Defining the Pulp Condition

By Dr. Michael Brown

This week’s blog will be the first part of a 2 part series.

This blog will not be heavy with cases, endodontic technology, or unique tooth conditions as blogs of past, but I do feel it is important to post the definitions of pulpal diagnosis. The second part of this series will focus on the definitions of the periradicular (apical) conditions. I will post the second part in the next week or two.

Certainly the basis of endodontic treatment relies upon proper diagnostics. The process of diagnostic testing allows us to interpret a tooth condition and then ultimately recommend a treatment. Every day and with every patient we classify a tooth diagnosis based upon both a pulpal and periradicular condition. And we can use a set of terms to categorize the symptoms and/or signs a tooth displays. This makes it easier to talk with the patient and much more accurate to talk with colleagues when describing the tooth and any treatment recommendations. The same is true when discussing the classification system of tooth decay, mobility, ECIR defects, and so many other examples.

Not only does it make sense to have a standard set of terms to talk amongst or colleagues, but I find it to be helpful when I record this information in the patient record. I can always reference that when a patient returns for treatment or for future recall exam.

I am sure that at one point or another all dentists have learned these terms. They might even be commonly used now in your practice. But it never hurts to have a simple reminder. It might even make sense to return to this blog series as a reference in the future. I personally keep these definitions on my computer desktop. They are also stored within our dental software.

These definitions are taken from the American Association of Endodontics glossary.

Pulpal Diagnosis:

Normal pulp.  A normal pulp is symptom free and will normally be responsive to the electric pulp tester (EPT).  When evaluated by thermal testing, the normal pulp produces a positive response that is mild and subsides immediately when the stimulus is removed.

Reversible pulpitis.  Caries, cracks, restorative procedures or trauma may cause a pulp to become inflamed.  The patient’s chief complaint is usually of an exaggerated response to thermal stimulus but once the stimulus is removed, the discomfort does not linger.  EPT results are responsive.

Irreversible pulpitis.  If the inflammatory process progresses, irreversible pulpitis can develop.  Patients may have a history of spontaneous pain and complain of an exaggerated response to hot or cold that lingers after the stimulus is removed.  EPT results are usually responsive.  The involved tooth will often present with a history of an extensive restoration and/or caries.
In certain cases of irreversible pulpitis, the patient may arrive at the dental clinic sipping a glass of ice water or applying ice to the affected area.  In these cases, cold actually alleviates the patient’s pain as the dental pulp has developed allodynia and is hyperalgesic.  Normal body temperature is now causing the nociceptors in the pulp to discharge.10  Removal of the cold causes return of symptoms and can be used as a diagnostic test.

Irreversible pulpitis can also present as an asymptomatic condition.  Internal resorption and hyperplastic pulpitis (pulp polyp) are examples of asymptomatic irreversible pulpitis.

Pulpal necrosis.  Necrosis is a histologic term that denotes death of the pulp.  Teeth with total pulpal necrosis are usually asymptomatic unless inflammation has progressed to the periradicular tissues.  The pulp will not respond to the EPT and if using a digital EPT, this result should be reported as no response (NR) over 80.  The pulp will not respond to thermal tests.  The dental record entry for this pulpal diagnosis should be pulpal necrosis.

Pulpless tooth.  A tooth from which the pulp has been removed.  For example, a tooth with previous pulpotomy/pulpectomy/root canal debridement or previous root canal therapy should be recorded as a pulpless tooth for the pulpal diagnosis.

Previously endodontically treated tooth.  Even though this is classified by the AAE as a “pulpless tooth”. I personally still like to make a distinction between a tooth that has been accessed and partially instrumented vs. a tooth that has been obturated.

These terms are fairly straight forward and easy. You will find that the periradicular definitions are a bit more complex. We will cover those soon. Also I would encourage you to copy and paste these terms to your desktop. It is always nice to have a quick reference. Sooner than you think they simply become as easy as defining a class 1 carious lesion.

Stay tuned for part deux of this definitions series!! 🙂

Thanks for visiting Tri-City and Fallbrook Micro Endodontics, serving the greater San Diego, CA area.