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roots - international magazine of endodontology No. 1, 2016

| CE article diagnosis 12 roots1 2016 Asymptomatic irreversible pulpitis is a clinical di- agnosis based on subjective and objective findings in­dicating that the vital inflamed pulp is incapable of healing and that root canal treatment is indicated. These cases have no clinical symptoms and usually respond normally to thermal testing but may have had trauma or deep caries that would likely result in exposure following removal. Pulpnecrosis is a clinical diagnostic category indi- catingdeathofthedentalpulp,necessitatingrootca- nal treatment. The pulp is non-responsive to pulp testing and is asymptomatic. Pulp necrosis by itself does not cause apical periodontitis (pain to percus- sionorradiographicevidenceofosseousbreakdown) unless the canal is infected. Some teeth may be non-­ responsive to pulp testing because of calcification, recenthistoryoftrauma,orsimplythetoothisjustnot responding. As stated previously, this is why all test- ingmustbeofacomparativenature(e.g.patientmay not respond to thermal testing on any teeth). Previously treated is a clinical diagnostic category indicating that the tooth has been endodontically treatedandthecanalsareobturatedwithvariousfill- ingmaterialsotherthanintracanalmedicaments.The toothtypicallydoesnotrespondtothermalorelectric pulp testing. Previously initiated therapy is a clinical diagnostic category indicating that the tooth has been previ- ously treated by partial endodontic therapy such as pulpotomy or pulpectomy. Depending on the level of therapy, the tooth may or may not respond to pulp testing modalities. Apical diagnoses9-14 Normalapicaltissues are not sensitive to percus- sion or palpation testing and radiographically, the lamina dura surrounding the root is intact and the periodontal ligament space is uniform. As with pulp testing,comparativetestingforpercussionandpal- pation should always begin with normal teeth as a baseline for the patient. Symptomatic apical periodontitis represents in- flammation, usually of the apical periodontium, producing clinical symptoms involving a painful re- sponsetobitingand/orpercussionorpalpation.This may or may not be accompanied by radiographic changes (i.e. depending upon the stage of the dis- ease, there may be normal width of the periodontal ligament or there may be a periapical radiolucency). Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp and root canal treatment is needed. Asymptomatic apical periodontitis is inflammation and destruction of the apical periodontium that is of pulpalorigin.Itappearsasanapicalradiolucencyand does not present clinical symptoms (no pain on per- cussion or palpation). Chronicapicalabscess is an inflammatory reaction topulpalinfectionandnecrosischaracterizedbygrad- ual onset, little or no discomfort and an intermittent discharge of pus through an associated sinus tract. Radiographically, there are typically signs of osseous destruction such as a radiolucency. To identify the source of a draining sinus tract when present, a gut- ta-percha cone is carefully placed through the stoma oropeninguntilitstopsandaradiographistaken. Acute apical abscess is an inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation and swelling of associated tissues. There may be no radiographic signs of destruction and the patient often experi- ences malaise, fever and lymphadenopathy. Condensing osteitis is a diffuse radiopaque lesion representingalocalizedbonyreactiontoalow-grade inflammatorystimulususuallyseenattheapexofthe tooth. Diagnostic case examples Amandibularrightfirstmolarhadbeenhypersen- sitive to cold and sweets over the past few months but the symptoms have subsided (Fig. 1). Now there isnoresponsetothermaltestingandthereistender- ness to biting and pain to percussion. Radiographi- cally, there are diffuse radiopacities around the root Fig.3

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