Endodontic diagnosis can be very confusing. Much of this confusion comes from differences in diagnostic terminology. The diagnostic terminology used from school to school is different. Even endodontic textbooks fail to create a systematic approach to endodontic terminology. The American Board of (ABE), the organization which oversees the board certification of endodontists, even allows for board candidates to describe the terminology they will be using during their board certification process.
Endodontic diagnostic terminology is based on clinical signs & symptoms, radiographic appearance & presence or lack of swelling or drainage. It is easily understood how confusing this can be with so many variables.
In an effort to simplify and unify the endodontic diagnostic terminology, the ABE has recently published a list of pulpal and periapical diagnostic terminology. In our practice we have adopted this terminology and will be using it in our daily practice of endodontics. We will also begin using this terminology in our cases presented in the blog. The following is the new terminology recommended by the ABE.
A complete endodontic diagnosis is made up of two parts:
1. Pulpal diagnosis
2. Periapical diagnosis
Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.
Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.
Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.
Symptomatic – Lingering thermal pain, spontaneous pain, referred pain
Asymptomatic – No clinical symptoms but inflammation produced by caries,
caries excavation, trauma, etc.
Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.
Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments.
Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).
Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.
Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area. (This category includes what many of us call Acute Apical Periodontitis & Phoenix Abscess)
Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms. (This is what many of us have previously called a Chronic Apical Periodontitis)
Acute apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.
Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract.
You can see that the pulpal diagnostic terminology has not changed. The periapical terminology is where are the confusion was and that is what they have tried to simplify. If you look closely at the definitions, you will see that the radiographic signs are not part of the periapical definition anymore. That is the reason that a Acute Apical Periodontitis & Phoenix Abscess are now both called a Symptomatic Apcial Periodontitis. Is your head spinning yet? Go back to the top and read it again. We'll have more on diagnosis to help you apply these definitions in your practice.