Endodontics

American Association of Endodontists

Differential diagnosis of pulp conditions

Samuel Seltzer, D.D.S., I. B. Bender, D.D.X.,** Harold Nazimov, D.D.S., Philadelphia, Pa.
UKIVERSITY OF PENNSYLVANIA SCHOOL OF DENTISTRY

and

ur recent studies of the dynamics of pulp inflammation have brought into sharp focus the difficulties encountered by the general practitioner in attempting to evaluate the histologic status of the pulp on the basis of clinical data. Other endodontists have had similar difficulties in attempting to fit clinical findings into the framework of pre-existing classifications of pulp disease. Revisions of previous classifications and nomenclature are obviously in order and are being made. 2-4 We are critical, however, of any suggested changes in classification which again utilize histologic diagnostic terms that are meaningless to the practitioner in terms of treatment. Rather, a clinical classification based on subjective symptoms, past dental history, and objective findings should be adopted. Such a classification should permit the general practitioner to place involved teeth into one of two categories-treatable or nontreatable. The term treatable refers to treatment of the dental pulp with a view toward its conservation. Nontreatable teeth are those whose pulps would require endodontic treatment or extraction. On the basis of our previous and current studies, a probable correlation of clinical signs, symptoms, and test results with histologic diagnosis has been evolved (Tables I and II), Teeth with pulps in the categories designated as intact-uninflamed pulp, transitional sta.ge, atrophic pulp, acute pul-

This study was supported by Grants D-946 and DE-01930 from the National Institute of Dental Research, National Institutes of Health, United States Public Health Service, Bethesda, Md. *Associate Professor of Oral Pathology and Oral Histology. *Associate Professor of Oral Medicine. 383 ***Research Associate.

Table

I. Probable correlation diagnosis

OF clinical signs and symptoms wit It histologi(*

Severity Pain
dence

inciAbsent 87 89 75 i5 58

il4ild to
mod-

Previous history of pain Present No so

pi0

Category i-\. Treatable t erth

aisto1ogic diagnosis intact uninflamed pulp Transitional stage Atrophic pulp Acute pulpitis Chronic partial pulpitis without necrosis Chronic partial pulpitis with partial necrosis Chronic total pulpitis Total pulp necrosis are expressed its per

Pwsent 13 11 25 25 42

erate 13 11 20 25 37

Severe 0 0 0 0 5

Absmt Yes Yes Yes Yes so

Pain on percussioz.c PresAbsent ent 4 5 8 0 17 9G 93 92 100 x3

/ Pulp

cxIjo. szcre ; prw 1 ent 0 1I !I 0 21

so 1-w

1% Nontreatable teeth

6-L 78 54 rent.

36 22 46

21 60 29

43 18 25

Yes Yes Yes

No so so

43 36 38

57 64 62

79 78 71

Sumhers

Table

II. Probable correlation of clinical tests with histologic diagnosis

Thermal Response to / tests to No ~spzi? Response Heat 1

I
Above Category A Treatable teeth

cold

Pulp Beloa

tests

aist010gic diagnosis Intact uninflamed pulp Transitional stage Atrophic pulp Acute pulpitis Chronic partial pulpitis without necrosis Chronic partial pulpitis with partial necrosis Chronic, total pulpitis Total pulp necrosis

i
11 31 21 22 13 21 Sot, 62 50 57 test~ed 1 50 27 50 xi 9

27

n.

Nontreatable teeth

20 40 22 cent.

20 6 0

40 19 6

20 35 72

33 21 11

33 21 11

25 25 11

25 20 6

25 50 78

Numbers

are

expressed

as per

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pitis, and chronic partial pulpitis without necrosis have a reasonable chance for resolution with conservative treatment (t.reatable). Teeth whose pulps arc in the remaining states-chronic partial pulpitis with partial necrosis, chronic total pulpitis, and total pulp necrosis-require endodontic treatment or extraction (nontreatable). We hold this view despite recent reports that painful pulpitis may be successfully treated with glucocorticoids and antibiotics.5-7 The evidence presented in such reports is suggest.ive but not conclusive. Until further documentation is available, the probability of the reversal of chronic pulpitides, especially those in which liquefaction necrosis has occurred, remains doubtful. Information that can be utilized to help make a judgment as to whether treatment. of the dental pulp is likely to be successful or whether endodontic treatment or extraction is indicat.ed includes the following : intensity, duration, and previous history of odontalgia; presence of dental caries with or without pulp exposure, restorations, swelling, and/or periodontal disease; roentgenographic findings ; results of thermal, percussion, palpation, anesthetic, and electric pulp tests; test drilling; and regions of referred pain.
SUBJECTIVE FINDINGS Intensity and duration

of odontalgia

The intensity and duration of a toothache give a significant clue. If the odontalgia is absent or mild, the pulp of the tooth is likely to be in any one of the following conditions, designated as Category A (treatable). 1. Intact uninflamed pulp 2. Atrophic pulp 3. Transitional stage 4. Acute pulpitis 5. Chronic partial pulpitis (without necrosis) A. Hyperplastic pulpitis 6. Necrosis of pulp Except in casesof hyperplastic pulpitis and necrosis of the pulp, treatment along conservative lines, directed toward pulp conservation, is indicated. Hyperplastic pulpitis may be treated by pulpotomy when the root ends are incompletely formed. Otherwise, endodontic treatment or extraction is indicated. Where the odonta,lgia is moderate to severe, the dental pulp is probably in one of the states designated as Category B (nontreatable) : 1. Chronic partial pulpitis with partial necrosis 2. Chronic total pulpitis with partial necrosis 3. Total necrosis of pulp 4. Acute exacerbation of chronic pulpitis Teeth with pulps in any of these st.ates require endodontic treatment or extraction.
Previous history of odontalgia

A prior history of toothache is significant in terms of diagnosis. If there has been no previous history of pain, the chances arc good that the pulp of

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t,he tooth will be in one of the: c*onditions listed in Latcgory \! \vith t hc exception of necrosis of the pulp and hyperplast~ic pulpitis. Conrcvsely, il. Iiistur>, of previous pain is good evidence that the pulp is severely inflamctd or ncerotic ( Category B) .
OBJECTIVE FINDINGS

The following objcctivc findings are significant aids in pulp diagnosis,

Dental caries

The depth of the cavit,y, plus the presence or absence of pain, is important. A tooth with a deep cavity but without painful sympt,oms probably has a pulp in one of the conditions listed under Category A. Conversely, teeth with deep dental caries associated with pain generally have pulps in one of the stages listed under Category B. Therapy is affected by the categorization. Teeth in Category A may be successfully t.reated with sedative dressings or indirect or direct pulp cappings. There is greater assurance of successful resolution than for t,eeth in Category B, except where the pulp is necrotic. The presence of necrosis must be determined by other tests. In teeth with necrotic pulps, cndodontic treatment or extraction is recommended.
Extensive restorations

The presence of cxtcnsivc restorations in teeth is an important diagnostic finding. Pain in a tooth with a large restoration is good evidence that the pulp is in Category B. Teeth with extensive restorations are prime suspects if the patient has odontalgia but is unable to point to the exact tooth. In the absence of pain, the category may be A-l , 2, 3, or 5 (intact-uninflamed or atrophic pulp, transitional stage, or chronic partial pulpitis without necrosis).
Pulp exposure

A carious pulp exposure automatically places the pulp of the tooth in one of the stages listed under Category B. Mechanical or traumatic pulp exposures are probably in Category A-4 (acute pulpitis). Treatment of the former must bc endodontic or exodontic. More conservative treatment can be considered for the teeth with mechanical exposures.
Swelling

Swelling of the pulp tissue itself is an indication of hyperplastic pulpitis (Category A). Swelling of t.hc mucosa in the mucobuccal fold over the apical region of the tooth is invariably associated with a pulp in Category B (either chronic total pulpitis with necrosis or total necrosis). Some amount of liquefaction necrosis is usually present. Treat,ment must be designed for evacuation of the pus.
Fistula

The presence of a fistula. indicates that the pulp of t.he tooth has undergone partial or total necrosis (Category B). Endodontic t,reatment or extraction

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is indicated. Occasionally the origin of the fistula is doubtful, in which case the use of a 0.01 inch stainless steel orthodonbic wire is helpful in determining which tooth is responsible. This wire is inserted into the orifice of the fistula and twisted until it penetrates to the base of the bone. A roentgenogram is then taken. The mire frequently goes directly to the offending tootll.8
Periodontal disease

The presence of periodontal disease in a tooth that is free of pain or shows sensitivity to thermal changes points the way to a pulp diagnosis compatible with Category A-2 (atrophic pulp) .9 Where pain is present, however, the chances for the presence of more advanced pulp disease increase. The category is then B. In the latter case, combined endodontic and periodontal treatment or extraction is indicated.
OTHER DIAGNOSTIC AIDS

Other diagnostic aids are available to help the practitioner make a diagnosis. Among these are roentgenograms, electric pulp tests, thermal tests, percussion tests, test drilling, palpation, and the use of local anesthesia.
Roentgenograms

Roentgenograms are valuable as an aid in visualizing the presence or absence of the following : A. Deep-seated caries 1. With possible pulp involvcmcnt 2. With definite pulp involvement B. l)eep restorations 1. With liners 2. Without liners C. Root fractures D. Resorptions 1. Internal 2. External E. Width of canal and pulp chamber F. Calcifications and reparative dentine within pulp and/or root canal Roentgenograms are valuable as an aid in visualizing the depth of a carious lesion. Carious pulp exposures are frequently detected in the roentgenogram, although it is sometimes difficult to ascertain the presence of an exposure from the roentgenologic appearance alone. When in doubt, the operator should be guided by his other findings as well as an exploratory excavation of the lesion. Where there arc deep rcstorat.ions, the rocntgenogram is often helpful in det,ermining t,he presence or absence of liners or sub-bases under the restorations. When I~IV.YS arc absent, there is reasonable suspicion of pulp involvement in those teeth. If pain is present, t,he lmlps of these teeth arc probably in one of the conditions listctl undt~r Catclgory B, hence, cndodontic treatment or cxtract ion is indicated. The presence of root fractures can frequently be determined only from

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0,s.. ().;\I. s, 0.1. SI:rwh. 1clcirt

the roentgenogram. Therapy depends upon i IIV loratioll 01 the facet ~IW. the time of occurrence, the presence or absence of symptoms, 21 t.1~ results oi ud other tests. Generally, these tests are aimed at determining the> \-itality of th(s pulp. A fracture in the vicinity of the apical third of the root, without, pain and with continued pulp vitality, points to the probnbi1it.y that the: pulp bcxlongs in Category A. Observation is then the course ot choice. \Vhc~~c pulp vitality is absent, fractures in the apical third may bc treated by cndodont,ic thcrapy and root resection. The presence of extensive resorpt.ions, detected by roentgenograms, usually is indicative of severe pulp involvement. It is frequently difficult to determine whether the resorpbion is internal or external in origin. In either case, the pulp is in Category B, being either chronically inflamed or necrotic. Attempts at. preserving the pulp in such circumstances is contraindicated.
idiopathic (internal) resorption

Occasionally, a pink spot develops in a tooth. In this condition, granulation tissue is formed within the pulp. The exact cause is unknown, but the condition ma.y be due to trauma or to an unresolved pre-existing chronic pulpitis. Some of the cells of the chronically inflamed pulp begin to resorb tho dentinal wall of the pulp chamber or root canal. The conversion of undifferentiated reserve connective tissue cells of the pulp to odontoclasts has been demonstrated by Toto and R&arski. lo These cells arc occasionally seen in Howships lacunae present at the resorbing dent.inal wall. Possibly, the resorption occurs from outside the tooth and eventually invades the pulp chamber. A sharply outlined defect is seen in the roentgenogram. Clinically, the crown of the toot.h looks pinkish because of the presence of granulation tissue with its numerous capillaries together with the loss of dentinc. Resorptions of t,hc root portion of the tooth, both internal and external, may also occur. The cause is sometimes obscure, but both chronic total pulpitis and periodontal disease are frequently implicated. Treatment of resorptions is difficult. Endodontic treatment, must bc performed as an alternative to extraction, but the outcome is always questionable. Somctimes the resorption ceases; at other times it continues despite removal of t,he pulp, pointing to the possibility that the resorption was oxtc~rnal in origin. The width of the pulp chamber or root canal, as seen in a roentgenogram, affords significant information concerning the pulp status. Excessively narrowed or widened pulp spaces, when compared to adjacent t&h, are the result of periodontal disease, previous trauma in the t.ooth, or prior pulp capping or pulpotomy procedures, especially where calcium hydroxide has been used. Atrophied pulps sre usually the end result. Vnusually wide pulp spac,esarc indicative of previously severe pulp damage with resultant necrosis of the pulp. This condition is sometimes found following severe trauma, such as a blow on a tooth, or following excessive orthodontic tooth movement. Calcifications within the pulp chamber or root canals haye no special significance, except that they increase in the presence of periodontal disease and following extensive operative procedures. Perhaps of greater significance is an

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excessive amount of reparative dentine formation in the coronal pulp chamber. This is usually a sequel to severe pulp damage from previous operative procedures. Pain in such teeth is an indication that the pulp is in one of the states listed under Category B.
Thermal tests

In normal responsesto heat and cold tests the patient feels pain when the irritant is applied to the tooth, but the pain disappears as soon as the stimulus is removed. Such responsesare usually indicative of uninvolved pulps. Abnormal responses are those in which pain persists after the stimulus is removed from the tooth. Such abnormal responses are usually indicative of pulps in Category B. Lack of response to the thermal tests occurs when the pulps are necrotic. The diagnosis of necrosis of the pulp is more secure when there are also no reactions to the electric pulp tester.
Electric pulp tests

The electric pulp tester is a crude device, and not too much reliance can be placed upon it. There is usually a lack of reaction to the electric pulp tester when the pulp is necrotic, although this test is not infallible. When a tooth fails to respond to both electric pulp tests and thermal tests, a diagnosis of necrosis of the pulp is fairly reliable. The pulp tester may be of limited value in pointing to the possibility of pulp involvement when the reactions of the tooth in question differ from those of a control tooth. Not too much reliance should be placed on this test alone, however. It must be evaluated together with all the other accumulated diagnost,ic data.
Percussion test

A positive percussion test response is a fairly reliable indication of the presence of periapical tissue involvement (Category B). The converse is not completely true, however; lack of a positive response to the percussion test does not give assurance that inflammation has not extended into the periapical tissues.
Palpation test

Soreness of the mucosa over the root of a tooth is a reliable indication of inflammation of the periodontal ligament. The inflammation may be of pulpal origin, but it may also be the result of traumatic occlusion. If it is pulpal in origin, endodontic treatment or extraction is indicated.
Test drilling

When teeth are covered with full crowns, test drilling is frequently of help in determining pulp vitality. A sensation of pain when the dentine is pierced is an indication of the presence of a Gtal pulp. Ilowcver, this does not imply that no inflammation is present.
Anesthetic test and referred pain

The use of a local anesthetic is a significant aid in diagnosis, especially where the pain is not localized or where the teeth are crowned. In the latter instance,

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OS., O.&L & 0.1. Ma.rch. 1966

The region to which the pail1 is rcferrcd may bc used as a. guitlo in locating the offending tooth. Each tooth usua,lly has a separate area of pain references, although this is not absolute. Knowledge of these sites is a valuable guide for determining the probable origins of the pain. According to Head,ll the focal points to which pain from the teeth may be referred are as follows: The upper central and lateral incisors refer pain to the frontal region. The upper cuspids and first premolar refer pain to tho nasolabial region. The ripper second premolar refers pain to the temporal and maxilla.ry regions. The upper first molar refers pain to the mental region. The lower second premolar refers pain to the hyoid or mental region. The lowc~* first and second molars refer pain to the ear and behind the angle of the jaw. The lower third molar refers pain to the superior laryngeal region and to t.he car. Our current studies indica.te that such a direct correlation does not always exist, however. Local anesthesia must then be employed as an aid in diagnosis. The patient should be given a mandibular block injection. If pain persists after the symptoms of anesthesia appear, the offending tooth is most likely in the upper jaw. If the pain disappears with the onset of symptoms of anesthesia, the offending tooth is located in the mandible. From the regions of referred pain, the location of the offending tooth can then be directed to one or two teeth. The offending tooth is usually the one with the deepest restoration. 1C doubt still exists, it is preferable to wait, until the pain begins to localize, if it is cndurablc. It is noteworthy that pulpitis rarely occurs simultaneously in more than one tooth, even though several teeth may become consecutively involved. Also, pain is never referred to the other side of the same jaw, although it, may lx referred from maxilla t.o mandible (or vice versa) on the same side. Referred pain to the teeth ma?; also be due to coronary insufficienq(angina pectoris a.nd myocardial infarction). The pain is usually referred to an entire jaw, but it may be more intcnsc in carious or restored teet,h. This possibility should be considered in making a differential diagnosis. In sinusitis, pain may bc localized around the apices of the upper premolars and molars. The teet.h may be tender to percussion, but they usually arc not overly sensitive to thermal changes. Pain usually increases when the head is lowered or upon jumping. Table III shows the relationships of subjective symptoms and objective findings to probable treatment categorization. All clinical tests are diagnostic aids, but no single one of them can be conclusively or exclusively used for a definite diagnosis. A summary of all the symptoms, clinical findings, and test results must be tempered with the judgment of the operator before a final diagnosis can be made. In spite of all efforts, the final diagnosis might still be clouded in doubt. Under those circum-

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Table III. Subjective and objective findings correlated with type of treatment probably indicated
Cutegory (Treatable) Pain incidence Pain intensitv Pain duration Previous history Dental caries Extensive restoration A Category (Nontreatable) B

of

pain

Pulp exposure Swelling Fistula Periodontal disease Fracture Extensive resorption Response to heat and cold Response to electric pulp tester Percussion test Palpation test Referred pain Roentgenographic area of rarefaction Tooth color

Absent or infrequent Absent or mild to moderate Short (minutes) Absent Shallow to moderate Deep (without pain) Absent Present (without pain) Absent Absent Absent Absent or present (without pain) Without both pain and mobility Absent Normal Similar to control Absent Absent Absent Absent Normal

Frequent Moderate to severe Long (hours to day) Present Deep (with pain) Present Present Present Present Present Present ity Present Abnormal Different Present Present Present Present Abnormal (with pain)

(with with

pain) pain and mobil-

from

control

stances, watchful waiting is preferable to a misdiagnosis and may be necessary before the diagnosis can be clarified.
We wish to thank Walter Soltanoff, and versity of Pennsylvania
REFERENCES

Drs. Robert Ellison, Louis Glatt, Richard Moodnik, David Snyder, Murray Ziontz, members of an endodontic research group at the UniSchool of Dental Medicine, for their participation in this project.

1. Seltzer, S., Bender, I. B., and Ziontz, M.: The Dynamics of Pulp Inflammation: Correlation Between Diagnostic Data and Actual Histologic Findings in the Pulp, ORAL SURG., ORAL MED. & ORAL PATH. 16: 846, 969, 1963. 2. Mitchell, D. F., and Tarplee, R. E.: Painful Pulpitis, ORAL ST-RG., ORAL MED. & ORAL PATH. 13: 1360, 1960. 3. Mitchell, D. F.: Differential Diagnosis of Odontalgia. In: Healy, H. J. (Editor) : Endodontics, St. Louis, 1960, The C. V. Mosby Company. 4. Ingle, J. I.: A Suggested Nomenclature for Pulpal and Periapical Pathosis, J. Seattle Dist. D. Sot. 1: 11, 1963. 5. Fry, A. E., Watkins, R. F., and Phatak, N. M.: Topical Use of Corticosteroids for the Relief of Pain Sensitivity of Dentine and Pulp, ORAL SURG., ORAL MED. & ORAL PATH. 13: 594, 1960. 6. Schroeder, A., and Triadan, H.: The Pharmacotherapy of Pulpitis, ORAL SIJRG., ORAL MED. &ORAL PATH. 15: 345.1962. 7. Lawson, B. G., and Mitchell, D. F.: Pharmacologic Treatment of Painful Pulpitis; a Preliminary, ControIled Double-Blind Study, _ ORAL SURG., ORAL MED. & ORAL PATH. 17: 47, 1960. - 8. Bender, I. B., and Seltzer, S.: The Oral Fistula: Its Prognosis and Treatment, ORAL SURG., ORAL MED. & ORAL PATH. 14: 1367,1961. 9. Seltzer, S., Bender, I. B., and Ziontz, M.: The Interrelationship of Pulp and Periodontal Disease, ORAL SURG., ORAL MED. & ORAL PATH. 16: 1474, 1963. 10. Toto, P. D., and Restarski, J. S.: The Histogensis of Pulpal Odontoclasts, ORAL SURG., ORAL MED. & ORAL PATH. 16: 172, 1963. Anatomy of the Head and Neck, ed. 2, 11. Head, H.: Illustration in Shapiro, H. H.: Applied Philadelphia, 1947, J. B. Lippincott Company.