Diagnosis of Pulpal Diseases

and Periapical Diseases 

Gao Yan
Guanghua School of Stomatology
Sun yet-sen University
 Pulpal and periapical disease
 Normal conditions
A normal tooth is (a) asymptomatic and
exhibits a (b) mild to moderate transient
response to thermal and electric pulpal stimuli;
and (c) the response subsides almost
immediately when such stimuli are removed.
(d) The tooth and its attachment apparatus do
not cause a painful response when percussed
and palpated.
What is pulpal, or periapical disease?
The disorders involved in pulp, or
periapical tissues
 The classifications of pulpal
disease
 Reversible pulpitis
The pulp is inflamed to the extent that thermal stimuli
cause a quick, sharp, hypersensitive response that
subsides as soon as the stimulus is removed.

Reversible pulpitis is not a disease but merely a

symptom. If the cause is removed, the pulp should
revert to an uninflamed state and the symptom should
subside. Conversely, if the cause remains, the symptom
may persist, and the inflammation may become more
widespread, and eventually, leading to an irreversible
pulpitis.

Causes: any irritant that can affect the pulp may cause
reversible pulpitis such as caries, thermal, deep
periodontal scaling and root planing.
 Distinguishing reversible pulpitis from the
irreversible:
1. A sharp painful response to thermal stimulation.
2. Spontaneous pain.

 Treatment choice:
Sedative dressing, or called temporary
restoration with sedative package, such as zinc
oxide.
 Irreversible pulpitis
An irreversible pulpitis may be acute,
subacute, or chronic, and it may be partial
and total. Clinically, acute one is
symptomatic, whereas the chronic is
asymptomatic. At this stage, the dynamic
changes in the pulp are always occurring.
 Symptomatic irreversible pulpitis
• This type of pulpitis is characterized by
spontaneous intermittent or continuous
paroxysms of pain.
• The pain may be caused by sudden temperature
changes, which is prolonged.
• The pain caused by cold stimulation can be
relieved by heat, and similarly, the pain caused by
heat can be relieved by cold.
• There may even be a painful response
to both cold and heat stimulation too.
• The pain also can be caused by a
change in posture.
• The pain may be localized or referred
(e.g. referred from mandibular molars
toward the ear or up to the temporal area.)
• In the advanced stage, a slight thickening
in the periodontal ligament may be
presented through a radiography.
A symptomatic irreversible pulpitis
can be diagnosed by a thorough
dental history, visual examination,
thermal tests and radiography.
 Asymptomatic irreversible pulpitis
This type of irreversible pulpitis is
asymptomatic because the inflammatory
exudate are quickly vented.
It can develop by the conversion of a
symptomatic one into a quiescent state.
It also can caused by long and low-grade pulp
irritant (carious lesions), traumatic injury.
 There are three types of asymptomatic
pulpitis
1. Hyperplastic pulpitis
Clinically, it is a reddish cauliflower-like overgrowth
of pulp tissue through and around a carious
exposure. It is characteristically found in young
people since the generous vascularity of the pulp.
2. Internal resorption
It is a resorption of the dentine from the pulp
outward, which is often caused by trauma or pulp
capping. It is usually can be diagnosed by
radiography.
3. Canal calcification
A large amounts of reparative dentine over deposit
Throughout the canal system, which is caused by
periodontal therapy, abrasion, trauma etc.
 Necrosis
1. Death of pulp, may result form an untreated
irreversible pulpitis or may occur immediately
after a traumatic injury that disrupts the blood
supply to the pulp.
2. Necrosis may be partial or total, and the partial
may exhibit some of the symptoms of an
irreversible pulpitis.
3. Occasionally with anterior teeth the crown will
darken.
 Classification of periapical disease
 Acute apical periodontitis
• It describes inflammation around the apex.
• The tooth with it may exquisitely tender to
percussion.
• The tooth may be carious
• Radiographically the apical periodontal ligament
may appear slightly widened or normal.
Causes:
• Extension of pulpal disease into the periapical
tissue.
• Endodontic procedures such as canal filling
beyond
the apical foramen.
• Occlusal trauma from a high restoration or from
chronic bruxism.
 Acute apical abscess
• It implies a painful, purulent exudate around
the apex.
• Rapid onset of slight to severe swelling, pain,
and pain to percussion, and possible mobility.
• The distinguishing acute apical abscess from
the lateral periodontal abscess and from the
phoenix abscess
For periodontal abscess
Thermal and electric pulp testing indicate
the pulp vital; there is a periodontal
pocket; the tooth may be normal.
For the phoenix abscess
All symptoms of acute apical abscess plus
apical radiolucency around the apex of
the tooth.
 Chronic apical periodontitis
1. Chronic apical periodontitis implies long-
standing asymptomatic inflammation around
the apex. Although chronic apical
periodontitis tends to be asymptomatic, there
may be occasional slight tenderness to
palpation and percussion.
2. Only biopsy and microscopy examination can
reveal whether these apical lesions are dental
granulomas, abscesses, or cysts.
3. Diagnosis is confirmed by the presence of a
radiolucency that may be either diffuse or
well-circumscribed, the absence of pulp
vitality, and a sinus tract.
 Phoenix abscess
A phoenix abscess is a chronic apical
periodontitis that suddenly becomes
symptomatic
The symptoms are identical to those of an
acute apical abscess, the man difference
being that the phoenix abscess is
preceded by a chronic condition
 Periapical osteosclerosis
Periapical osteosclerosis is excessive bone
mineralization around the apex caused by
low-grade, relatively asymptomatic,
chronic pulpal inflammation
which is most commonly found in young people
 Causes
 Although many factors can cause the
endodontitis which further develop into apical
periodontitis, the bacteria are the most
common one.
 The factors include:
1. Bacteria
2. Trauma
3. Thermal
4. Static electricity
5. Laser
6. Filling materials
7. Etch or adhesive agents
8. Drugs for toilet the cavity
9. Immunological aspect
 Treatment planing
Once the tooth has been confirmed as
irreversible pulpitis or any of apical diseases,
the endodontic treatment must be done.
Before you decide to do the endodontic
treatment you need to consider follows:
1. Physical evaluation
it mainly concerned about systemic conditions
(diseases) such as cardiovascular diseases,
bleeding disorders, diabetes, cancer, AIDS,
pregnancy, allergies, steroid therapy, infectious
diseases etc.

2. Psychological evaluation
A patient who shows no incentive (motivation)
to maintain good oral hygiene or one who
constantly misses appointments may not be a
good candidate for endodontic therapy.
3. Evaluation of tooth
 Morphology
• Unusual length
• Unusual shapes
• Unusual numbers (canal or roots)
• Resorptions
• Calcifications
 Previous treatment
• Canal blockage
• Ledge
• perforations
 Location of tooth
• Accessibility
• Proximity to other structures
• Restorability
• Periodontal status
Canal shape: an open apex requires apical losure
techniques before obturation
Proximity to other structures
mental foramen
Maxillary sinus
 Restorability
decay into the furcation may render a tooth untreatable.
4. Treatment planning
general process and sequence:
• Management of acute pulp or periodontal pain.
• Oral surgery for extraction of unsalvageable
teeth.
• Caries control of deep lesions that may
threaten the pulp.
• Periodontal procedures to manage soft tissue.
• Endodontic procedures for asymptomatic teeth
with necrotic pulps and surgical treatment or
re-treatment of failing root canals.
• Restorative and prosthetic procedures.
One-appointment root canal therapy
 What do we know now?
 What is pulpitis or apical periodontitis?
 What are the symptoms for these two
diseases?
 The significance of clinical classifications?
 What need to be considered when you are
about doing endodontic treatment?