I usually see this in teeth with a large carious lesion that has already reached the nerve. It’s asymptomatic because the patient doesn’t have pain, and it’s irreversible because the bacteria has permanently damaged and exposed the pulp. - Symptomatic Irreversible Pulpitis: Exaggerated response to cold or heat.
This diagnosis always means trouble for our patients, who generally are having a ton of pain and walk in as an emergency. It doesn’t always need to be a “hot” tooth, but this type of pulpitis has an exaggerated response to cold or heat. When I do a cold test, and the patient has a stronger response to cold or a lingering response to cold (more than 10-15 seconds), this will be their pulpal diagnosis. - Necrotic Pulp: Tooth has no response to cold.
It’s such an easy one to diagnose! - Previously Initiated: The tooth has had a root canal started, but it hasn’t been finished.
I see this one when one of my referring dentists starts the endo, gets stuck, and then sends it to me to finish up. Or the patient moved from another state, or they never returned to finish treatment. - Previously Treated: Tooth has had a completed root canal.
Note the difference from the Previously Initiated diagnosis, and make sure you distinguish this clearly.
Periapical Diagnosis
The periapical diagnosis comes from your percussion test and your radiograph. This portion of the diagnosis indicates the status of the periapical tissues.
- Normal Periodontium: Everything’s normal.
The tooth has no pain to percussion, and the apex looks pristine on the radiograph. It has normal alveolar bone, a normal PDL, and an intact lamina dura. - Asymptomatic Apical Periodontitis: A periapical radiolucency is visible with no pain to percussion.
I call this “the silent lesion.” - Symptomatic Apical Periodontitis: The tooth is tender to percussion.
It may or may not have a periapical radiolucency. - Chronic Apical Periodontitis: The tooth has a sinus tract.
Abscess indicates the presence of pus, and chronic means that it’s an infection that has been there for some time. Most of these patients don’t have pain, but they can still be a bit tender to percussion. When I see a sinus tract, the diagnosis of Chronic Apical Periodontitis (CAP) will trump that of Symptomatic Apical Periodontitis (SAP). And don’t forget you can have a sinus tract that drains through the sulcus, too! - Acute Apical Abscess: The patient is swollen.
Sometimes they have significant facial swelling, and sometimes it’s a small vestibular swelling, so bear in mind there is a variety of how this can show up. Again, abscess signifies the presence of purulence. Your patient may have little pain or a lot pain with pain to percussion, but the diagnosis of Acute Apical Abscess (AAP) will always trump that of SAP.
Let’s go over some cases
I’ll present three cases with background information and radiograph imaging. From the information you’re provided, what are your pulpal and periapical diagnoses?
Scroll to the bottom of the blog post for the correct answers.
CASE #1: This patient has no response to cold, but does have severe tenderness to percussion. What are your pulpal and periapical diagnoses?
CASE #2: This patient has no pain, but there was a pulp exposure while doing the crown preparation. The tooth responded normal to cold and was slightly tender to percussion. What are your pulpal and periapical diagnoses?
CASE #3: The tooth has no response to cold and no pain to percussion. However, there is a 9mm probing on the disto-buccal. What are your pulpal and periapical diagnoses?
Here are the answers. How did you do?
CASE #1:
Pulpal Diagnosis: Necrotic Pulp
Periapical Diagnosis: Symptomatic Apical Diagnosis
CASE #2:
Pulpal Diagnosis: Asymptomatic Irreversible Pulpitis
Periapical Diagnosis: Symptomatic Apical Periodontitis
CASE #3:
Pulpal Diagnosis: Necrotic Pulp
Periapical Diagnosis: Chronic Apical Periodontitis
Note: This tooth is totally saveable! Don’t get fooled by the amount of bone loss and the probing depth; it’s just a sinus tract draining through the sulcus.
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As always, thanks for stopping by, and don’t forget to give teeth a chance!
My best,
Sonia
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-Sonia
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Thank you so much for reading, and for your kind words.
-Sonia
Hi! Why is it on case no. 3 not ASSYMPTOMATIC apical periodontitis? Why did you also not mention the the diagnostic term CHRONIC Apical Periodontitis on your disscusion about periapical diagnosis? And hie does CHRONIC Apical Periodontitis differ from ASSYMPTOMATIC Apical Periodontitis? Thank you! Nice blog by the way🙂
Hi there. Case #1 is symptomatic Apical Periodontitis because there is tenderness to percussion. The definition of Chronic Apical Abscess is the presence of a sinus tract. Apical Periodontitis has been split up between Asymptomatic and Symptomatic Periodontitis to differentiate when there is tenderness to percussion. These terms have been amended over the years.Thank you.
-Sonia
honestly, i learn so much from your blog and your knowledge and ease of explaining difficult concept cease to amaze me. Thank you, doctor. I can never thank you enough as a current struggling dental student. I hope to mentor others and strive for excellence for my patients in the future.
Best,
HS
Thank you so much for your kind words. I have no doubt you’ll become an excellent mentor in the future!
-Sonia
Thank you for that informative post.
I have a small doubt from case 2. Could you please explain how the pulpal diagnosis is irreversible pulpitis since the sensibility test was normal? Is it because the apical periodontitis cannot occur without a pulpal cause or there was the long-standing pulpal exposure from the crown prep?
Hi AC. Many times, when there is decay into the pulp or a pulp exposure, there is no pain. It’s irreversible pulpitis because the bacteria has landed in the pulp, but it’s asymptomatic irreversible pulpitis because they don’t have any pain at all and these patients test normal. Hope this helps!
-Sonia