1. Pulpal and Apical Diagnoses

Question 1

What are the two components should be included in an Endo diagnosis ?

Answer 1

Apical and pulpal.

Question 2

What are the six pulpal diagnoses ?

Answer 2

Reversible pulpitis.
Asymptomatic irreversible pulpitis.
Symptomatic irreversible pulpitis.
Pulpal necrosis.
Previous RCT.
Previously initiated partial RCT.

Question 3

Define reversible pulpitis.

Answer 3

Inflammation of the pulp which should return to normal on appropriate treatment of aetiology.

Question 4

What symptoms might a patient complain of with reversible pulpitis ?

Answer 4

Sensitive to cold and sweet lasting <30 seconds.
Pain is not spontaneous - requires stimulus.

Question 5

What should a patient with reversible pulpitis present with in a radiograph ?

Answer 5

Normal, no radiographic changes.

Question 6

What treatment should be given for reversible pulpitis ?

Answer 6

Treatment of cause.

Question 7

What can cause reversible pulpitis ?

Answer 7

Caries.
Deep restoration.
Exposed dentine - dentine sensitivity.

Question 8

Define symptomatic irreversible pulpitis.

Answer 8

Vital inflamed pulp incapable of healing.

Question 9

What symptoms might a patient complain of with symptomatic irreversible pulpitis ?

Answer 9

Sensitive to thermal stimulus lasting >30 seconds.
Spontaneous pain.
Referred pain.
Analgesics ineffective.

Question 10

What results should you expect for special tests (radiographs, TTP, EPT and sensibility testing) of symptomatic irreversible pulpitis ?

Answer 10

ETP - positive - vital pulp.
TTP - negative - inflammation not reached apical tissues yet.
Radiograph - no changes - inflammation not reached apical tissues yet.
Sensibility testing - positive - lasting >30 seconds.

Question 11

What treatment should be provided for patient with symptomatic irreversible pulpitis ?

Answer 11

RCT.
Pulpotomy - if multicoated tooth and only one root canal affected.
Pulpectomy - if single canal or all roots affected.

Question 12

Define asymptomatic irreversible pulpitis.

Answer 12

Vital inflamed pulp incapable of healing.

Question 13

What are the causes of symptomatic irreversible pulpitis ?

Answer 13

Deep restorations or caries.
Fractures exposing pulpal tissues.

Question 14

What results should you expect from special tests (radiographs, TTP, EPT and sensibility testing) of asymptomatic irreversible pulpitis ?

Answer 14

TTP - negative - inflammation not reached apical tissues yet.
EPT - positive - pulp still vital.
Radiograph - no changes.
Sensibility testing - negative.

Question 15

What are causes of asymptomatic irreversible pulpitis ?

Answer 15

Caries or trauma exposing dentine on removal.

Question 16

What treatment should be provided for patient with asymptomatic irreversible pulpitis ?

Answer 16

RCT.

Question 17

What results should you expect from special tests (radiographs, TTP, EPT and sensibility testing) of pulpal necrosis ?

Answer 17

TTP - only if root canal infected.
Radiograph - sclerosed pulp chamber.
EPT - negative - non-vital pulp.
Sensibility testing - negative - non-vital pulp.

Question 18

What treatment should be provided for patient with pulpal necrosis ?

Answer 18

RCT.

Question 19

What will make necrotic pulp unresponsive to EPT and thermal testing ?

Answer 19

Calcification and sclerosis of the pulp chamber.
Recent trauma.

Question 20

What is TTP indicative of ?

Answer 20

Osseous breakdown, inflammation in PD/apical tissues.

Question 21

What results should you expect from special tests (radiographs, TTP, EPT and sensibility testing) of previous RCT or previously initiated partial RCT ?

Answer 21

Previous RCT - non-responsive to any TTP, EPT, sensibility testing.
Previously initiated partial RCT - varied results depending upon pulpotomy or pulpectomy.

Question 22

What should normal apical tissues look like in a radiograph ?

Answer 22

Uniform PDL and intact lamina dura.

Question 23

Define symptomatic apical tissue diagnosis.

Answer 23

Inflammation of apical periodontium.

Question 24

What are the symptoms and radiographic diagnosis of symptomatic apical tissues ?

Answer 24

Pain to TTP and biting.
+/- radiographic changes depending on stage of the disease.

Question 25

Define asymptomatic apical tissue diagnosis.

Answer 25

Inflammation and destruction of apical periodontium.

Question 26

What can be seen on radiograph of asymptomatic apical tissues ?

Answer 26

Apical radiolucency.

Question 27

Will asymptomatic apical tissues be TTP + or - ?

Answer 27

Negative.

Question 28

What is an apical abscess ?

Answer 28

Inflammatory reaction to pulpal infection and necrosis.

Question 29

How can you locate what tooth periapical abscess is coming from ?

Answer 29

GP cone, into sinus and radiograph.

Question 30

What radiographic signs will be seen with condensing osteitis ?

Answer 30

Diffuse radiopaque lesion at apex.

Question 31

Define condensing osteitis.

Answer 31

Localise bony reaction to low grade inflammation at apex.

Question 32

Mandibular right first molar has been hypersensitive to cold and sweets over the past few months but symptoms have subsided recently. Now no response to thermal testing and TTP+. Radiograph - diffuse radiopacities around root apex. What is the initial and current diagnosis ?

Answer 32

Initial diagnosis - symptomatic apical diagnosis. Current diagnosis - pulp necrosis with condensing osteitis.

Question 33

Following placement of full gold crown on maxillary right second molar. Patient complained of sensitivity to both hot and cold liquids, now discomfort is spontaneous. Ethyl chloride - experience pain and upon removal, 12 seconds. TTP - normal. Radiographic - no changes. What is the diagnosis ?

Answer 33

Symptomatic irreversible pulpitis with normal apical tissues.

Question 34

Maxillary left first molar has occlusal-medial caries and patient has been complaining of sensitivity to sweets and to cold liquids. No discomfort to biting or percussion. Tooth is hyper-responsive to ethyl chloride with no lingering pain. What is the diagnosis ?

Answer 34

Reversible pulpitis with normal apical tissues.

Question 35

Mandibular right lateral incisor has an apical radiolucency that was discovered during a routine examination. History of trauma more than 10 years ago and the tooth was slightly discolored. The tooth did not respond to Endo-Ice® or to the EPT; the adjacent teeth responded normally to pulp testing. There was no tenderness to percussion or palpation in the region. What is the diagnosis ?

Answer 35

Pulp necrosis. Asymptomatic apical periodontitis.

Question 36

Mandibular left first molar - relatively large apical radiolucency, both the mesial and distal roots along with furcation involvement. Periodontal probing depths were all within normal limits. The tooth did not respond to thermal (cold) testing and both percussion and palpation elicited normal responses. Draining sinus tract on the mid-facial of the attached gingiva which was traced with a gutta-percha cone. There was recurrent caries around the distal margin of the crown. What is the diagnosis ?

Answer 36

Pulp necrosis. Chronic apical abscess.

Question 37

Maxillary left first molar was endodontically treated more than 10 years ago. The patient is complaining of pain to biting over the past three months. There appear to be apical radiolucencies around all three roots. The tooth was tender to both percussion. What is the diagnosis ?

Answer 37

Previous RCT. Symptomatic apical periodontitis.

Question 38

Maxillary left lateral incisor exhibits an apical radiolucency. No history of pain and the tooth is asymptomatic. There is no response to Endo-Ice® or to the EPT, whereas the adjacent teeth respond normally to both tests. There is no tenderness to percussion or palpation. What is the diagnosis ?

Answer 38

Pulp necrosis. Asymptomatic apical periodontitis.