Pulp, Root Canal and Periapical Conditions - Part 1¹

Note

This document covers the first part of a two-part lecture series, focusing on the conditions affecting the dental pulp and the root canal system. The second part will address periapical conditions.

General Principles for Treating ALL Conditions / Diseases:

IDENTIFY the disease and its cause

==General Principle: Understand what the disease is and what caused it.==
- ==Endodontic Application: This involves taking a thorough patient history, conducting comprehensive clinical and radiographic examinations, and arriving at a specific diagnosis. A critical part of this is identifying the etiological factors, such as caries, cracks, or failing restorations.==

REMOVE the CAUSE of the disease

==General Principle: Eliminate the source of the problem to prevent its continuation.==
- ==Endodontic Application: This means removing the pathway for bacteria, which typically involves addressing coronal issues like caries, cracks, fractures, or the marginal breakdown of restorations.==

TREAT the EFFECT of the disease

==General Principle: Address the damage or changes the disease has caused.==
- ==Endodontic Application: The primary effect is often an infected root canal system leading to apical periodontitis. Treatment involves cleaning, shaping, and disinfecting the canal system to remove bacteria and debris. Canal medicaments can be used to kill remaining bacteria and encourage periapical healing.==

PREVENT further disease and complications

==General Principle: Take steps to stop the disease from returning and to avoid future problems.==
- ==Endodontic Application: This is achieved by placing a three-dimensional root canal filling to seal the system, followed by a well-sealed coronal restoration to prevent re-infection.==

RESTORE to normal function

==General Principle: Return the affected body part to its normal functional state.==
- ==Endodontic Application: The final coronal restoration restores the tooth’s ability to function in mastication.==

MONITOR healing and stability over time

==General Principle: A good practitioner follows up to ensure the tissues have healed and remain stable over time.==
- ==Endodontic Application: This involves periodic clinical and radiographic follow-up examinations, typically starting at six months post-treatment and continuing at regular intervals for as long as the patient is under care.==

graph TD
    A[IDENTIFY the disease and its cause] --> B[REMOVE the CAUSE of the disease]
    B --> C[TREAT the EFFECT of the disease]
    C --> D[PREVENT further disease and complications]
    D --> E[RESTORE to normal function]
    E --> F[MONITOR healing and stability over time]

    A --> A1[History, examination, diagnosis & identify the cause(s)]
    B --> B1[Remove cause(s) - restorations, caries, cracks, etc]
    C --> C1[Clean the canal - remove bacteria, debris]
    C --> C2[Medicate canal - modify periapical response]
    D --> D1[Root canal filling and coronal restoration]
    E --> E1[Coronal restoration]
    F --> F1[Review 6 months, 3 years, 5 years, etc]

    style A1 fill:#fff1
    style B1 fill:#fff1
    style C1 fill:#fff1
    style C2 fill:#fff1
    style D1 fill:#fff1
    style E1 fill:#fff1
    style F1 fill:#fff1

Foundational Principles of Diagnosis²³

The First Two Steps to Diagnose Any Condition / Disease

You must UNDERSTAND the CONDITION (or the disease process)
- Pulp, root canal and peri-radicular conditions are PROGRESSIVE
  - i.e. They CHANGE over time - generally become worse or more severe
  - Hence you must also UNDERSTAND how they CHANGE over time
  - And you must be able to RECOGNIZE the DIFFERENT stages
You must also UNDERSTAND the CAUSE(S) of the condition / disease
- And IDENTIFY them during your examination
- So you can REMOVE them during treatment

Main Coronal Pathways for Bacteria

Caries

Cracks

Fractures

Marginal breakdown of restorations

-   Remember:
    -   Pulps do not become inflamed for no reason !!!
    -   Pulps do not die for no reason !!!

Four Key Components of a Diagnosis

When formulating a diagnosis for an endodontic problem, four key elements must be assessed and recorded:

==The Tooth Involved: Identify the specific tooth.==
==The State of the Pulp/Root Canal: Determine the condition of the pulp (if present) or the root canal system.==
==The State of the Periapical Tissues: Assess the condition of the tissues surrounding the root apex.==
==The Cause of the Disease: Determine the etiological factor(s).==

Pulp, Root Canal and Periapical Conditions

Necrobiosis

(Louis Grossman - 1985)

Part of the pulp is necrotic and infected PLUS
The rest of the pulp is inflamed

Pulp chamber -v- root canals One canal -v- other canal(s)

Terminology: Necrobiosis vs. Partial Pulp Necrosis⁴

Necrobiosis	Partial Pulp Necrosis
Necrobiosis - more descriptive, meaningful, & useful	Partial Pulp Necrosis - does not require treatment
- Since it reflects the two different tissue conditions that are present within the one pulp/tooth	- Unless the necrotic portion of the pulp is infected
- Indicates treatment is required - e.g. Endodontics or extraction	→ In which case, the rest of the pulp is likely to be inflamed
	- If not, then can not clinically determine if it is infected or not

Clinical Classification of Pulp & Root Canal Conditions - Other Conditions

Previous Endodontic Treatment	Other Conditions
- RF + No sign of infection	- Atrophy
- RF + Infected RCS	- Pulp Canal Calcification
- Incomplete RCT	- Hyperplasia (pulp polyp)
- Technical standard **	- Internal Resorption
→ Inadequate	→ Surface
→ Adequate	→ Inflammatory
- Other problems **	→ Replacement
→ e.g. perforation, fractured file, missed canal, etc.

** based on radiographic appearance

Diagnose the state of the pulp or the root canal A form of chronic irreversible pulpitis

The Progression of Pulp Disease: Flowcharts⁵

Note

The dental pulp reacts to injury in a predictable, progressive sequence, similar to other bodily tissues, but with the unique ability to form reparative dentine.

==Initial Stimulus: The process begins with an injury or stimulus, most commonly microorganisms (bacteria) from caries, cracks, etc.==
==Inflammation (Pulpitis): The pulp becomes inflamed. Even shallow carious lesions that have just penetrated the dentine can elicit a pulpal response, as dentinal tubules are extensions of the pulp.==
==Necrosis and Infection: If the stimulus persists without treatment, the inflammation intensifies. Bacteria invade the pulp, causing microabscesses. The tissue begins to die (necrosis) and becomes infected concurrently.==
==Tissue Destruction: The bacteria feed on the necrotic tissue, eventually destroying and removing it entirely, leaving a

Clinically Normal Pulp

Info

This is the baseline state, representing a pulp with no signs or symptoms of disease. Histologically, it may not be perfectly

graph TD
    A[Clinically Normal Pulp] --> B{+ TRAUMA\n(e.g. luxation,\navulsion, etc)};
    B --> C[Pulp Necrosis];

Progression Following Trauma⁶

Note

A traumatic injury, such as luxation (displacement) or avulsion (tooth knocked out), can sever the blood supply at the apical foramen.

==This leads to almost instantaneous pulp necrosis.==
If no bacteria enter the tooth, the necrotic tissue may remain sterile.
==More commonly, the necrotic tissue becomes a nutrient source for bacteria, leading to pulp necrosis with infection.==
==This progresses to a pulpless and infected root canal system.==

Trauma → Pulp Necrosis (potentially sterile) → Pulp Necrosis with Infection → Pulpless & Infected Root Canal System

flowchart TD
    A[Clinically Normal Pulp]
    B{+ TRAUMA (e.g. luxation, avulsion, etc)}
    C[Pulp Necrosis]
    D[Necrotic and Infected Pulp]
    E[Pulpless and Infected Root Canal System]
    F{+ Micro-organisms}
    
    A --> B
    B --> C
    C --> F
    F --> D
    D --> E
    
    style A fill:#00FF00, color:black
    style B fill:#808080, color:white
    style C fill:#800000, color:white
    style D fill:#FF00FF, color:white
    style E fill:#FF00FF, color:white
    style F fill:#800000, color:white

Progression Following Irritation

Note

This is the more common pathway in clinical practice, driven by bacterial irritation from caries, cracks, or failing restorations.

Reversible Pulpitis:
- A mild, short-term irritation causes a localized, mild inflammation.
- ==This can be acute (recent onset) or chronic (long-standing, mild symptoms).==
- If the cause is removed (e.g., caries excavated, new restoration placed), the pulp can return to a clinically normal state.
Irreversible Pulpitis:
- If the irritation persists, the inflammation becomes more widespread and severe. The damage is considered beyond the point of repair.
- ==This can also be acute (severe, recent pain) or chronic (milder, long-standing).==
- Patients may cycle between acute and chronic phases.
Necrobiosis:
- This is a transitional stage where part of the pulp is necrotic and infected, while the remaining apical portion is irreversibly inflamed.
- This stage may be very brief (hours to days).
Pulp Necrosis with Infection:
- The bacterial front progresses through the remaining inflamed tissue until the entire pulp is necrotic and infected.
Pulpless and Infected Root Canal System:
- Based on monkey studies (Jansson et al.), bacteria completely consume the necrotic pulp tissue within a relatively short time (e.g., 1-2 months), leaving an empty but infected canal system. The anaerobic environment in a closed tooth accelerates this process.

flowchart TD
    A[Clinically Normal Pulp]
    B{Short-term irritation}
    C[Acute Reversible Pulpitis]
    
    A --> B
    B --> C
    
    style A fill:#00FF00, color:black
    style B fill:#FFA500, color:black
    style C fill:#FF0000, color:black

graph TD
    A[Clinically Normal Pulp] -->|Short-term irritation| B(Acute Reversible Pulpitis);
    A -->|Long-term irritation| C(Chronic Reversible Pulpitis);
    B -->|Long-term irritation| C;

graph TD
    A(Clinically Normal Pulp) -->| + Micro-organisms| B(Acute Reversible Pulpitis);
    A -->| + Micro-organisms| C(Chronic Reversible Pulpitis);
    B --> D(Acute Irreversible Pulpitis);
    C --> E(Chronic Irreversible Pulpitis);
    B --> C;
    C --> B;
    D --> E;
    E --> D;

Comprehensive Progression of Pulp Disease⁷⁸⁹

graph TD
    A[Clinically Normal Pulp]
    B[Chronic Reversible Pulpitis]
    C[Acute Reversible Pulpitis]
    D[Chronic Irreversible Pulpitis]
    E[Acute Irreversible Pulpitis]
    F[Necrobiosis]
    G[Pulp Necrosis]
    H[Necrotic and Infected Pulp]
    I[Pulpless and Infected Root Canal System]
    J[+ Micro-organisms]
    K[+ TRAUMA\n(e.g. luxation,\navulsion, etc)]

    A --> B
    A --> J
    J --> C
    B --> C
    B --> D
    C --> E
    D --> E
    D --> F
    D --> G
    E --> F
    F --> H
    G --> H
    H --> I
    A --> K
    K --> G

> [!abstract] Summary
> 
> Pulp disease is a continuum. A tooth can progress through these stages over time, and different parts of the same pulp can be in different stages simultaneously.
> 
> *Clinically Normal Pulp -> Reversible Pulpitis (Acute/Chronic) -> Irreversible Pulpitis (Acute/Chronic) -> Necrobiosis -> Pulp Necrosis with Infection -> Pulpless & Infected Root Canal System*

The pulp status changes over time
- It progresses through several stages
- A continuum …

flowchart LR
    A[Clinically Normal Pulp] --> B(Chronic Reversible Pulpitis)
    B --> C(Acute Reversible Pulpitis)
    C --> B
    C --> D(Chronic Irreversible Pulpitis)
    D --> E(Acute Irreversible Pulpitis)
    E --> D
    E --> F(Pulp Necro-biosis)
    F --> G(Pulp Necrosis With Infection)
    G --> H[Pulpless Infected RCS]

Critique of Terminology¹⁰¹¹

”Vital” vs. “Non-vital” Pulps

But what about …
- “Vital” pulps
- “Non-vital” pulps
Old terminology !!!
Encourages incorrect thinking about the disease processes
Not meaningful or useful terms

The Problem with

Pulp Sensibility vs. Vitality Tests¹²

Key Distinction

==Pulp Sensibility: The ability of the pulp’s nerves to respond to a stimulus. The answer is a simple

Pulp Vitality Test
- “Vital pulp”
- “Non-vital pulp”
Pulp Sensibility Tests
- CO₂
- Electric
- Heat
Thermal & electric pulp tests are “Sensibility Tests”

	When testing for pulpitis	When testing for pulp necrosis / pulpless RCS
Yes / No		Yes / No
Nature of response	Nature of response

Sensibility: → Ability to respond to a stimulus
Note: NOT “Sensitivity” tests → Sensitivity is a condition of being very responsive to a stimulus

Pulp Tests

Sensibility Tests

e.g. Thermal (cold, heat) and Electric
Test for a nerve response
- Do NOT indicate blood supply
- Do NOT indicate health of the tissue

Vitality Tests¹³

Note

These tests measure blood supply directly. They are not practical for routine clinical use due to cost, complexity, and difficulty of use on teeth.

e.g. Laser Dopplerflowmetry, Pulse Oximetry
Test for blood supply
- Do NOT indicate tissue health

Interpretation of Pulp Tests

Must be interpreted in conjunction with:

The patient’s symptoms → What the patient tells you
The clinical signs → Findings from the examination
The radiographic findings → Pulp canal calcification → Previous endodontic treatment
- Including pulp cap, pulpotomy, etc. → Periapical / peri-radicular condition(s)

Interpreting a Negative Response

A negative response to a sensibility test does not automatically mean the pulp is necrotic. Other reasons include:

Pulp canal calcification

Previous pulp therapy (e.g., pulpotomy)

Immature apex

==Recent trauma (pulp may be

Example: Pulp Canal Calcification

No treatment reqd	Endodontics reqd

Issues with Old Terminology¹⁴

Pulp disease
- “Vital” Pulp
- “Non-vital” pulp
Leads to incorrect and inconsistent thinking about the disease processes
- And the treatment needs

Ambiguity of “Vital” Pulp¹⁵

Could be several different conditions which require very different clinical management: 12 different conditions !!!

Clinically normal pulp
Sensitive dentine
Reversible pulpitis
- Acute or chronic
Irreversible pulpitis
- Acute or chronic
Necrobiosis
Three types of internal resorption
Pulp atrophy
Pulp hyperplasia
Management ranges from:
- Nil
- Desensitisation
- New restoration
- Conservative pulp therapy
- Endodontics
- Extraction

Ambiguity of “Non-Vital” Pulp

Could be several different conditions which require very different clinical management: 10 different conditions !!!

Clinically normal pulp
- With or Without Pulp Canal Calcification
Necrobiosis
Pulp Necrosis
- With or Without Infection
Pulpless Infected Canal
- With Apical Periodontitis
Previous Endodontic Treatment
- With or Without Infection
Internal infl. or repl. resorption
Management ranges from:
- Nil
- Orthograde endodontics
  - - Different medicaments
- Re-treatment
- Periapical surgery
  - - Curettage
  - - Apicoectomy
  - - Retrograde endodontics
- Extraction

”Symptomatic” vs. “Asymptomatic” Terminology¹⁶

AAE Consensus Conference Recommended Diagnostic Terminology (2009)

J Endod 2009; 35: 1634.

Normal pulp
Reversible pulpitis
Symptomatic irreversible pulpitis
Asymptomatic irreversible pulpitis
Pulp necrosis
Previously treated
Previously initiated therapy

Critique of “Symptomatic” and “Asymptomatic”¹⁷

Not descriptive enough to indicate the management required
- “Symptomatic” could be many conditions - ranging from having mild pain to severe pain
  - e.g. chronic reversible pulpitis; acute irreversible pulpitis

flowchart TD
    A[***P***x - ***Restoration***]
    B[***P***x - ***Endodontics*** or ***Extraction***]
    C(chronic reversible pulpitis)
    D(acute irreversible pulpitis)
    C --> A
    D --> B

“Asymptomatic” could be several different conditions
- e.g. clinically normal pulp; necrotic & infected pulp
Inconsistent with terminology used in other areas of Dentistry
- e.g. acute ulcerative gingivitis, chronic marginal periodontitis, etc
Inconsistent with terminology used in Medicine
- e.g. acute appendicitis, chronic maxillary sinusitis, etc.

Inconsistent with terminology used in Medicine
- e.g. acute appendicitis, chronic maxillary sinusitis, etc.

Condition	Treatment
Clinically normal pulp	Rx - NIL
Necrotic & infected pulp	Rx - Endodontics or Extraction

Literature Review and Scientific Basis¹⁸

From: Gutmann et al - JoE 2009 (Review article and AAE Consensus Conference)

“Little if any support in the historic or contemporary peer-reviewed literature for the use of the terms ‘symptomatic’ and ‘asymptomatic’”
“These terms have crept into usage with no scientific basis”
”… little validity other than empiricism.”
“…minimal rationale or scientific basis.”

Study: Assessment of Australian Dentists’ Treatment Planning Decisions¹⁹²⁰

Bestall S, Flynn R, Charleson G, Abbott PV. J Endod 2020; 46: 483-489.

Method:
- Surveyed 194 dentists
- Provided radiographs and diagnoses of 14 cases
  - Different diagnostic terminology for the same condition
- Instructed to assume all teeth were suitable for the management options given
- Asked what management they would recommend
  - e.g. Review, RCT, Re-RCT, Extraction, Surgery, etc.
Analysis:
- Responses were grouped as:
  - ==“Operative” or “Non-Operative” Management== → i.e. To treat or not to treat !
- Compared for statistical significance:
  - ==“Chronic” -v- “Asymptomatic”==
  - ==“Acute” -v- “Symptomatic”==
Method:
- Surveyed 194 dentists
- Provided radiographs and diagnoses of 14 cases
  - Different diagnostic terminology for the same condition
- Instructed to assume all teeth were suitable for the management options given
- Asked what management they would recommend
  - e.g. Review, RCT, Re-RCT, Extraction, Surgery, etc.
Analysis:
- Responses were grouped as:
  - “Operative” or “Non-Operative” Management → i.e. To treat or not to treat !
- Compared for statistical significance:
  - “Chronic” -v- “Asymptomatic”
  - “Acute” -v- “Symptomatic”
Results:

| Condition | % of Dentists That Would Treat | Significance | | :---: | :---: | :---: | :---: | | | “Chronic” | “Asymptomatic” | | | Irreversible Pulpitis | 93.3% | 59.8% | Yes | | Apical Periodontitis | 96.9% | 89.7% | Yes | | Apical Abscess | 99.0% | 83.5% | Yes |

| Condition | % of Dentists That Would Treat | Significance | | :---: | :---: | :---: | :---: | | | “Acute” | “Symptomatic” | | | Irreversible Pulpitis | 99.0% | 96.9% | No | | Apical Periodontitis | 1° - 83.0% | 97.0% | Yes | | | 2° - 100% | | No | | Apical Abscess | 1° - 82.0% | 93.3% | Yes | | | 2° - 96.4% | | Yes |

Summary of Findings:
- Dentists were more likely to treat if “chronic” than “asymptomatic”
- Dentists were more likely to treat if “acute” than “symptomatic”
  - But slightly less significant
  - And NOT if Irreversible Pulpitis or 2° Acute Apical Abscess
  - And the OPPOSITE for 1° Acute Apical Periodontitis and Abscess

**Words DO matter !!!**

CONCLUSIONS
Dentists base their treatment decisions largely on the presence or absence of symptoms - → And not on the actual condition / disease present - → Suggests poor understanding of pulp, root canal & periapical conditions
- ==AVOID using “Asymptomatic” and “Symptomatic”==
- Dentists base their treatment decisions largely on the presence or absence of symptoms
  - → And not on the actual condition / disease present
  - → Suggests poor understanding of pulp, root canal & periapical conditions
- AVOID using “Asymptomatic” and “Symptomatic”

Comparison of Classification Systems²¹²²

AAE Consensus Conference (2009)

7 Conditions
1. Normal pulp
2. Reversible pulpitis
3. Symptomatic irreversible pulpitis
4. Asymptomatic irreversible pulpitis
5. Pulp necrosis
6. Previously treated
7. Previously initiated therapy

Pulp & Root Canal Conditions - Abbott & Yu (ADJ 2007)

17 Conditions
- Clinically normal pulp
- Reversible pulpitis → Acute ⋄ Chronic
- Irreversible pulpitis → Acute ⋄ Chronic

Definitions

Reversible Pulpitis: Mild inflammation where the pulp is expected to heal if the irritant is removed. Irreversible Pulpitis: More severe inflammation where the pulp is considered incapable of healing. Requires root canal treatment or extraction.

-   Pulp necrobiosis
-   Pulp necrosis → Infected ⋄ No sign of Infection
-   Pulpless and infected root canal system
-   Previous Endodontic Treatment → Infected RCS ⋄ No signs of infection
-   Pulp atrophy
-   Pulp canal calcification
-   Pulp hyperplasia
-   Internal resorption → Surface ⋄ Inflammatory ⋄ Replacement

Abbott & Yu -v- AAE²³

Clinically normal pulp
Reversible pulpitis → Acute → Chronic
Irreversible pulpitis → Acute → Chronic → Symptomatic → Asymptomatic
Pulp necrobiosis
Pulp necrosis → Infected → No sign of Infection
Pulpless and infected root canal system
Previous Endodontic Treatment → Infected RCS → No signs of infection
Pulp atrophy
Pulp canal calcification
Pulp hyperplasia
Internal resorption → Surface → Inflammatory → Replacement

The AAE Classification has a SHORTFALL of 10 conditions that have been shown to occur - plus INAPPROPRIATE terminology !!!

Missing Conditions in AAE Classification

The AAE classification is missing 10 clinically relevant conditions that are known to exist and require specific consideration for management. These include:

Distinction between acute and chronic pulpitis

Necrobiosis

Distinction between infected and non-infected pulp necrosis

The pulpless and infected state

Pulp canal calcification

Internal resorption (3 types)

Pulp hyperplasia

Clinical Diagnosis of Pulp/Canal Status

Pulpitis
- Reversible or Irreversible → Based on:
  - Severity of symptoms
  - Duration of symptoms

Mainly with temperature changes

    **Mainly with temperature changes**

Infected Canal
- Necrosis, Pulpless or RFd → Based on:
  - Pulp sensibility tests
  - Periapical status
  - Radiographs

Based on presence/absence of a periapical radiolucency i.e. diagnosing apical periodontitis

    **Based on presence/absence of a periapical radiolucency**
    **i.e. diagnosing apical periodontitis**

Typical Symptoms of Pulp Conditions²⁴

Condition	Symptoms	Additional Notes
Clinically Normal Pulp	No symptoms or signs
Chronic Reversible Pulpitis	Few &/or occasional symptoms - short, sharp pain to heat, cold
Acute Reversible Pulpitis	Occasional sharp & lingering pain with heat, cold
Chronic Irreversible Pulpitis	Regular short, sharp pain with heat, cold
Acute Irreversible Pulpitis	Severe sharp & lingering pain with heat, cold; Spontaneous; Worse lying down; Wakes patient	May or may not have acute apical periodontitis
Pulp Necrobiosis	Mixed symptoms or signs of pulpitis & necrosis
Pulp Necrosis with Infection	No pulp symptoms	Eventually acute apical periodontitis
Pulpless Infected RCS	No pulp symptoms

Example: Acute Irreversible Pulpitis

(Olgart & Bergenholtz - Textbook of Endodontology - 2003)

Mesial Root
- “Pulp breakdown”
- Intense inflammation
Distal Root
- Less inflammation
- Normal apical pulp
- No inflammation
- + normal odontoblasts

Symptom-Based Diagnostic Chart²⁵

Symptoms	Reversible Pulpitis	Irreversible Pulpitis	Infected RCS + Chr. Ap. Periodontitis
Nature	Sharp, mild → mod.	Sharp & aching	Dull ache, throb
Thermal sensitivity	Extreme temp’s	Mild changes	−
Duration	Short (sec’s → min’s)	Lingers (? > 5-10 min’s)	On + off → Continuous
Biting pain	+	+	+
Percussion	−	+	+
Spontaneous	−	+	+
Wakes at night	−	+	+
Worse lying down	−	+	−
Radiographic changes	−	+	+
History previous problems	−	+	+

Summary of Pain Characteristics

==Reversible Pulpitis: Pain is short and sharp, provoked by extreme temperature changes (e.g., ice cream), and stops when the stimulus is removed.==

==Irreversible Pulpitis: Pain lingers for minutes to hours and can be provoked by even mild temperature changes (e.g., tap water). It can also be spontaneous and wake a patient at night.==

==Infected Root Canal System: The primary symptom is pain on biting or pressure (percussion). The tooth does not respond to thermal stimuli, but pain can be a dull, spontaneous throb.==

Comprehensive Clinical Classification of Pulp & Root Canal Conditions

NO SIGNS OF DISEASE

CLINICALLY NORMAL PULP (based on history, clinical examination, tests, radiographs, etc)

PULPITIDES

REVERSIBLE PULPITIS - Acute
- Chronic
IRREVERSIBLE PULPITIS - Acute
- Chronic

PULP NECROSIS

PULP NECROBIOSIS (still vital (living) due root is incompletely formed)
PULP NECROSIS with NO signs of infection
NECROTIC AND INFECTED PULP

PULPLESS TEETH

PULPLESS AND INFECTED ROOT CANAL SYSTEM
TEETH WITH PREVIOUS ROOT CANAL TREATMENT
- Root-filled with NO signs of infection
- Root-filled and infected:
  - Incomplete endodontic treatment (e.g. rootment chamber structure)
  - Technically unacceptable (based on the radiographic appearance)
  - Technical standard (based on the radiographic appearance)
    - Adequate
    - Inadequate
  - Other problems - specify the problem: e.g. Perforation, Untreated canal(s), Fracture indications, Open prior, etc)

DEGENERATIVE CHANGES

PULP CANAL CALCIFICATION - Partial
- Complete (based on radiographic appearances)
- NOTE: Also specify the diagnosis/condition of the pulp/root canal system.
PULP HYPERPLASIA NOTE: as above (specify the pulp status also)
INTERNAL RESORPTION
- INTERNAL SURFACE RESORPTION
- INTERNAL INFLAMMATORY RESORPTION
- INTERNAL REPLACEMENT RESORPTION

Pain Characteristics in Pulp Conditions

Feature	Reversible Pulpitis	Irreversible Pulpitis	Necrotic Pulp
Nature	Sharp, mild &implies; mod.	Sharp & aching	Dull ache, throb
Thermal sensitivity	Extreme temp's	Mild changes	-
Duration	Short (sec's &implies; min's)	Lingers (? > 5-10 min's)	On + off &implies; Continuous
Biting pain	+	+	+
Percussion	-	+	+
Spontaneous	-	+	+
Wakes at night	-	+	+
Worse lying down	-	+	-
Radiographic changes	-	+	+
History previous problems	-	+	+

Clinical Classification of Pulp & Root Canal Conditions

NO SIGNS OF DISEASE

CLINICALLY NORMAL PULP (based on history, clinical examination, tests, radiographs, etc)

PULPITES

REVERSIBLE PULPITES - Acute
- Chronic
IRREVERSIBLE PULPITES - Acute
- Chronic

PULP NECROSIS

PULP NECROBIOSEN
- PULP NECROBIOSIS (still vital (living) due root is incompletely formed)

Info

This is a transitional state where part of the pulp is necrotic/infected, and the remainder is irreversibly inflamed. This term is preferred over

PULP NECROSIS with NO signs of infection
NECROTIC AND INFECTED PULP

PULPLESS TEETH

PULPLESS AND INFECTED ROOT CANAL SYSTEM
TEETH WITH PREVIOUS ROOT CANAL TREATMENT
- Root-filled with NO signs of infection
- Root-filled and infected:
  - Incomplete endodontic treatment (e.g. rootment chamber structure)
  - Technically unacceptable (based on the radiographic appearance)
  - Technical standard (based on the radiographic appearance)
    - Adequate
    - Inadequate
  - Other problems - specify the problem: e.g. Perforation, Untreated canal(s), Fracture indications, Open prior, etc)

DEGENERATIVE CHANGES

PULP CANAL CALCIFICATION - Partial
- Complete (based on radiographic appearances)
- NOTE: Also specify the diagnosis/condition of the pulp/root canal system.
PULP HYPERPLASIA NOTE: as above (specify the pulp status also)

Info

An overgrowth of chronically inflamed pulp tissue out of a large, open carious lesion, most common in young patients.

INTERNAL DESCRIPTION - INTERNAL SURFACE RESORPTION
- EXTERNAL SURFACE RESORPTION
- INTERNAL REPLACEMENT RESORPTION

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L1.Pulp Root Canal and Peri-radicular Conditions - Part 1 - DMD2 - Handout - 2023_formatted_text

Pulp, Root Canal and Periapical Conditions - Part 11

General Principles for Treating ALL Conditions / Diseases:

Foundational Principles of Diagnosis23

The First Two Steps to Diagnose Any Condition / Disease

Four Key Components of a Diagnosis

Pulp, Root Canal and Periapical Conditions

Necrobiosis

Terminology: Necrobiosis vs. Partial Pulp Necrosis4

Clinical Classification of Pulp & Root Canal Conditions - Other Conditions

The Progression of Pulp Disease: Flowcharts5

Clinically Normal Pulp

Progression Following Trauma6

Progression Following Irritation

Comprehensive Progression of Pulp Disease789

Critique of Terminology1011

”Vital” vs. “Non-vital” Pulps

Pulp Sensibility vs. Vitality Tests12

Pulp Tests

Sensibility Tests

Vitality Tests13

Interpretation of Pulp Tests

Issues with Old Terminology14

Ambiguity of “Vital” Pulp15

Ambiguity of “Non-Vital” Pulp

”Symptomatic” vs. “Asymptomatic” Terminology16

AAE Consensus Conference Recommended Diagnostic Terminology (2009)

Critique of “Symptomatic” and “Asymptomatic”17

Literature Review and Scientific Basis18

Study: Assessment of Australian Dentists’ Treatment Planning Decisions1920

Comparison of Classification Systems2122

AAE Consensus Conference (2009)

Pulp & Root Canal Conditions - Abbott & Yu (ADJ 2007)

Abbott & Yu -v- AAE23

Clinical Diagnosis of Pulp/Canal Status

Typical Symptoms of Pulp Conditions24

Example: Acute Irreversible Pulpitis

Symptom-Based Diagnostic Chart25

Comprehensive Clinical Classification of Pulp & Root Canal Conditions

NO SIGNS OF DISEASE

PULPITIDES

PULP NECROSIS

PULPLESS TEETH

DEGENERATIVE CHANGES

Pain Characteristics in Pulp Conditions

Clinical Classification of Pulp & Root Canal Conditions

NO SIGNS OF DISEASE

PULPITES

PULP NECROSIS

PULPLESS TEETH

DEGENERATIVE CHANGES

Footnotes

Graph View

Table of Contents

Backlinks

Pulp, Root Canal and Periapical Conditions - Part 1¹

Foundational Principles of Diagnosis²³

Terminology: Necrobiosis vs. Partial Pulp Necrosis⁴

The Progression of Pulp Disease: Flowcharts⁵

Progression Following Trauma⁶

Comprehensive Progression of Pulp Disease⁷⁸⁹

Critique of Terminology¹⁰¹¹

Pulp Sensibility vs. Vitality Tests¹²

Vitality Tests¹³

Issues with Old Terminology¹⁴

Ambiguity of “Vital” Pulp¹⁵

”Symptomatic” vs. “Asymptomatic” Terminology¹⁶

Critique of “Symptomatic” and “Asymptomatic”¹⁷

Literature Review and Scientific Basis¹⁸

Study: Assessment of Australian Dentists’ Treatment Planning Decisions¹⁹²⁰

Comparison of Classification Systems²¹²²

Abbott & Yu -v- AAE²³

Typical Symptoms of Pulp Conditions²⁴

Symptom-Based Diagnostic Chart²⁵