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Clinical Classification of Clinical Classification of Pulpal and Periapical Pulpal and Periapical
DiseasesDiseases
Van Hassel’s Theory of Pulpal DeathVan Hassel’s Theory of Pulpal Death
ENDO 331, Friday, January 12, 2007
Dr. C.S. Wenckus
ALL ENDODONTIC Dx ALL ENDODONTIC Dx MUST INCLUDE A:MUST INCLUDE A:
• Pulpal DiagnosisPulpal Diagnosis
• Periapical DiagnosisPeriapical Diagnosis
COLLECTION COLLECTION OF DATAOF DATA
RECORD RECORD OBJECTIVE OBJECTIVE FINDINGSFINDINGS
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
• Normal pulpNormal pulp
• Reversible Reversible
PulpitisPulpitis
• Stressed PulpStressed Pulp
• Irreversible PulpitisIrreversible Pulpitis– AcuteAcute– ChronicChronic
• Necrotic PulpNecrotic Pulp• Previously TreatedPreviously Treated
Pulpal Diagnostic Terms
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Pulpal Diagnostic Terms
Normal Normal PulpPulp
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Pulpal Diagnostic Terms
ReversiblReversible Pulpitise Pulpitis
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Pulpal Diagnostic Terms
Stressed Stressed PulpPulp
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Pulpal Diagnostic Terms
IrreversiblIrreversible Pulpitise Pulpitis
Acute?Acute?Or Or Chronic?Chronic?
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Pulpal Diagnostic Terms
NecroticNecrotic
THE STRANGULATION THE STRANGULATION THEORYTHEORY
Van Hassel chokes off the Strangulation TheoryVan Hassel chokes off the Strangulation Theory
SO, HOW DOES A PULP DIE?SO, HOW DOES A PULP DIE?
INITIAL INSULT
TOTAL PULPITISTOTAL PULPITIS
INCREASED LOCAL TISSUE PRESSURE
IRRITATION TO CLINICAL CROWN
LOCALIZED PULPAL INFLAMMATION
LOCALIZED EFFECTVENOUS COLLAPSE STASIS ISCHEMIA LOCAL NECROSIS
RELEASE OF INFLAMMATORY MEDIATORS
LOCAL NECROSIS OF ADDITIONAL TISSUE
CIRCUMFERENTIAL VASCULAR DISTURBANCE
INCREASED TISSUE PRESSURE
MECHANISM OF
SPREAD
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Pulpal Diagnostic Terms
PreviouslPreviously Treatedy Treated
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
• NormalNormal
• Acute Apical Periodontitis Acute Apical Periodontitis [AAP][AAP]
• Subacute Apical Subacute Apical Periodontitis [SAP]Periodontitis [SAP]
• Chronic Apical Chronic Apical Periodontitis [CAP]Periodontitis [CAP]
• Acute Apical Abscess [AAA]Acute Apical Abscess [AAA]
• Chronic Apical Abscess [CAA]Chronic Apical Abscess [CAA]
• Condensing OsteitisCondensing Osteitis
• Lesions of Non-endodontic Lesions of Non-endodontic
OriginOrigin
Periradicular Diagnostic Terms
In the latest glossary of In the latest glossary of endodontic terms, the endodontic terms, the
specialty is leaning toward specialty is leaning toward substituting “periradicular” substituting “periradicular” for “periapical” or “apical” .for “periapical” or “apical” .
Seventh Edition, copyright 2003, AAE
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
NormalNormal
Periradicular Diagnostic Terms
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Acute ApicalAcute Apical
(Periradicular)(Periradicular)
PeriodontitisPeriodontitis
Periradicular Diagnostic Terms
Irreversible Pulpitis with AAP
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Periradicular Diagnostic TermsSubacute Subacute
Apical Apical
(Periradicular (Periradicular ) )
PeriodontitisPeriodontitis
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Periradicular Diagnostic Terms
Chronic Chronic
Apical Apical
PeriodontiPeriodontitistis
A clarification is needed in A clarification is needed in you text book.you text book.
Page 37 states “As a consequence of Page 37 states “As a consequence of pulpal necrosis pathologic changes can pulpal necrosis pathologic changes can
occur in the periradicular tissues”.occur in the periradicular tissues”.
What is What is missing?missing?
A clarification is needed in A clarification is needed in you text book.you text book.
Page 37 should state “As a Page 37 should state “As a
consequence of pulpal necrosis, consequence of pulpal necrosis, in the in the presence of microorganismspresence of microorganisms, , pathologic changes can occur in the pathologic changes can occur in the
periradicular tissues”.periradicular tissues”.
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Acute Apical Acute Apical AbscessAbscess
Periradicular Diagnostic Terms
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Acute Apical Acute Apical AbscessAbscess
Periradicular Diagnostic Terms
ACUTE APICAL ACUTE APICAL
(PERIRADICULAR) (PERIRADICULAR)
ABSCESS IS THE ABSCESS IS THE ONLY ONLY
CONDITION WHICH CONDITION WHICH MAYMAY
REQUIRE LEAVING A REQUIRE LEAVING A
TOOTH OPEN FOR TOOTH OPEN FOR
DRAINAGE!DRAINAGE!
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Chronic Apical Chronic Apical AbscessAbscess
Periradicular Diagnostic Terms
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Condensing Condensing OsteitisOsteitis
Periradicular Diagnostic Terms
CLINICAL DIAGNOSTIC CLINICAL DIAGNOSTIC TERMINOLOGYTERMINOLOGY
Lesions of Lesions of Non-Non-
Endodontic Endodontic OriginOrigin
Periradicular Diagnostic Terms
The Difficult DiagnosisThe Difficult Diagnosis
“CC”; “This tooth” (patient points to #30) “had been very sensitive to hot and cold, but recently it just sort of aches and will occasionally wake me out of a deep sleep.”
The Difficult DiagnosisThe Difficult Diagnosis
Pulp Tests:Pulp Tests: Thermal, percussion, palpation and EPT all WNL.WNL.
ARE YOU A LITTLE CONFUSED?ARE YOU A LITTLE CONFUSED?
THEN DON’T DO THEN DON’T DO ANYTHING!!!!ANYTHING!!!!
““There is no more There is no more
miserable human being miserable human being
than one in whom nothing is than one in whom nothing is
habitual but indecision.”habitual but indecision.”
William James (1842 - 1910)
The Difficult DiagnosisThe Difficult Diagnosis
The pain The pain diminished and diminished and eventually eventually disappeared disappeared altogether. altogether. Routine follow-Routine follow-up six months up six months later….later….