Pulpal and periapical pathosis

Review of Clinical Update terminology Omar alsfri

Purpose
In the fall of 2003, a new lossary of !ndodontic "erms# was pu$lished $y the %merican %ssociation of !ndodontics& In %ugust of 200', a Clinical Update2 was pu$lished to inform clinicians of revised terminology for endodontic diagnosis&

"he purpose of this Clinical Update is to inform clinicians of further revisions to this terminology&

 "he significant changes are primarily in the classification of chronic periradicular periodontitis with symptoms& "his term has $een eliminated and is now considered historical& It is critically important to have standard diagnostic terminology& (tandardi)ation of terms will improve communication $etween all clinicians&

*iagnostic procedures
*iagnosis is the art of distinguishing one disease from another *iagnostic procedures I& review of medical and dental histories II& radiographic e+amination III& and clinical e+amination, e+traoral and intraoral-

"he results
Pulpal diagnoses
I& .ormal pulp II& Reversi$le pulpitis III& Irreversi$le pulpitis I/& Pulpal necrosis /& Pulpless tooth

. Periradicular diagnoses
I& .ormal Periradicular "issues II& %cute periradicular periodontitis III& %cute periradicular a$scess I/& Chronic periradicular periodontitis /& (u$acute periradicular periodontitis ,chronic periradicular periodontitis with symptoms/I& Chronic periradicular a$scess /II& condensing osteitis /III&0ocal osteopetrosis

Pulpal diagnoses

.ormal pulp
% normal pulp is symptom free and will normally $e responsive to the electric pulp tester ,!P"-& 1hen evaluated $y thermal testing, the normal pulp produces a positive response that is mild and su$sides immediately when the stimulus is removed&

Reversi$le pulpitis
Caries, crac2s, restorative procedures or trauma may cause a pulp to $ecome inflamed "he patient3s chief complaint is usually of an e+aggerated response to thermal stimulus $ut once the stimulus is removed, the discomfort does not linger& !P" results are responsive&

Irreversi$le pulpitis
If the inflammatory process progresses, irreversi$le pulpitis can develop& Patients may have a history of spontaneous pain and complain of an e+aggerated response to hot or cold that lingers after the stimulus is removed& !P" results are usually responsive&

 In cases, cold actually alleviates the patient3s pain& .ormal $ody temperature is now causing the nociceptors in the pulp to discharge

Removal of the cold causes return of symptoms and can $e used as a diagnostic test&

 Irreversi$le pulpitis can also present as an asymptomatic condition I& Internal resorption II& and hyperplastic pulpitis ,pulp polyp-

Pulpal necrosis
.ecrosis is a histologic term that denotes death of the pulp& "eeth with total pulpal necrosis are usually asymptomatic unless inflammation has progressed to the periradicular tissues& "he pulp will not respond to the !P" and thermal tests&

Pulpless tooth
% tooth from which the pulp has $een removed& 0or e+ample, a tooth with previous pulpotomy , pulpectomy, root canal de$ridement or previous root canal therapy

Periradicular diagnoses

.ormal Periradicular "issues

.ormal periradicular tissues will $e non4 sensitive to percussion and palpation testing& Radiographically, periradicular tissues are normal with an intact lamina dura and a uniform periodontal ligament ,P*5- space&

%cute periradicular periodontitis

%%P occurs when pulpal disease e+tends into the surrounding periradicular tissues and causes inflammation& 6owever, %%P may also occur as the result of occlusal traumatism&

"he patient will complain of discomfort to $iting& (ensitivity to percussion& Palpation testing may or may not produce a sensitive response& "he P*5 space may appear normal or widened&

%cute periradicular a$scess

In this situation, $acteria have progressed into the periradicular tissues and the patient3s immune response cannot defend against the invasion& It is characteri)ed $y rapid onset, spontaneous pain, pus formation, and often swelling of the associated tissues& Percussion testing produces a response&

 Palpation testing produces a sensitive response& Radiographically, the P*5 space may $e normal, slightly widened, or demonstrate a distinct radiolucency& "his periradicular pathosis can occur with a necrotic pulp or a pulpless tooth

Chronic periradicular periodontitis

1hen $acteria or $acterial products from a necrotic pulp or pulpless tooth slowly ingress into the periradicular tissues& "he resultant inflammatory process causes periradicular $one resorption that manifests as a periradicular radiolucency on the radiograph& Clinically, the patient is asymptomatic& Percussion and palpation testing produce non4 sensitive responses&

(u$acute periradicular periodontitis

,chronic periradicular periodontitis with symptoms-

"he patient will present with mild to moderate symptoms that may include spontaneous pain or discomfort on $iting& Percussion testing produces a mild sensitive response palpation testing may or may not $e sensitive&

 Radiographically, the tooth will present any4 where from a normal periradicular appearance to a distinct radiolucency& "hese patients must receive endodontic treatment $ecause the condition can 7uic2ly progress into acute periradicular periodontitis or an acute periradicular a$scess&

Chronic periradicular a$scess

,suppurative periradicular perio4 dontitis-

%n inflammatory reaction to pulpal infection and necrosis characteri)ed $y gradual onset little or no discomfort and intermittent discharge of pus through an associated sinus tract& Clinically, the patient is usually asymptomatic $ecause the sinus tract allows drainage of any e+udate from the periradicular tissues&

 !P" and thermal testing are non4 responsive& Percussion and palpation testing usually produce non4 sensitive responses& Radiographically, a periradicular lesion is associated with the involved tooth& CO88O. I. C6I5*!R.

0ocal sclerosing osteomyelitis

,condensing osteitis "his entity may $e considered a true lesion of endodontic origin ,5!O-& "he involved tooth will have an etiologic factor for low grade, chronic inflammation such as a necrotic pulp, e+tensive restorative history or a crac2& "he patient may $e asymptomatic or demonstrate a wide range of pulpal symptoms&

 !P" and thermal tests may or may not $e responsive& Percussion and palpation testing may or may not $e sensitive& Radiographically, the involved tooth will present with increased radiodensity and opacity around one or more of the roots 9:; of these periradicular radiodensities resolve after endodontic therapy

0ocal osteopetrosis
,,periapical osteosclerosis

"his entity is not a 5!O& "he patient will $e asymptomatic& !P" and thermal testing are responsive& Percussion and palpation testing non4sensitive& "he involved tooth is usually a virgin tooth& Radiographically, the tooth will present with increased radiodensity and opacity around one or more of the roots& .o treatment is necessary and the tooth should simply $e monitored at periodic recall&,9 -

(ummary
*etermination of the etiology of the patient3s chief complaint& Reproduction of the patient3s chief complaint is critical& If the chief complaint cannot $e reproduced, consider consultation with or referral to an endodontist&

References
lossary of !ndodontic "erms 8cClanahan (<, oodell , "ordi2 P%& *orland3s illustrated medical dictionary& 8ontgomery (, 0erguson C*& !ndodontics& Cohen (, 5iewehr 0& (imon =6(, 1alton R!, Pashley *6, *owden 1!, <a2land 5>&

"ora$ine?ad 8, 1alton R!& (imon =6(& Periapical pathology .air P.R& 6argreaves, >8& !liasson (, 6alvarsson C, 5?ungheimer C&

"han2 you