Review Article Identify and Define All Diagnostic Terms for Periapical/ Periradicular Health and Disease States James L. Gutmann, DDS,* J. Craig Baumgartner, DDS, MS, PhD,† Alan H. Gluskin, DDS,‡ § Gary R. Hartwell, DDS, MS, and Richard E. Walton, DMD, MSjj Abstract Introduction: The purpose of this in-depth investigation ne of the hallmarks of any profession is its distinct lexicon; this is no different with was to identify, clarify, and substantiate clinical terminology Othe dental specialties. Within this framework of the lexicon, there should exist relative to apical/periapical/periradicular diagnostic states, clarity, succinctness, and specificity that are based on sound biological principles which is used routinely in the provision of endodontic and understandings, clinical realities, and daily usages. Even in a global society in which care. Furthermore, the information gleaned from this inves- differences may exist, there must be a commonality of thought, a distinct explicitness of tigation was used to link diagnostic categories to symp- meaning, and a rational basis for the choice of terminology and its routine application, toms, pathogenesis, treatment, and prognosis wherever as opposed to personalized, empiric bias that is used to exaggerate an individual’s possible, along with establishing the basis for the metrics thought process or perceived and unsupported interpretation. Oftentimes, the latter used in this diagnostic process. Materials and Methods: is identified as colloquial and bears little resemblance to the actual issue, event, or Diagnostic terminologies and their relevance to clinical procedure at hand. Within the discipline of endodontics, this latter type of lexicon situations were procured from extensive historic and elec- has been proffered in contemporary times regardless of the historic framework on tronic searches and correlatedwithcontemporaryconcepts which it has evolved. in disease processes, clinical assessments, histologic find- On the other hand, the clinical discipline of endodontics and its scientific ings (if appropriate), and standardized definitions that counterpart, endodontology, have been using a terminology in which biological have been promulgated and promoted for use in the last concepts are commingled with that of the clinical, often leaving the reader or 25 years in educational programs and test constructions clinician confused, with therealissuebeingobfuscatedbythedualmeaningof and for third-party concerns. Results: In general, clinical commonly used and unclear definitions. Hence, the communication between terminology that is used routinely in the practice of and among colleagues can suffer as well. For example, the specific determination endodontics is not based on the findings of scientific inves- of pulpal and apical (also known as periapical/periradicular) diagnostic states, tigations. The diagnostic terms are based on assumptions the instruments and tests used to determine these conditions, the clinician’s by correlating certain signs, symptoms, and radiographic understanding of such an ability to make the appropriate determination, and findings with what is presumed (not proven) to be the the patient’s understanding of the issues at hand are often times confusing, underlying disease process of a given clinical state. There with multiple clinicians arriving at vastly different interpretations of the same were no studies that specifically tried to assess the accu- data. Furthermore, this can lead to treatment that may or may not be warranted racy of the metrics used contemporarily for the classifica- or at least may not have a sound basis for application. For example, one practi- tion of clinical disease states. Conclusion: Asuccinct tioner may describe a clinical set of diagnostic data as being an abscess, whereas diagnostic scheme that could be described thoroughly, another might label it as an acute apical periodontitis, another an apical infection, agreed on unanimously, coded succinctly for easy elec- and another a tooth that has had a ‘‘blow up.’’ Moreover, neither definition nor tronic input, and ultimately used for follow-up analysis interpretation identifies a treatment appropriate to the clinical reality that is would not only drive treatment modalities more accurately, present or how the information gleaned during the examination of the patient, but would also allow for future outcomes assessment and if thorough and defining, was used to make the final determination of the patient’s validation. (J Endod 2009;35:1658–1674) status. However, there is a perception bymanycliniciansthatthetreatmentis actually not different with the different diagnostic terms stated, which raises the Key Words question as to whether the diagnosis should be a separate activity from the treat- Apical, periapical and periradicular disease, diagnostic ment. The diagnosis may affect the treatment plan, prognosis, and the need for categories, diagnostic terms supportive therapy in additiontothetreatmentitself. The purpose of this investigation was to examine, through an extensive search of the literature, the scientific and clinical bases for periapical diagnostic states and their diagnostic terms in an attempt to answer the following questions. † From *Baylor College of Dentistry, Dallas, TX; Oregon 1. How should the degree of periapical pain be quantified clinically? Health & Science University, Portland, Oregon; ‡Department of Endodontics, University of the Pacific, San Francisco, Califor- 2. What are the endodontically related conditions involving root-supporting nia; §Naval Postgraduate Dental School, Bethesda, Fairfax, Vir- tissues? ginia; and jjDepartment of Endodontics, University of Iowa 3. Based on the highest level of available evidence, what diagnostic terms best represent College of Dentistry, Iowa City, Iowa. apical/periapical/periradicular health and the various forms of periapical/ perira- Address correspondence to James L. Gutmann, DDS, 1416 dicular disease? Spenwick Terrace, Dallas, TX 75204-5529. E-mail address: [email protected]. 4. Which combination(s) of metrics provide the maximal accuracy for establishing 0099-2399/$0 - see front matter periapical diagnoses? Copyright ª 2009 American Association of Endodontists. 5. What gaps in knowledge remain for developing and validating metrics and the doi:10.1016/j.joen.2009.09.028 resulting periapical diagnosis? 1658 Gutmann et al. JOE — Volume 35, Number 12, December 2009 Review Article Chronic apical abscess—long-continued infection maintained by Material and Methods Literature Search organisms of relatively low virulence. Four general types: 1. Abscess is partially opened and there is drainage via the root The historic basis for the classification of diseases of the root- canal supporting tissues and the terminology used to describe each diagnostic 2. ‘‘Fistulous’’ opening is present—known as chronic abscess with state were investigated by using information obtained from textbooks sinus that have been identified as classic and meaningful in the evolution of 3. Granuloma (chronic dentoalveolar abscess) the discipline of endodontics. Each text consulted is detailed later 4. Variation of #2 with the ‘‘fistulous discharge’’ coming at the free with the data gleaned from within. The initial purpose of providing margin of the gingival between the root and the alveolar wall this information in detail is for the contemporary reader to appreciate the historic evolutionary process of the diagnostic issues that have These four classifications were described from more of a histo- served as the basis for current thinking and applied terminology. pathological standpoint by Gilmer (6) in 1914. Marshall appears to have characterized the chronic lesion radiographically in a manner Historic Review that is still used today: ‘‘The roentgenograph is one of the best means Harris (1) wrote that the only disease entity that was pertinent was at our disposal for determining the existence of a chronic condition. the alveolar abscess. Alveolar abscess is defined as deep-seated, throb- It is characterized by a rather well-defined radiolucent area, or dark bing, and painful disease that at times is excruciating and continues with shadow, which may or may not be exactly at the apex of the tooth.’’ only occasional slight intermissions after matter is formed, when it, in Prinz (7, 8) in his text publications of 1928 and 1937, identified a great degree, subsides, and is succeeded by slight paroxysms of heat specific diseases of the ‘‘pericementum’’ with reference to inflammation and cold. He recognized that the abscess could open to the oral cavity of the ‘‘peridental’’ membrane. after bone resorption but did not provide a specific designation (eg, Clinical observations for the inflammation of the peridental fistula or sinus). membrane were: Tomes and Nowell (2) focused on the inflammation of the alveolar The diseased tooth is readily located—the pain is steady in degree periosteum (lining membrane of the sockets of the teeth) and addressed general inflammation, identifying it as being from ‘‘.a and in its position. No reflex symptoms are observed. The tooth is very sore to touch; occlusion in mastication or ordinary bad state of the system.’’ and local inflammation ‘‘involving the peri- osteal investment of the roots of one or two teeth.’’ They described this shutting of the teeth produces pain irrespective of thermal changes. inflammation as acute or chronic and referred to acute and chronic Percussion induces pain. The tooth is raised in its socket and strikes before any of the