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Endodontic diagnosis and treatment planning lecture
Dental History Interview
What Indicate A Difficult Diagnosis?
Diagnosis And Treatment Plan
There are limited numbers of possible diagnosis for
pulpal and periapical conditions, that includes:
• Reversible pulpitis
• Irreversible pulpitis (symptomatic/ asymptomatic)
• Symptomatic apical periodontitis
• Asymptomatic apical periodontitis
• Acute apical abscess
• Chronic apical abscess
• Condensing osteitis
These will be discussed at the end of the article.
This is the first information that volunteered by the pa-
tient and should be recorded in the exact formula. It
can help in both diagnosis and treatment plan because
these comments are direct and non-biased.
Investigate past dental history for recent trauma, re-
cent restoration or periodontal treatment, and previous
treatment for TMJ dysfunction.
DENTAL HISTORY INTERVIEW
The dentist should interview (ask) the patient about the
symptoms he has to get the full idea of ‘what’ is hap-
pening and ‘why’ it is happening.
Patient may complain from:
• Sinus tract
• Broken tooth
• Loose tooth
• Tooth discoloration
• Bad taste
endodontic diagnosis and
Osama Asadi, B.D.S, Published for Iraqi Dental Academy Blog
The journey to definitive treatment begin with accurate diagnosis. However, accurate diagnosis is not al-
ways possible, due to complexity of the symptoms and many diseases share the same signs and symptoms.
Also it established that histological condition of the pulp does not relate to the sign and symptoms.
The basic steps in diagnostic procedure are:
• Chief complaint
• History (medical and dental)
• Oral examination
• Clinical tests
• Data analysis and differential diagnosis
• Treatment plan
If patient complain of pain, ask him the following
• When did pain begin?
• Where is the pain located?
• Is the pain always in the same place?
• What is the character of the pain (short, sharp, long,
lasting, dull, throbbing, continuous, occasional)?
• Doses the pain prevent sleeping or working?
• Is the pain worse in the morning?
• Is the pain worse when you lie down?
• Did or does anything initiate the pain (trauma, bit-
• Once initiated, how long does the pain last?
• Is the pain continuous, spontaneous or intermittent?
• Does anything make the pain worse (hot, cold, bit-
ing)? Does anything make the pain better (cold, an-
Similarly, if patient is presented with swelling, take
• When did the swelling begin?
• How quickly has the swelling increased in size?
• Where is the swelling located?
• What is the nature of the swelling (soft, hard, ten-
• Is there drainage from the swelling?
• Is the swelling associated with loose or tender
WHAT INDICATE A DIFFICULT DIAGNOSIS?
The following presentations may indicate a case that
is difficult diagnositically:
• Patient can not localize the pain source
• No local dental cause for the pain can be identified
(no caries, no restoration, etc..)
• Pain is spontaneous or intermittent
• Stimulation of suspected tooth (using vitality tests)
does not produce symptoms
• More than one tooth is suspected
• Symptoms are bilateral
• Selective anesthesia fail to localize the source of
Clinician should look and analyze the patient as soon
as he enter the room. Look for general appearance, skin
tone, facial asymmetry, swelling, discoloration, red-
ness, extraoral scars, sinus tracts and lymphadenopathy.
Palpation of face and neck area is also important, to
check for swelling or tenderness. Many times these
swelling are not clear visually, and require palpation to
Palpation of cervical and submandibular lymph nodes
is important part of diagnostic procedure. If there is
swelling or feels firm and tender, with elevated tem-
perature, then these is greater chance of systemic in-
Loss of definition of nasolabial fold on one side of the
nose may be the earliest sign of canine space infec-
tion. This can result from infected maxillary canine, or
Oral tissue is dried and examination begin of the lips,
oral mucosa, cheeks, tongue, periodontium, gingiva,
palate and muscles.
Look for any sign of discoloration, inflammation, ul-
ceration, and sinus tract formation.
Sinus tract can be traced to its source using gutta-per-
cha points size #25 or #30 and inserted into the open-
ing until resistance is felt. It may cause slight discom-
fort to the patient.
Examine teeth with mirror and explorer and look for
discoloration, fracture, abrasion, attrition, erosion, car-
ies, defective restoration, or other abnormalities.
A discolored crown can be an indication of pulp pa-
Examine mobility of the tooth by placing the back end
of mirrors on both buccal and lingual surface of the
tooth, then apply pressure in bucco-lingual direction
Figure 1. Look at loss of definition of nasolabial fold at the left
side of the face
and also in vertical direction. Any movement more than
1 mm should be considered abnormal.
Increased mobility does not mean the pulp is not vital,
mobility is an indicative of the status of the periodontal
Increased mobility can occur due to trauma, occlusal
prematurities, rapid orthodontic movement, parafunc-
tional habits, periodontal diseases, root fracture or pul-
Probing is an important step in diagnosis. Teeth with
wide periodontal pocket usually are periodontal in or-
igin, while teeth with narrow localized pocket are usu-
ally endodontic in origin, or could be vertical root frac-
Furcation bone loss could be periodontal or endodontic
in origin, and should be recorded in the chart.
• Thermal tests
• Electric pulp test
• Bite test
• Test cavity
• Staining and transillumination
• Selective anesthesia
These has been discussed extensively in previous lec-
tures, however, a short overview will be presented here.
Firm digital pressure with index finger is applied to the
apical area of the tooth, and adjacent teeth.
Any soft tissue swelling, bony expansion should be
noted and recorded. Pain or tenderness during the pro-
cedure should be recorded too. This may indicate an
active periapical inflammation, however, it does not
determine whether it is endodontic or periodontal in
This test is performed when the patient complain of
pain during biting or mastication.
Pressure is applied with index finger on the incisal/oc-
clusal surface of the tooth vertically and horizontally.
The adjacent teeth should be tested first to serve as con-
trol and to know the normal response of the patient. If
patient does not report any pain after completing this
test, then a blunt instrument is used to tap on the tooth.
This test does not indicate the status of the pulp, rather
it indicate presence of inflammation in the PDL.
These include cold test, and heat test.
Cold test can be used with ice sticks, dry ice (co2),
or refrigerant spray. Adjacent teeth should be isolated
with gauze to prevent false-positive results, then cold
instrument is applied to the tooth surface and response
is waited. If patient response to the test and pain sub-
side after removal of the instrument then the pulp is
normal. If pain does not diminish or rather increase af-
ter removal of the instrument then this tooth most likely
has a pulpal pathosis.
Heat test can be applied using heated water with syringe
(after isolation with rubber dam), heated gutta-percha
(remember to add lubricant to the tooth surface to pre-
vent adhesion of gutta-percha to the tooth), or the use
of rotating rubber cup (not recommended).
Cold test has been reported to be equal or even superior
to electrical pulp testing according to several studies.
ELECTRICAL PULP TEST
This test does not indicate the presence of vascular sup-
ply in the pulp (a sign of vitality), but rather indicate the
presence of intact nerve fibers.
It has been reported that electrical pulp testing is most
accurate when detecting necrotic teeth.
Some studies has been reported that cold test has supe-
rior advantage over electrical test, while some studies
reported no significant difference between the two tests.
It begin by applying firm pressure using cotton tip ap-
plicator, toothpick, or tooth slooth on each cusp of the
Patient will report pain when there is apical pathology
or root fracture. Sometimes patient feel pain when the
instrument is removed, which may indicate a fractured
tooth or root.
This test is not recommended because it is an invasive
procedure. It only used when other test results failed to
determine the condition of the pulp. A bur in high speed
with water coolant is used to drill the tooth, when den-
tin is reached the patient will feel pain which indicate
vital pulp tissue. However, when no pain is felt then
the tooth is necrotic and the procedure is continued to
access opening and further endodontic treatment.
STAINING AND TRANSILLUMINATION
Stains can be used to determine the presence of fracture
in the root. Also tranillumination with strong fiberoptic
light can determine the fracture site. Area that is close
to the light source will appear bright, while area beyond
the fracture will appear dim.
It used when other tests are inconclusive. PDL injec-
tion is applied to each tooth, starting from the maxilla.
A most posterior tooth should be anesthetized first and
progressing anteriorly. If all teeth in maxilla anesthe-
tized and pain is still present, the same procedure is ap-
plied to the mandible until pain disappear.
However, it should noted that PDL injection can anes-
thetize more than one tooth at a time which make it
less useful in determining which tooth is the source of
pain. Therefore, this technique is most useful in recog-
nizing which arch (maxilla or madibule) is the source,
and not a specific tooth.
The value of radiographic image are sometimes overes-
timated by the clinician. Proper diagnosis and clinical
tests are necessary, and radiograph is only supplemen-
Traditional radiography is two-dimensional presenta-
tion of three-dimensional structures, therefore multiple
radiograph should be taken from different angles to vi-
sualize more hidden structures.
A well-prepared radiograph can find multiple canals,
multiple roots, resorption, caries, defective restoration,
root fracture and state of root maturation and apical de-
Periapical pathology can be presented radiograph-
• The lamina dura is absent apically
• Radiolucency at the apex
However, not all apical pathosis are seen on radiograph,
especially early lesions.
Studies has found that radiolucency on radiograph can
be seen only when pathosis reach the cortical bone, it
can not be seen when presented in cancellous bone.
The root apecies of most anterior and premolars are
close to the cortical bone, therefore seen early. While
molar teeth are found in the cancellous bone, therefore
not seen early in the radiograph.
Absence of radiolucency in the the radiograph does not
mean there is no pathology, other clinical tests should
be performed to reach that level of diagnosis. 4
Lamina dura is the most consistent radiographic finding
when tooth is not vital. If lamina dura is widened, or in-
termitted then it can be an indication of pulpal pathosis.
In addition to that, radiograph can shows presence of
pulp calcifiction, or canal obliteration due to dentin for-
mation, and these conditions are normal and need no
intervention unless pulp is offended.
It worth mentioning that more advance radiographic
has been incorporated in dental practice in recent years
with superior imagining qualities compared to conven-
tional 2D radiograph.
DIAGNOSIS AND TREATMENT PLAN
The tooth response normally to pulp tests. It response
with pain to the tests when applied and pain is disap-
pear after removal of the stimuli.
It mean that the pulp is inflammed but the condition is
reversible. Pulp return to normal after removal of the
It usually presented with caries, defective restoration,
exposed dentin, recent periodontal treatment.
The offending stimuli should be removed, and the tooth
is restored. In case of deep caries, direct pulp capping
technique is applied.
The pulp is inflammed beyond repair. It can be subdi-
vided into two categorizes: symptomatic and asymp-
Symptomatic irreversible pulpitis
The pain usually spontaneous or intermittent. Response
rapidly to thermal stimuli and pain persist even after
removal of the stimuli. The pain could be sharp, dull,
localized, diffuse or referred. Radiographically, it can
be presented with widened PDL, however, sometimes
no sign of pathology can be seen.
When the patient presented with symptoms of symp-
tomatic irreversible pulpitis in anterior teeth without
any sign of caries or local factor, the patient should be
ask of past history of general anesthesia or endotracheal
intubation procedures. He also should be ask about any
history of orthodontic treatment.
Root canal treatment
Asymptomatic irreversible pulpitis
In this case, even that the tooth is presented with deep
caries or apical or lateral radiolucency the patient com-
plain of no symptoms.
RCT should be done for this tooth as soon as possible
so that it do not convert to symptomatic pulpitis or fu-
ture necrosis occur with lingering pain.
The pulp is dead and RCT is indicated. Tooth does not
respond to electrical or cold test, however it may re-
sponse to heat test if applied for long time. Thickened
PDL can be seen on the radiograph.
When necrosis is chronic the infection reach the peri-
apical area and lead to apical pathosis which presented
as radiolucency at the apex.
Symptomatic apical periodontitis
This condition is characterized by inflammation of peri-
odontal area of the infected tooth. The tooth response
to biting, percussion or palpation tests. The tooth may
or may not response to vitality test. Radiographically,
the tooth presented at least with widened PDL. Apical
radiolucency may or may not be seen.
Asymptotic apical periodontitis
The tooth usually does not response to vitality tests, and
does not response to biting test but it “feels different”.
The tooth usually exhibit apical radiolucency. Howev-
er, patient does not complain of any symptoms
Acute apical abscess
The patient complain of spontaneous pain, the tooth
is tender to biting, percussion and palpation test ,and
radiograph ranges from widened PDL to apical radio-
lucency. Swelling of adjacent area is present and cervi-
cal and submandibular lymph nodes usually tender to
Drainage of abscess if localized, and RCT.
Chronic apical abscess
Patient presented with sinus tract with pus discharge,
with little or no pain. Vitality test report no response,
and tooth usually not sensitive to biting test but “feels”
different. Radiographically, apical radiolucency can be
RCT. Sinus tract will resolve after few days to months
from endodontic treatment. If sinus tract is extraoral it
will leave a scar.
The tooth present with apical localized or diffuse apical
radiopacity. The tooth could be vital or non-vital.
It depend on the condition of the pulp. If pulp is nor-
mal then no treatment is required. If pulp is irreversibly
inflammed then RCT is indicated. It should be noted
that even with successful endodontic treatment some-
times condesing ostietis does not resolve (according to
a study 50% does not resolve). However, this can not
present any problem to be concerned about.
• Endodontics principles and practice
• Cohen’s pathways of pulp