DIAGNOSIS OF PULP &PERIRADICULAR DISEASE

S.O.A.P
First lesson on clinical dentistry
Material for this presentation was
provided by the following
Endodontics by Arnaldo Castellucci
Visual Endodontics and Traumatology
Robert Roda D.D.S
Torbinijad and Walton Endodontics 4
th

edition
Endodontic Techniques ada c-e-r-p
Alex Fleury
S O A P
Rootamentory
information
Endodontics
Deals with the diagnosis, prevention & or
treatment of periradicular disease
It is concerned with the morphology
pathology and physiology of the dental
pulp and periradicular tissues

According to recent data from the
American Association of
Endodontists.
82% of endodontics is performed
by general practitioners. Therfore
they make a majority of
endodontic diagnosis
A systematic approach to
collecting information is critical for
an accurate diagnosis and
treatment.
The SOAP approach to achieving
this diagnosis is an efficient and
simple method to utilize.
S.O.A.P.
Subjective Information
Objective Findings
Assessment
Plan of Treatment
S.O.A.P.
SUBJECTIVE

Chief complaint-------
Location & source of pain
History of pain
Frequency of the pain Stimulus/relief of the pain
Duration of the pain
Severity of the pain
Spontaniety of pain

Dental History
Allows patient to voice his/her chief
complaint
Allows patient input into the diagnostic
process
Accelerates the clinicians determination
of the etiology of the chief complaint
Must be augmented by directed relevant
questions by the clinician
S.O.A.P.
Objective Findings
Clinical Examination
Radiographic Assessment
Comparative Testing
The Examination
Extraoral Exam
Methodical
Note asymmetries
Pupillary dilitation or constriction
Dermatologic presentation (lesions,
etc.)
Lymph node palpation and TMJ
evaluation
Intraoral Examination

Number and quality of existing
restorations
Discolored teeth
Evidence of parafunctional habits
Presence of disease (caries, periodontal
disease, etc.)
Overall oral hygiene
S.O.A.P.
Objective Findings
Comparative Testing
Thermal Tests
Cold (H
2
O, CO
2
, Endo Ice)
Heat (Warm Gutta Percha)
Bite Test
Electric Pulp Test
Transillumination
Anesthetic Test
Test Cavity
Pulp Vitality Tests
Intended to differentiate between a vital
and non-vital pulp
Normal teeth should be tested first to
establish a baseline for that patient
Most gauge nerve fiber activity rather than
blood supply
As An Aside
Not good in Primary Teeth

See Dr Creech
Radiographs
Periapical views most often employed
Customized stints allow reproducible
angulations and should be used for initial,
final and recall films
Intraoperatively, the Endo-Ray is used
Radiographic Interpretation
Is the lamina dura intact?
Is the bony architecture intact or is there evidence of
demineralization?
Is the root canal system within normal limits or is
there resorption or calcification?
What anatomic landmarks could be expected in this
area?
Are the films of sufficient diagnostic quality?
Several angulations may be needed
Evaluate crown margins
Look at number ,size, and shape of roots
S.O.A.P.
Assessment
Diagnostic Categories Should Correspond
to Treatment-Oriented Categories

Diagnosis should indicate the pulpal and
periradicular status and the kind of treatment
needed to rectify the problem.
(Gutmann et al , 1992)
S.O.A.P.
Assessment
Pulpal Diagnosis
Periradicular Diagnosis
Non-Endodontic Pathology
S.O.A.P.
Assessment
Pulpal Diagnosis
normal pulp
Reversible Pulpitis
Irreversible Pulpitis
symptomatic
asymptomatic
Necrotic pulp
Previous Root Canal Therapy
Previously initiated therapy
S.O.A.P.
Assessment
Periradicular Diagnosis
Apical
Normal periradicular tissue
Symptomatic apical periodontitis
Asymptomatic apical periodontitis
Acute apical abscess
Chronic apical abscess
Condensing osteitis
possible new classifications
Normal apical tissues
normal tissue not sensitive to percussion ,palpation,lamina dura intact
periodontal space is uniform
Symptomatic apical periodontitis
inflammation present producing symptoms painful to
biting,percussion,palpation. may or may not have apical radiolucency
Asymptomatic apical periodontitis
inflammation and destruction of apical periodontium that is pulpal in origin
appears as an apical radiolucent area no symptoms
Acute apical abcess
inflammatory reaction to pulpal infection and necrosis . Rapid onset,
spontaneous pain, tenderness to pressure, pus formation swelling
Chronic apical abscess
inflammatory reaction to pulpal infection and necrosis characterized by
gradual onset, little or no discomfort intermittent discharge of pus through a sinus
tract
Condensing osteitis
diffuse radiopaque lesion is a bony reaction to low grade inflammation
usually at apex of the tooth

In the absence of
obvious reasons for
pain you must then
consider the possibility
of non-odontogenic
causes.
S.O.A.P.
Assessment
Non-Endodontic Pathology
Acute Periodontal Abscess
Vertical Root Fracture
Acute / Chronic Sinusitis
TMD / MPD (incl. Occlusal Trauma)
Neuropathic Pain
Vascular Pain
Atypical Facial Pain
periodontal abscess teeth are vital
What to consider
There are no apparent dental reasons
A burning type pain
Pain that has been around for a long
time
Not able to relieve pain with
anesthesia
Failure to respond to treatment
Multiple root canals and still no
resolution
S.O.A.P.
Plan of Treatment
Endodontic Therapy
Emergency Treatment
Elective Treatment
Extraction
Referral
Pulpal States

Normal Pulp &
Dentin hypersensitivity

Normal is symptom free and responds normal
to testing
Dentin hypersensitivity
From exposed dentin
More a symptom than a disease
Not due to caries etc.
Due to thermal, chemical or tactile stimulus
? Not sure of cause hydrodynamic theory
Reversible Pulpitis
Pulp is vital with some minor degree of inflammation
Mild symptoms or no symptoms
Mostly sensitive to cold
Pain rapidly subsides when stimulus is removed
No carious exposure
No sensitivity to percussion
Pain is not spontaneous or unprovoked
Irreversible pulpitis
Symptomatic Irreversible

Pulp is vital severely inflamed
Symptoms usually intense acute could be chronic
Pain may be poorly localized
Pain is spontaneous
Pain to hot & cold (cold may make it feel better at later stages)
Pain lingers after stimulus is removed
May or may not be sore to percussion
Normal PDL or may be thickened
Asymptomatic irreversible
No clinical symptoms but inflammation due to caries or trauma
all carious exposures are considered under this category
Necrotic Pulp
Pulp is non-vital symptoms from asymptomatic
to intense
May or may not have periradicular lesion
Non responsive to hot and cold and electric tests
Can be percussive sensitive with the onset of
periradicular inflammation
May or may not show apical pathology
Previously treated
The tooth has been endodontically treated
and the canals are obturated with various
filling materials other then just intracanal
medicaments
Previously Initiated Therapy
Tooth has been previously treated by partial
endodontic therapy
pulpotomy
pulpectomy

Periradicular Disease
Normal periradicular tissues
patient is asymptomatic
PDL space is uniform in width
around entire root-intact lamina
dura.
But, could also be necrotic!!!
Periradicular Pathosis
Consequence of pulpal necrosis
Can range from slight inflammation to
extensive destruction of tissue
Apical Diagnosis

Normal apical tissues
Symptomatic apical periodontitis
Asymptomatic apical periodontitis
Acute apical abscess
Chronic apical abscess
Condensing osteitis
Speed of resorption