Diagnosis of Pulpal and Periapical Diseases

Sumamry
This lesson will guide you through pulpal and periapical diagnosis, and simplify the sequelae of
pulpitis.

Overview

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It is extremely important to achieve the correct diagnosis before moving on to treatment
The wrong diagnosis will lead to the wrong treatment
If there are any uncertainties, it may be worth referring to a specialist to help establish the

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diagnosis or if the case is too complex and outside your capability

Normal pulp
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Symptom-free
Tooth will respond positively to sensitivity testing
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Normal periapical tissues

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Tooth is symptom free

There is no tenderness to palpation or percussion
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Intact PDL
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Key words:¹

Acute Having a short course of severe symptoms

Persisting for a long time
Chronic
It is possible to have acute episodes of chronic conditions
Apical, periapical and Relating to the apex or tip of the root of the tooth
periradicular Used interchangeably
A well-developed capsule attached to the root apex
Granuloma
Contains chronic inflammatory cells surrounded by collagenous fibres
Epithelial lined cavity filled with fluid
Periapical cyst Bay cysts are attached to the root surface
True cysts are not attached to the root surface

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Pulpal Diseases
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Reversible pulpitis
Mild or transient pulpal inflammation
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Cause:
Caries
Exposed dentine
Recent dental treatment
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Defective restoration
Symptoms:
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Patients complain of a short sharp pain

Initiated by cold and hot stimulus
Radiographically:
Periapical tissues appear normal
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The removal of caries or leaking restorations will usually relieve the symptoms
Irreversible pulpitis
The pulp is more severely affected and the inflammation is irreversible
Causes:
Caries
Deep restorations
Pulp exposure
Any other direct or indirect insult to the pulp
Symptomatic:
Intermittent or spontaneous pain
Initiated by hot or cold stimulus and prolonged episodes for minutes to hours
Pain may be aching or dull, localised, diffuse or referred (irreversible pulpitis pain
is nearly always aching or throbbing in nature, pain associated with dentine
 exposure is sharp)
If untreated, will become necrotic
Asymptomatic:
Occasionally occurs when deep caries has not produced any symptoms
40% of irreversible pulpitis cases are asymptomatic
If untreated, the tooth will become symptomatic or become necrotic
Radiographically:
Periapical tissues may appear normal
Slightly widened PDL may be evident
Root canal treatment or extraction is required
Pulpal necrosis
Can be partial or complete
Causes:

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Following from symptomatic or asymptomatic irreversible pulpitis
Caused by a loss of blood or inadequate blood supply
Symptoms:
The tooth may become sensitive to heat with partial pulpal necrosis

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Symptoms may result from the inflammatory reaction in the periapical tissues
Radiographically
The periapical tissues appear normal until they become infected and the
periodontium is involvedta
Root canal treatment or extraction is required
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Apical (Periapical) Diseases

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Acute Apical Periodontitis (symptomatic)

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Signs and symptoms:

Exquisitely tender to touch, biting or percussion
Radiographically
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There may be slight widening of the PDL

Chronic Apical Periodontitis (asymptomatic)
There may not be any symptoms
The patient may also report that the tooth 'feels different' or is slightly TTP
Radiographically
There may be a widening of the PDL
A periapical radiolucency may be present
'Phoenix' abscess: acute exacerbation of chronic apical periodontitis
Acute Apical Abscess
Signs and symptoms
Intense throbbing pain
Very TTP and associated soft tissues tender to palpation
Tooth may be mobile
An intraoral or extraoral swelling may be visible
 In severe cases, there may be lymphadenopathy and malaise
Radiographically
There will be widening of the PDL
There may or may not be a periapical radiolucency on a radiograph
Chronic Apical Abscess
There may not be any symptoms
The patient may also report that the tooth 'feels different' on TTP but not sensitive
Radiographically
A periapical radiolucency is present
Usually associated with a draining sinus tract

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An image to demonstrate a pulpal disease versus a periapical disease
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Spread of infection

If the pulpal and periapical diseases are left untreated, the infection can spread into the soft tissues,
blood or bone which can cause conditions which can be fatal.

Osteomyelitis
 Painful bone infection
Types:
Suppurative osteomyelitis
Non-suppurative osteomyelitis
Signs and symptoms
Tenderness, swelling around the affected bone
Fever, fatigue

Purulent Sinusitis

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Spread of infection from a maxillary tooth
Signs and symptoms
Nasal congestion
Purulent rhinorrhea

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Postnasal drip
Facial pain and pressure
Referred pain to the ears and teeth
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Cellulitis
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Orbital cellulitis can occur from the spread of infection from a maxillary tooth
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Signs and symptoms:

Protruding eye
Pain, redness and swelling
Inability to open the eye
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Vision loss, or impaired vision

Ludwig's angina is a severe form of cellulitis. The origin can be a mandibular tooth infection
Signs and symptoms:
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Pain in the floor of the mouth

Difficulty swallowing
Speech difficulties
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Swelling, redness and pain in the neck

Cavernous sinus thrombosis

The formation of a blood clot in the cavernous sinus due to the spread of infection from the
head
The blood clot prevents the infection from spreading further but causes restriction of blood
flow to the brain
Signs and symptoms:
Sharp pain
High temperature
 Feeling confused
Vomiting
Swelling, redness and pain in the eyes
Vision problems

Mediastinitis

An infection affecting the mediastinum

Signs and symptoms:
Fever, rigor

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Shortness of breath and chest pain
Swollen neck
Confusion

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Parapharyngeal abscess
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Deep neck abscess
Signs and symptoms:
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Fever
Sore throat
Painful swallowing
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Swelling in the neck

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Flow diagram to show the sequelae of pulpal disease

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Orofacial pain

If after all of the testing procedures have been carried out and it has been decided that the pain is
not of odontogenic origin, the patient should be referred to an orofacial pain clinic for further
testing.

Differential diagnosis of orofacial pain (coming soon in the oral medicine section)

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Neurologic e.g. trigeminal neuralgia
An unusual local cause e.g. osteomyelitis
Referred from a distant origin e.g. cardiac
Psychogenic in origin e.g. atypical persistent facial pain
Sinusitis

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Facial pain:
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Facial pain can have very similar symptoms to pulpal conditions and therefore can cause some
confusion
Symptoms:
Throbbing, nagging, achy pain
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Doesn't tend to follow any anatomical boundaries

May be a disturbance in sleep pattern
Analgesics only 'take the edge off' the pain
Other chronic pain conditions may be present e.g. headache, lower pack or abdominal
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pain
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Maxillary sinus
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Due to the close proximity of the sinus to the teeth in the maxillary arch, this can also cause
confusion
Symptoms:
Acute sinusitis rarely occurs without preceding symptoms of a cold
TTP of the whole quadrant of teeth is a usual sign
Be aware that periradicular infection of premolar or molar teeth can lead to purulent
discharge into the sinus with associated pain

Conclusion
The tooth demonstrates different symptoms depending on the extent of pulpal inflammation,
necrosis and infection. If pulpal or periapical infections remain untreated, there is a chance they can
develop into something more fatal. Patients may have symptoms which are closely related to the
symptoms of a pulpal condition but instead are due to other conditions e.g. Facial pain and sinusitis

Third Party Links

References
¹Farlex, Medical Dictionary. The Free Dictionary Accessed May 1st, 2020. Hargreaves KM, Berman

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LH. Cohen's pathways of the pulp expert consult. Elsevier Health Sciences; 2015 Oct 2. link San
Chong B. Harty's Endodontics in Clinical Practice E-Book. Elsevier Health Sciences; 2016 Jul 28. link
Tronstad L. Clinical endodontics: a textbook. Stuttgart; New York: Thieme,; 2009. link National
Health Service. Health A to Z. nhs.uk Health A to Z; Accessed May 2020

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