ENDODONTICS:
Colleagues for Excellence
2
H
Examination procedures required to make an endodontic diagnosis (8)
Medical/dental history Past/recent treatment, drugs
Chief complaint (if any)
How long, symptoms, duration of pain, location, onset, stimuli, relief,
referred, medications
Clinical exam
Facial symmetry, sinus tract, soft tissue, periodontal status (probing,
mobility), caries, restorations (defective, newly placed?)
Clinical testing:
pulp tests Cold, electric pulp test, heat
periapical tests Percussion, palpation, Tooth Slooth (biting)
Radiographic analysis New periapicals (at least 2), bitewing, cone beam-computed tomography
Additional tests Transillumination, selective anesthesia, test cavity
istorically, there have been a variety of diagnostic classication systems advocated for determining endodontic disease (1).
Unfortunately, the majority of them have been based upon histopathological ndings rather than clinical ndings, often
leading to confusion, misleading terminology, and incorrect diagnoses (2). A key purpose of establishing a proper pulpal
and periapical diagnosis is to determine what clinical treatment is needed (3, 4). For example, if an incorrect assessment is
made, then improper management may result. This could include performing endodontic treatment when it is not needed
or providing no treatment or some other therapy when root canal treatment is truly indicated. Another important purpose
of establishing a universal classication system is to allow for communication between educators, clinicians, students and
researchers. A simple and practical system which uses terms related to clinical ndings is essential and will help clinicians
understand the progressive nature of pulpal and periapical disease, directing them to the most appropriate treatment
approach for each condition.
In 2008, the American Association of Endodontists held a consensus conference to standardize diagnostic terms used
in endodontics (1). The goals were to propose universal recommendations regarding endodontic diagnoses; develop a
standardized denition of key diagnostic terms that will be generally accepted by endodontists, educators, test construction
experts, third parties, generalists and other specialists, and students; resolve concerns about testing and interpretation of
results; and determine the radiographic criteria, objective test results, and clinical criteria needed to validate the diagnostic
terms established at the conference. Both the AAE and the American Board of Endodontics have accepted these terms and
recommend their usage across all dental disciplines and health care professions (5, 6, 7). Each of the following diagnostic
terms will be dened with typical respective clinical and radiographic characteristics along with representative case
examples when appropriate. However, clinicians must recognize that diseases of the pulp and periapical tissues are dynamic
and progressive and as such, signs and symptoms will vary depending on the stage of the disease and the patient status.
Coupled with this are the limitations associated with current pulp testing modalities as well as clinical and radiographic
examination techniques. In order to render proper treatment, a complete endodontic diagnosis must include both a pulpal
and a periapical diagnosis for each tooth evaluated.
Examination and Diagnostic Procedures
Endodontic diagnosis is similar to a jigsaw puzzle—diagnosis cannot be made from a single isolated piece of information
(4). The clinician must systematically gather all of the necessary information to make a “probable” diagnosis. When taking
the medical and dental history, the clinician should already be formulating in his or her mind a preliminary but logical
diagnosis, especially if there is a chief complaint. The clinical and radiographic examinations in combination with a thorough
periodontal evaluation and clinical testing (pulp and periapical tests) are then used to conrm the preliminary diagnosis
(4). In some cases, the clinical and radiographic examinations are inconclusive or give conicting results and as a result,
denitive pulp and periapical diagnoses cannot be made. It is also important to recognize that treatment should not be
rendered without a diagnosis and in these situations, the patient may have to wait and be reassessed at a later date or be
referred to an endodontist.
Diagnostic Terminology
Approved by the American
Association of Endodontists and the
American Board of Endodontics (5-7)
Pulpal Diagnoses (9-14)
Normal Pulp is a clinical diagnostic category
in which the pulp is symptom-free and
normally responsive to pulp testing. Although
the pulp may not be histologically normal, a
“clinically” normal pulp results in a mild or
transient response to thermal cold testing,
lasting no more than one to two seconds after
the stimulus is removed. One cannot arrive at
a probable diagnosis without comparing the tooth in question with adjacent and contralateral teeth. It is best to test the
adjacent teeth and contralateral teeth rst so that the patient is familiar with the experience of a normal response to cold.