Clinical Endodontics (eBook)

2 The Definitive Diagnosis

The data collected from the subjective and objective examinations is what directly facilitates the development of a definitive diagnosis. While the great majority of pain and infection in the orofacial region relates to endodontic pathology, clinicians must also be aware of nonendodontic diseases that may present similarly. This chapter reviews the diagnosis of endodontic pathology and its adjuncts, as well as common differential diagnoses.

Diagnosis of Endodontic Pathology

Every endodontic diagnosis consists of two parts: the pulpal diagnosis and the periapical diagnosis (Fig 2-1).1 These diagnoses are developed based on the results of the clinical and radiographic examinations. The diagnostic terminology for both the pulpal and periapical diagnosis is defined in the glossary of this book, and the clinical test results used to establish these diagnoses are organized in Tables 2-1 and 2-2. The pulpal and periapical diagnoses are separate but related entities. Certain pulpal diagnoses correlate with certain periapical diagnoses (Fig 2-2), and typical patterns emerge in diagnosis.

Fig 2-1 Pulpal and periapical diagnoses.1

+ = response similar to controls; ++ = heightened response; – = no response; PDL = periodontal ligament; PARL = periapical radiolucency.

+ = greater sensitivity than controls; – = similar to control responses; PARL = periapical radiolucency; PDL = periodontal ligament.

Fig 2-2 Common combinations of pulpal and periapical diagnoses.

Though diagnosis-specific clinical and radiographic findings are generally well defined, the chief complaint may be variable, particularly for teeth with necrotic pulps or teeth that were previously endodontically treated or where endodontic treatment was initiated. For example, a previously treated tooth containing untreated anatomy may present with a history of heat sensitivity as well as biting tenderness (Fig 2-3). Teeth with vital pulp tissue can similarly present in a myriad of symptomatic and asymptomatic states. Additionally, radiographic findings may be limited by anatomical noise when 2D imaging is used,2 though CBCT imaging will overcome these limitations to showcase apical pathology whenever present.3 For example, although periapical radiolucencies in the posterior maxilla are difficult to visualize with periapical imaging due to overlap with the maxillary sinus, CBCT removes this obstruction4 (Fig 2-4).

Fig 2-3 Heat sensitivity may develop in previously endodontically treated teeth with untreated canals. (a) This patient presented with a chief complaint of heat sensitivity in the right maxilla that was localized to the maxillary right first molar during testing. (b) Preoperative CBCT imaging revealed an untreated second mesiobuccal canal. (c) Retreatment of the tooth resolved symptoms.

Fig 2-4 Periapical pathology is often much more apparent on CBCT imaging than periapical imaging due to anatomical noise, particularly in the posterior maxilla. In this case, periapical pathology was suspected only in the maxillary right first molar when studied with periapical imaging (a) but confirmed to extend also to the second molar in the sagittal section of CBCT imaging (b).

Adjunctive endodontic diagnoses

Beyond the pulpal and periapical diagnoses defined for each endodontically involved tooth, certain teeth have comorbid conditions either causing the endodontic pathology or increasing its complexity. These adjunctive diagnoses include fractures, resorption, periodontal-endodontic infections, and traumatic dental injuries, described in detail in part III. It is important for the diagnosing clinician to understand and define these conditions because they greatly impact management strategies. Each condition involves its own nuanced diagnostic methodology and criteria and management strategy.

Maxillary sinusitis of endodontic origin

Not only can nonodontogenic sinus pathology produce dental symptoms including thermal sensitivity and pressure discomfort, but dental pathology also has the ability to produce unilateral sinus disease. The latter effect has long been recognized by the medical community. Otolaryngologists often refer patients with unilateral sinusitis for dental evaluation.5,6 This pathologic extension of endodontic disease into the maxillary sinus, referred to as maxillary sinusitis of endodontic origin (MSEO), should be considered in the context of adjunctive endodontic pathology.7

Whenever sinus pathology is present secondary to endodontic disease, patients will often volunteer a history of symptoms including low-grade nasal drainage, congestion, or headaches. Although 2D images rarely depict obvious signs of MSEO given the limitations of this modality in visualizing the sinus,2 CBCT images readily depict sinus pathology.4 The earliest and most common sign of MSEO is periapical mucositis, a thickening of the sinus mucosa greater than 2 mm often creating a dome-shaped appearance adjacent to the apex of an infected tooth.8,9 Later stages of MSEO present with periapical osteoperiostitis, an osteogenic reaction that elevates the sinus periosteum into the sinus. This creates a corticated border superior to the periapical lesion that may close around the lesion or open and drain into the adjacent sinus cavity. MSEO may also present as unilateral opacification of the entire maxillary sinus adjacent to the diseased tooth (Fig 2-5).

Fig 2-5 (a) Endodontic pathology in the posterior maxilla is often associated with periapical mucositis, even before pulp necrosis develops and apical radiolucencies are apparent. (b) Late stage MSEO is associated with periapical osteoperiostitis. (c) Severe MSEO is associated with unilateral opacification of the sinus. (d) Air bubbles may also be noted in the mucosa, suggestive of MSEO.

Endodontic treatment represents first line therapy for MSEO. It will typically resolve both mild sinonasal symptoms and radiographic sinus pathology7 (Fig 2-6). If symptoms remain or radiographic findings persist at follow-up, referral to otolaryngology specialists is advised. Patients with severe or chronic sinonasal symptoms or disease should be informed of the potential need for concomitant medical management of sinus disease, usually by way of saline irrigation and topical corticosteroids10 and possibly surgical interventions to facilitate...