Semiologia y Dg 2

8/10/2019 Semiologia y Dg 2

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Review Article

Diagnostic Terms for Pulpal Health and Disease States 109J! " #olume $%& 'um(er 1)& Decem(er )009

A

*dentif+ and Define All Diagnostic Terms for PulpalHealth and Disease States

,inda -. ,evin& DDS& PhD&/ Alan S. ,aw&DDS& PhD&

-.R. Holland& Sc& DS& PhD& 2ert !ndo&

2RS!&3

Paul #. A((ott& DSc& 4DS& 5RA2DS6!ndo7&8

and Ro(ert S. Roda& DDS& 4S

A(stract

*ntroduction: 2onsensus 2onference Su(committee )

was charged with the identification and definition of

all diagnostic terms for pulpal health and disease states

(+ using a s+stematic review of the literature. 4ethods:

!ight data(ases were searched& and numerous

widel+ recogni;ed endodontic te tions that can (e

identified in the dental pulp& diagnostic terms that can

(est represent pulpal health and disease& and metrics

used to arrive at such designations. Results and

2onclusions: n the (asis of the findings of this

in=uir+& specific diagnostic terms forpulpal health and

disease are suggested. *n addition& numerous areas

for further stud+ were identified. 6J !ndod

)009?$%:1@%B

1@%C7

e+ EordsDental pulp& diagnosis& metrics

5rom the /School of Dentistr+& Fniversit+ of'orth 2arolinaat 2hapel Hill& 2hapel Hill& 'orth 2arolina?

Private

Practice& ,aGe !lmo& 4innestoa?3School of Dentistr+&

Fniversit+ of 4ich> igan& Ann Ar(or& 4ichigan?8School of

Dentistr+& Fniversit+ of Eestern Australia& Perth& EA&Australia? and

a+lor2ollege of Dentistr+& Dallas& Tevid& Pu(4ed& Ee( of nowledge& 2ochrane ral Health -roup& !4AS!&S2PFS& -oogle Scholar& and 4edstor+. 'onB!nglish language citations andnonhuman studies were e!lsevier& St ,ouis& 4& )00@? Principles and Practice of !ndodontics&th ed& Tora(inead 4& Ealton R!& Saunders& Philadelphia& PA& )00M? !nc+clopediaof Pain& Schmidt R5& Eillis ED& Springer& erlin& -erman+& )00@? !ssential!ndodontol> og+: Prevention and Treatment of Apical Periodontitis& NrstaviG D&Pitt 5ord TR& lacGwell Pu(lishing&


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Review Article

110 ,evin et al. J!" #olume $%& 'um(er 1)& Decem(er )009

pain& moderate pain& and severe pain. The patientchooses the word that (est descri(es their

pain& and a num(er is assigned to this& depending onits ranGing in terms of intensit+.

'umeric rating scales are a list of num(ers& fore sponds to their pain intensit+.


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TA,! 1. Fse of Dolorimetr+ Techni=ue in (servations of Pulpal Pain

#er(al rating 'umeric rating #isual analog 2olor analog 2ali(rated 5inger Span 2ortical evoGedscales scales scales scales =uestionnaires Scale potentials

1@ $ 1@ ) ) $ %

#isual analog scales consist of a line with ) end points of no painLLand worst pain ever.LL The patient marGs a point on the line that relatesto the intensit+ of their pain. The distance of that point from nopainLListhe measure of pain intensit+.

2olor analog scales are used with children. A series of graded inintensit+ colors are anchored at each end (+ the terms no painLLandworstpain.LL

2ali(rated =uestionnaires should reall+(e cali(rated =uestion>naire (ecause there is onl+ one that has gained widespread acceptance&the 4c-ill Pain uestionnaire. This consists of )0 groups of descriptorsselected from the medical literature that descri(e the sensor+ =ualitiesof the pain& the affective =ualities of the pain& or are evaluativedescri(ingthe overall intensit+ of the e mined on the ranG values of the words. The 4c-ill Painuestionnairehas (een translated into at least 1@ languages and is ver+ widel+ used. *tsadvantage is that it allows measurement of the different components ofthe pain edimensional measure ofthe edimen>sional.

5inger span scaling has largel+ (een used in children (ecause itovercomes the comple sent a tin+LL hurt& and a somewhat wider distance ismediumLLhurt. Ehen the forefinger and thum( are moved as farapart aspossi(le&this is mostpossi(le hurt.LLThe span in each instance is measured.

2ortical evoGed potentials are components of an electroencepha>logram taGen while appl+ing a no


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ined the efficac+ of the various scales in descri(ing pulpal pain. Thisrepresents a significant deficit of Gnowledge in the area of pulpal

pain assessment. The most prevalent approach endodontists use toassess pulpal pain is an informal ver(al descriptor scale& withterms such as severe& intermittent& or spontaneous (eing widel+used. The visual analog scale has achieved wide acceptance in thee sion to num(ers. The scale is clinicall+ useful&

particularl+ with long> term pain& and serves as a valua(le tool for themonitoring and assess> ment of clinical interventions. 2ali(rated

=uestionnaires 6essentiall+ the 4c-ill Pain uestionnaire7 have ver+(road acceptance in man+ areas&(ut the+ would (e less appropriateand more time>consuming in the setting of the dental office thaneither ver(al descriptor or visual analog scales. The use of fingerspan and color analog scales is generall+ confined to ver+ +oungsu(ects and would (e of limited application in the dental office.Although electroencephalograph+ would (e an e


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s+mptoms or pain. *rreversi(le inflammation of the pulp is produced (+carious e


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enhanced (lood suppl+ created (+ the open apices allows the immaturepulp to(etter resist (acterial invasion than a more mature pulp 6M1&M$7& and the opening through the carious lesion into the oralcavit+esta(lishes a pathwa+ for drainage of pulpal inflammator+ efloatingcells of the oral mucosa are seededLL onto the proliferating granuloma>tous tissue& resulting in a stratified s=uamous epithelium 6C7& andthe resultant lesion is rarel+ painful epathic in that the trigger for the metaplastic transformation ofnormal pulp cells into clastic ones is unGnown. Several h+potheseshave(eenproposed 6M& M%7& and it is possi(le that it might (e acom(ination of these that starts the resorptive process. The resorptionsometimes moves swiftl+ and then might (e followed (+ a time ofslower or no growth in the si;e of the lesion 6C7. *nternalresorption is generall+ painless and is usuall+ found clinicall+ throughroutine radiographic screening& when it appears generall+ as anovoid enlargement of the pulp space 6M@7 in which the original

(orders of the pulp space (ecome distorted or disappear altogether6M& M%& MC7. The lesion sta+s associ> ated with the root canal on

angled radiographs 6M& M%7. The tooth might respond to pulpsensi(ilit+ tests& (ut occasionall+ the tests might(e negative if there ispartial necrosis with the advancing resorptive lesion within theliving portion of the pulp tissue su(acent to the necrotic tissue6@%& M& M%7. *f perforation of the tooth structure has occurred andthe tissue in the pulp space is e lowingthe color of the underl+ing granulomatous tissue to (e visi(le?however& this might also (e due to undermining& su(epithelial e f+ing 6MM& M97. -enerall+& pulp fi(rosis or atroph+ isa histologic change that is not clinicall+ discerni(le unless the pulpspace is entered during the initial phases of root canal therap+& so itsvalue as a diagnostic term is =uestiona(le. Pulp calcification& however&is usuall+ clinicall+ detect> a(le (efore treatment and can directl+ affectthe prognosis of treatment& in that severel+ calcified teeth arepredisposed to tooth perforation during the search for canals 6907.This entit+ is also sometimes referred to as pulp canal o(literation 6@%7or calcific metamorphosis 691& 9)7& (ut (oth terms appear to (einaccurate (ecause the canal is rarel+ completel+ o(literated 69$7&and there is actuall+ no metamorphosisLL of the tooth& ust a

progressive deposition of dentin 6secondar+ or tertiar+7 resultingin radiographicall+ apparent shrinGage of thepulp


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canal space 6@7. 2alcification& per se& does not necessaril+ impl+that progressive inflammation of the pulp or pulp necrosis willoccur. *n fact& pulp necrosis is found in less than C of traumaticall+induced calcified pulps 697. ,astl+& the mineral content of thetertiar+ dentin represents more than ust calcium hence the term pulpcanal mineral> i;ation would (e a more accurate term.

Previousl+ *nitiated Treatment

ccasionall+& a tooth that has had endodontic therap+ previousl+started (ut not completed will present for diagnosis 6@7. These teeth

would have undergone previous pulpotom+ or pulpectom+& andthe histor+ and clinical e


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TA,! ). 2omprehensive 2linical Diagnostic S+stem

2linicall+ normal pulp: (ased on clinical eitis is defined in dictionaries as indicating inflammation of the tissuewhose name it is attached to& ie& the pulp 610C& 10M7.

Some teeth with pulpitis can (e clinicall+ managed via conservativemeans 6such as a simple restoration or a sedative dressing followed

(+ a restoration7& whereas others re=uire more radical treatment&which

implies removal of the pulp either as part of endodontic treatment orvia eversi(le pulpitis& although some dispute e ni;ed that in the disease continuum& partial necrosis cane


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most important aspect of this assessment is to determine whetherthe root canal s+stem is infected (ecause an infected canal willcause apical


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Review

Ar

ti

cl

e

1@%0TA,! $. 2omparative Terminolog+ and 2lassifications of Pulp Diseases Fsed (+ #arious Authors and rgani;ations 6)B17

Eorld Healthrgani;ation

)Eeine

$*ngle

Selt;er and ender

%2ohen and

urns@

TronstadC

6'ote: 'ormalpulp not 6'ote: 'ormal pulp not Health+pulp 6'ote: 'ormalpulp not Eithin normal limits& Health+pulpmentioned7 mentioned7 mentioned7 normal pulp& calcific

metamorphosisPulpitis: initial Pulpitis: h+peralgesia Pulpitis: h+per>reactive Pulpitis: incipient form Pulpitis: reversi(le& Pulpitis: as+mptomatic

6h+peremia7& acute& 6reversi(lepulpitis7& pulpalgia& of chronicpulpitis& irreversi(le& pulpitis& s+mptomaticsuppurative 6pulpal h+persensitive h+persensitivit+& acute pulpitis& as+mptomatic& pulpitisa(scess7& chronic& dentin& h+peremia& h+peremia& acute chronicpartial irreversi(lepulpitis&chronic ulcerative& painful pulpitis& pulpalgia& incipient& pulpitis with partial h+perplastic pulpitis&chronic h+perplastic acute pulpalgia moderate& advanced& necrosis& chronic internal resorption&6pulpal pol+p7& other 6acute pulpitis7& chronicpulpalgia& totalpulpitis with canal calcification&unspecified pulpitis& chronicpulpalgia h+perplasticpulposis partial li=uefaction s+mptomaticpulpitis unspecified 6su(acute pulpitis7& necrosis& chronic irreversi(lepulpitis

nonpainful pulpitis& partialpulpitischronic ulcerative 6h+perplastic form7

pulpitis& chronicpulpitis 6no caries7&chronic h+perplasticpulpitis 6pulp pol+p7

'ecrosis of thepulp Pulp necrosis Pulp necrosis& Pulp necrosis 'ecrosis: partial& 'ecroticpulpli=uefaction& sicca complete

Pulp degenerations& Pulp degeneration& Pulp degeneration& Pulp degeneration&denticles&pulpal atroph+& d+strophic atrophic pulposis& atrophic pulp&calcification& pulpal calcification calcific pulposis d+strophicstones minerali;ation

A(normal hard tissue *nternal resorption *nternal resorptionformation inpulp&secondar+ orirregular dentin

American Association of!ndodontists-lossar+

MHart+

9Ealton and

Tora(inead10

-rossman11

2astellucci1)

StocG1$

ergenholt;1

'ormalpulp 'ormalpulp 6'ote: 'ormalpulp not 6'ote: 'ormalpulp not Health+pulp 'ormalpulp Pulpa sanamentioned7 mentioned7

Pulpitis: reversi(le Pulpitis: reversi(le Pulpitis: reversi(le H+peremia&pulpitides& Pulpitis: H+peremia& 2oncussedpulp& Pulpitispulpitis& irreversi(le pulpitis& irreversi(le pulpitis& irreversi(le acute pulpitis& pulpitis irreversi(le reversi(lepulpitis&pulpitis pulpitis pulpitis& h+perplastic chronic ulcerative irreversi(le pulpitis

pulpitis pulpitis& chronich+perplastic pulpitis

Pulp necrosis 'ecrosis Pulpal necrosis 'ecrosis 'ecrosis Pulpal necrosis 'ecrosis pulpaePulp calcification& internal Pulp degeneration& *nternal resorption

6intracanal7 resorption calcific& fi(rous&atrophic& internal

resorption

5rom A((ott P #& Uu 2. A clinical classification of the status of the pulp and the root canal s+stem. Aust Dent J )00C?%):61 Suppl7:S1CBS$1. Reproduced with permission from the Australian Dental Journal.


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Review Article

Diagnostic Terms for Pulpal Health and Disease States 11%J! " #olume $%& 'um(er 1)& Decem(er )009

periodontitis. *t is also important to assess the technical standard ofthe root canal filling (ecause this might determine whether furthertreat> ment is re=uired andIor feasi(le. Such determination is usuall+(ased on the radiographic appearance of the root canal filling.

*f there are no signs or s+mptoms to suggest that a root>filled toothis infected& then the management of such a tooth might (e simpl+ one ofo(servation and reassessment. *n other cases& the root filling might(e

udged as(eing technicall+ unsatisfactor+ and re=uiring replacement(efore further restoration of the tooth. Hence& specific diagnostic termsare re=uired for these situations. ecause the tooth is not infected& itwould (e appropriate to sa+ it is a root>filled tooth with no signsof infectionLL 6@%7. The phrase no signs of infection does notnecessaril+ impl+ that the root canal s+stem is not infected& (ut merel+that there isno clinical or radiographic evidence of it (eing infected at the time ofefilled toothLL6@%7.

Teethwith *ncomplete !ndodontic TreatmentPatients might present to dentists andIor endodontists with a

tooth that has had endodontic treatment commenced at some time inthepast& (ut the treatment was not completed. There are a widevariet+ ofpossi(le reasons wh+ the treatment might not have (eencompleted 6eg& patient did not return for treatment& patient wasreferred to a specialist for further treatment7? these might or mightnot (e relevant to the diagnosis in all cases. *t is important todistinguish these cases from other conditions outlined a(ove and

(elow (ecause their clinical management might (e different.*f a tooth has had endodontic treatment commenced (ut

not completed and it has no signs of the root canal s+stem (eing

infected&then the tooth could (e classified as having incompleteendodontictreatment with no signs of infectionLL6@%7. The phrase no signs ofinfection does not necessaril+impl+ that the root canal s+stem is notinfected& (ut merel+ that there is no clinical or radiographic evidenceof it (eing infected at the time of etion& untreated canal7 should (e listed as part of the diagnosis 6@%7.

Teethwith Degenerative andIor Ph+siologic 2hanges tothe Pulp

Dental pulps undergo ph+siologic changes ust liGe allother tissues in the (od+. Such changes are not pathologic innature& and the+ might (e difficult to diagnose clinicall+. ,iGewise&some pulps might undergo degenerative changes over time. *f there areclinical or radio> graphic manifestations of the degeneration& it isimportant to consider these conditions as part of the diagnostic

process and therefore to include them in a classification of theStatus of the Pulp and the Root 2anal S+stem.LL

T+pical conditions are pulp canal calcification& either part of thenormal aging process or it can (e an indication of long>standing

irrita>tion to the pulp. 2alcification is defined as a(normaldeposition of

calcium salts within tissueLL 61107. H+perplasia is defined as ana(normal increase in cells in a tissue or organ& e


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Review Article

11@ ,evin et al. J!" #olume $%& 'um(er 1)& Decem(er )009

tion& where(+ the (ulG of the tissue or organ is increasedLL 61117.This term can (e used when there has (een an overgrowth ofgranulation tissue originating from the pulp& and it might result in thedevelopment of a pulp pol+p. *t has (een suggested that theinflammation might (e limited to the pulp cham(er and that theapical pulp tissues might (e normal& e tion. ecause this condition isassociated with inflammation& the term should (e h+perplasticpulpitis.

Teethwith *nternal ResorptionThree forms of internal root resorption have (een reported&

although var+ing terminolog+ has(een used to descri(e them. Thedifferent forms of internal resorption re=uire different clinical manage>ment& and therefore it is essential that the+ (e differentiall+ diagnosedfrom one another. The proposed terminolog+ is internal surface resorp>tion& when ust minor areas of the root canal wall have(een resor(ed611)7. This resorption might(e self>limiting and might repair if thepulp is relativel+ health+ and if the irritating stimulus has (een removedfrom the tooth.

*nternal inflammator+ resorption occurs when an inflammator+response within the pulp 6ie& pulpitis7 leads to activation of dentinoclas>tic cells& which resor( the dentin walls of the root canal and then prog>ress through the dentin toward the cementum 611$7. This resorption is

(elieved to (e a result of the presence of microorganisms withinthecoronal part of the root canal that cause pulpitis in the pulp apical tothe resorptive area 611$7. Hence& a tooth with active internal inflamma>tor+ resorption will have some necrotic and infected pulp tissue as wellas some pulp tissue with irreversi(le pulpitis. *f the condition is definedas such& then there is no need to mention each of these conditions in thediagnosis. The dentinoclasts present in internal inflammator+resorp>tion will onl+ remain alive and active as long as there is a via(le(loodsuppl+ to the apical part of the pulp. *f this (lood suppl+ is lost& then theapical part of the pulp will necrose& and the dentinoclasts will alsodie. Thus& the internal inflammator+ resorption will no longer (e

active.T+picall+& the necrotic apical pulp tissue is then digested and removed(+ the microorganisms& and the entire canal will (ecome pulpless 6asdescri(ed a(ove7& resulting in apical periodontitis. nce apicalperio>dontitis is evident& it is highl+ liGel+ that the resorption is no longeractive& which will maGe clinical management somewhat easier andless involved. Hence& it is important to distinguish (etween active andnonactive states of internal inflammator+ resorption.

*nternal replacement resorption is a metaplastic t+pe of change tothe dental pulp in which the pulp first is replaced (+ (one& andthensu(se=uentl+ the dentin is replaced (+ (one 611$7. This conditionmust (e distinguished from the other ) t+pes of internal resorptionmentioned a(ove (ecause its clinical management is =uite different&ie& the tooth can (e e


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TA,! . Accurac+ of 2old Testing

Reference -old standard Sensitivit+ Specificit+ Positive predictive value 'egative predictive value

Selt;er et al 61)M7 Histolog+ 0.CM 0.M1 0.C 0.9Dummer et al 61$)7 Histolog+ 0.@M 0.C0 0.$$ 0.91Petersson et al 61$$7 2linical

a

0.M$ 0.9$ 0.M9 0.90!vans et al 61)17 2linical

(0.9) 0.M9 " "

-opiGrishna et al 61)07 2linicalc

0.M1 0.9) 0.9) 0.M1

a*n Petersson et al 619997& gold standard was determined (+ directpulp inspec tion.LL

(*n !vans et al 619997& pulpal status was confirmed(+ pulpectom+. LLc*n -opiGrishn a et al 6)00C7& pulpal status was evaluated (+ direct visual inspection.

agreed on definition for pulpal disease& which might or might not(e impractical or desira(le to use within clinical practice& is termedthe gold standard test or reference test. The results from such a goldstan> dard test for pulp diagnosis is used to compare with thediagnostic test (eing evaluated for the determination of testing accurac+.Studies as> sessing diagnostic accurac+ for pulpal disease testinghave used ) differentgold standard tests: a clinicall+ derived measure6eg& presence of necrotic tissue on accessing a tooth would indicatethat the tooth was nonvital7 and a histologicall+derived measure 6eg&on e ular changes& metrics used toesta(lish a perirad icular diagnosis might aid in the determination of a

pulpal diagnosis. 5or e


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TA,! @. Accurac+ of !lectric Pulp Testing


Selt;er et al 61)M7 Histolog+ 0.9M " " "Petersson et al 61$$7 2linical

a

0.C) 0.9$ 0.MM 0.M!vans et al 61)17 2linical

(0.MC 0.9@

-opiGrishna et al 61)07 2linicalc

0.C1 0.9) 0.91 0.C

a*n Petersson et al 619997& gold standard was determined (+ directpulp inspection.LL

(*n !vans et al 619997& pulpal status was confirmed(+ pulpectom+. LL

c*n -opiGrishn a et al 6)00C7& pulpal status was evaluated (+ direct visual inspection.

!vans et al 61)17 reported that the presence of esion& and histor+ of pain were all found to have a high specificit+60.9C or (etter7 (ut low sensitivit+ 60.9 or lower7 for nonvitalit+.However& the authors failed to disclose the clinical criteria that wereused for assessment of these characteristics& maGing it impossi(le tovalidate their findings. A clinical finding of carious pulp e


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a*n -opiGrishn a et al 6)00C7& pulpal status was evaluated (+ direct visual inspection.


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TA,! M. Accurac+ of ,aser Doppler 5lowmetr+


!vans et al 61)17 2linicala 1.0 1.0 " "

a*n !vans et al 619997& pulpal status was confirmed(+ pulpect om+.LL

determine when the pulpal inflammation is irreversi(le. The a(ilit+ to

determine when inflammation of the pulp has(ecome irreversi(lewould& therefore& guide the pract itioner and patient in treatmentchoices 6ie& nonsurgical root canal treatment vs e =uent necrosis & infection& and apicalperiodontitis.

DiscussionSu(=uestion O%: Ehat -aps in nowledge Remain forDeveloping and #alidating 4etrics and the ResultingPulpal Diagnoses

*n the area of clinical =uantification of pulpal pain& it was o(servedthat the maorit+ of studies were performed in e ical setting. #er(al rating scales& numeric rating scales& visualanalog scales& color analog scales& cali(rated =uestionnaires& andfinger span scaling were reviewed in the conte

nolog+& clinical classifications are the most appropriate. The clinicall+normal pulp is that pulp that is free from s+mptoms and vital. *nflam>mation of the pulp orpulpitis is a(road categor+ that can (e furtherdivided into reversi(le or irreversi(le& depending on the degree andcharacter of presenting s+mptoms. The demarcation is significant

(ecause endodontic intervention is recommended for the latter. These) categories can (e further divided on the (asis of s+mptoms or thelacG thereof. As+mptomatic irreversi(le pulpitis and s+mptomaticirrevers> i(le pulpitis have different presentations (ut the sametherapeuticoutcome. Presuma(l+ ever+ tooth with deca+& minor trauma& or peri>odontal disease has as+mptomatic reversi(le pulpitis. 4inor s+mptomsof sweet or thermal sensitivit+ represent s+mptomatic reversi(le

pulpitis.

Pulp necrosis is characteri;ed (+ necrosis of thepulp tissue. Totalnecrosis is the most easil+ diagnosed entit+& whereas partial necrosiscan (e the most difficult. H+perplastic pulpitis is a rare condition usuall+descri(ed in immature teeth with gross pulpal etor+ mediators to resor( dentin. Although painless& it can threatentoothretention if left unchecGed. Pulp calcification is the result of degenera>tive changes in the dentalpulp& with efilled tooth without signs of infection Root>filled tooth with signs of infection

*ncomplete endodontic treatment without signs of infection *ncomplete endodontic treatment with signs of infection Pulp canal minerali;ation

H+perplastic pulpitis

*nternal inflammator+ resorption 6active or inactive7 *nternal surface resorption

The su(committee recogni;es that there are other =ualifierssuch as the perceived presence or a(sence of infection 6ie& necrotic

pulp with infection7. This is not alwa+s easil+ determined clinicall+. *tis recom> mended as a point of discussion in terms of adopting it as

part of termi> nolog+. *t should (e emphasi;ed that levels of evidence inthe literature supporting the use of specific clinical diagnosticterminolog+ are gener> all+ ver+ low& in that the classification schemesappear to (e mainl+ the opinions of the various authors who providelogical arguments for their choices in developing nomenclature on the

(asis of studies with levels of evidence rarel+ eopment of sensitivit+& specificit+& positive predictive values& and negative

predictive values (+ esta(lishing a gold standard. The identification of(iologic marGers for reversi(le and irreversi(le pulpal inflammationwill (e of immense value in determining the need for endodonticinter>vention and the prevention of apical periodontitis.

TA,! 9. A(normal Response to 2old Testing and *rreversi(le Pulpitis

Reference -old standardLL Sensitivit+ Specificit+ Positive predictive value 'egative predictive value


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Selt;er et al 61)M7 Histolog+ 0.1 0.C@ 0.$ 0.M1Dummer et al 61$)7 Histolog+ 0.@$ 0.M0 0.M 0.MM-arfunGle et al 61197 Histolog+ 0.%C " " "

5rom H+man JJ& 2ohen 4. The predictive value of endodontic diagnostic tests. ral Surg ral 4ed ral Pathol 19M?%M:$$B@.


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TA,! 10. 4etrics for pulpal diagnosis 6and specificall+ reversi(le versusirreversi(le pulpitis7 on the (asis of histor+ of the presenting s+mptoms

Reversi(le pulpitis *rreversi(le pulpitis

Sensitivit+ to mild discomfort Pain might(e a(sent orpresent

1C. de Pa; #illanueva ,!2. 5uso(acterium nucleatum in endodontic flare>ups. ralSurg ral 4ed ral Pathol ral Radiol !ndod )00)?9$:1C9BM$.

1M. DoroschaG A4& owles ER& Hargreaves 4. !valuation of the com(ination offlur> (iprofen and tramadol for management of endodontic pain. J !ndod1999?)%:@@0B$.

19. !hrmann !H& 4esser HH& 2larG R4. 5lare>ups in endodontics and their relation>Short duration or shooting

sensation

Histor+ of pain is usuall+given

ship to various medicaments. Aus !ndod J )00C?$$:119B$0.

)0. Hsiao>Eu -E& Susarla S4& Ehite RR. Fse of the cold test as a measure ofpulpal

'ot severe Pain is often moderate tosevere

anesthesia during endodontic therap+: a randomi;ed& (linded&place(o> controlled

clinical trial. J !ndod )00C?$$:0@B10.*nfre=uent episodes of

discomfort

Seldom hurts to (ite unless

tooth also fractured orrestoration is loose andocclusion is affected

2ould result in irreversi(lepulpitis if source notremoved

S+mptoms usuall+ su(side

immediatel+ after removal

if cause

Pain is often spontaneous

Pain is increasing infre=uenc+& often to thepoint of (eing continuous

Pain usuall+ lingers& especiall+with increasing episodes

Patient often re=uires some

t+pe of analgesic

4ight(e a(le to identif+specific or multiple stimuli

Pain radiates or is diffuse or

might(e locali;ed

)1. emppainen P& Ealtimo A& Ealtimo T& ononen 4& Pertovaara A. Differentialeffects of notar+ hospital. J Dent )00@?$:@$%B0.

@. 2oda & TanaGa A& Jaco(son R2& Donaldson -& 2hapman 2R. H+dromorphoneanalgesia after intravenous (olus administration. Pain 199C?C1:1BM.

C. 2oda A& Hill H5& Schaffer R,& ,uger TJ& Jaco(son R2& 2hapman 2R. !nhance>ment of morphine analgesia (+ fenfluramine in su(ects receiving tailored opioidinfusions. Pain 199$?%):M%B91.

M. 5alace DA& Reid & Ra+ens 4. The influence of deep 6odontogenic7pain inten>sit+& =ualit+& and duration on the incidence and characteristics of referred oro>facial pain. J rofac Pain 199@?10:)$)B9.

9. 5ran;en -& Ahl=uist 4,. The intensive aspect of information processing in theintradental A>delta s+stem in man: aps+choph+siological anal+sis of sharp dentalpain. ehav rain Res 19M9?$$:1B11.

10. -angarosaSr ,P& 2iarlone A!& 'eaverth !J& Johnston 2A& Snowden JD&

Thompson E. Fse of ver(al descriptors& thermal scores and electrical pulptesting aspredictors of tooth pain (efore and after application of (en;ocainegels into cavities of teeth with pulpitis. Anesth Prog 19M9?$@:)C)B%.

11. lages F& Fluso+ & ianifard S& Eehr(ein H. Dental trait antip intraosseous inection in patients with irreversi(le pulpitis. J!ndod )00$?)9:C)BM.

1%. wat; 2& han AA& Schindler E-& Schwart; SA& eiser & Hargreaves 4. Theincidence of mechanical allod+nia in patients with irreversi(le pulpitis. J !ndod)00C?$$:%%)B@.

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http://dictionary.reference.com/browse/itishttp://dictionary.reference.com/browse/itishttp://dictionary.reference.com/browse/pulpitishttp://dictionary.reference.com/browse/pulpitishttp://dictionary.reference.com/browse/pulpitishttp://dictionary.reference.com/browse/necrosishttp://dictionary.reference.com/browse/necrosishttp://dictionary.reference.com/browse/calcificationhttp://dictionary.reference.com/browse/calcificationhttp://dictionary.reference.com/browse/calcificationhttp://dictionary.reference.com/browse/calcificationhttp://dictionary.reference.com/browse/itishttp://dictionary.reference.com/browse/pulpitishttp://dictionary.reference.com/browse/necrosishttp://dictionary.reference.com/browse/calcificationhttp://dictionary.reference.com/browse/calcification


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