Clinical Classification of Pulpal and Periapical Diseases Van Hassel’s Theory of Pulpal Death ENDO 331, Friday, January 12, 2007 Dr. C.S. Wenckus.

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….