IR Feb Bellamy 8/1/04 11:54 am Page 1 CLINICAL The art and science of diagnosis in endodontics Dr Raphael Bellamy confronts current diagnostic terminology in endodontics and introduces Dr Schilder’s simple classification of pulpal disease In my article last month on the disease process. A liberal subsides as soon as the stimulus tooth (deep carious lesion, biological objectives of sprinkling of histological terms is removed. There is also pain extensive restoration). An EPT endodontic treatment laid and other language based upon reported when the tooth is in will produce a positive test. down by Schilder, I wrote the presenting condition does contact with acidic, basic This condition of the pulp is briefly about the concept of nothing, in my view, to help substances or sweetness. irreversible and requires having a real commitment to improve our ability in decision Patients may describe endodontic therapy. Usually the excellence in endodontics making of when to treat and symptoms of fleeting pain and application of ice or cold will based upon our knowledge, not to treat a tooth will often not be able to locate reverse the symptoms of a skill and desire. endodontically. the source of the pain. This pulpitis produced by heat. Excellence in endodontics is First and foremost we are stage can last for months or • Necrosis gangrene a decision and this degree of clinicians, not histologists. years. An investigation of the Conditions following the commitment starts from the They have their domain behind symptoms may reveal a carious untreated pulpitis or, for moment the patient presents microscopes of a different sort lesion, recent restorative example, trauma causing for treatment. Diagnosis is and they are essential in the procedures, defective disruption of the blood supply treatment. field of medicine and dental restorations or cervical erosion. may lead to necrosis and This month’s article medicine. Their ability to Confirmation is obtained with a gangrene. comments on the terminology identify subtle differences in positive cold test that will not The pulpal tissue is dead used in the art and science of histopathology on a cellular produce any lasting pain and a and if the condition is not diagnosis in endodontics. level is important for the positive electrical pulp test treated, the noxious materials, Certainly the area of classification of diseases. (EPT). No endodontic treatment infected or not, leaking from diagnosis in endodontics is However, I see these is needed for this condition. the pulp system will lead to a fraught with misapprehension. descriptions as little help for Usually a sedative-type dressing lesion of endodontic origin I feel this is due to the slow the clinician at the ‘rock face’. will suffice, followed by a (LEO) even in the absence of evolutionary process of To this end I set before you permanent restoration when the bacterial infection. understanding the endodontic the classification used by Dr symptoms have completely It is usually an asymptomatic Herbert Schilder, a superb wet- subsided. condition that will not give any gloved clinician in his day who The above are reversible. response to the EPT. To confirm during his practising career the condition stwo tests should wrote over 100 scientific Those below are irreversible: be conducted, preferably the articles, contributed chapters to • Pulpitis heat test and the electrical test. many textbooks on It is characterised by If no response is elicited, then endodontics, and lectured at intermittent or continuous endodontic treatment is major dental meetings in more episodes of spontaneous pain. required. than 25 countries on every Sudden temperature changes • Acute alveolar abscess continent. Put simply: will produce prolonged (AAA) • Normal episodes of pain. A heat test will The patient will complain of A normal tooth gives a confirm the symptoms and will throbbing, pulsing and moderate response to pulp tests produce a delayed or pounding pain. In this case the (EPT) and this response will paroxysmal response. Often the offending tooth is easily subside when the stimulus is patient cannot localise the pain, identifiable and the pain Raphael Bellamy BDS (NUI) removed. The tooth is free of only say whether it is the right localised to a specific area. Very Cert. Endo. is a graduate of spontaneous pain. Radiographs side or the left. These episodes often the subject will describe University College Cork and will show an absence of pulp of pain can last for hours, or the tooth as being in The Goldman School of Dental calcification, internal resorption even days, and will almost hyperocclusion. There is an Medicine in Boston, and an intact lamina dura. certainly be exacerbated by increased degree of mobility. Massachusetts, where he • Hyperaemia flight. Pain can also be reported The operator should rely on completed his postgraduate This is the first stage where the on changes in posture, exertion the EPT and heat test, with no studies in endodontics. He is pulp is symptomatic. There is a or exercise. response expected of either. currently in private practice sharp hypersensitive response Radiographs are helpful in One additional helpful limited to endodontics in Dublin to the cold test, but the pain certain cases to detect a suspect indication is the extreme 10 Irish Dentist February 2004 IR Feb Bellamy 8/1/04 11:54 am Page 2 sensitivity to percussion and old, multi-filled teeth of their palpation. Radiographically the Schilder’s classifications Commonly used classifications sclerotic, sluggish pulps prior periapical tissues may appear Normal Normal to full coverage or bridge normal as a result of the Hyperaemia Reversible pulpitis prostheses. acuteness of the stage. Well-performed endodontic The above are reversible Irreversible pulpitis therapy is a highly predictable, The importance of simplifying Symptomatic irreversible pulpitis successful means of eliminating the process pulpal disease and its sequelae. There is no doubt that the five Those below are irreversible Asymptomatic irreversible pulpitis It also retains the tooth, the listed classifications laid down Pulpitis Necrosis periodontium and the by Schilder are an over- surrounding bone. simplification of an extremely Necrosis gangrene Acute apical periodontitis Harping back to my complex disease process. The A Acute alveolar abscess Acute apical abscess previous article of belief in B C D of cardiovascular endodontic therapy, I say to resuscitation are too. But in the Chronic apical periodontitis you that if you really believe in heat of battle this is what we Phoenix abscess the predictability of need. It is a complex disease endodontics, as I do, then get And there may be more by now! process in that there is a on and get that pulp out so the continuum. A start of the tooth can be predictably disease process coronally, One can imagine easily the pulp is either healthy or not, restored for a long and several important stages along scenario of the dolorous patient and must either be removed or useful future. the journey south and then to being informed that root canal not. The capacity of the mature final Armageddon. The end therapy is not required because pulp to repair following References usually results in loss of the a diagnosis of reversible pulpitis traumatic, chemical, thermal, Cohen S (1994) Diagnostic tooth due to complete failure of has been made, and within mechanical or bacterial assault Procedures. In: Pathways of the Pulp. the support apparatus. But to hours a root canal is required as is extremely poor. The reasons 6th Edition, chapter 1 overcomplicate clinical the condition relentlessly for this are myriad and beyond diagnosis unnecessarily for the worsens to irreversible pulpitis. the scope of this short article. You can contact practising clinician is Not a great reflection on our Well-trained, experienced Dr Bellamy via email undesirable and certainly does learned profession. prosthodontists, quite rightly, at [email protected] the patient no favours. In the final analysis, the do not hesitate to rid 60-year- Irish Dentist February 2004 11.