Having been working on the Dental emergency clinic for the past few weeks I have noticed that a lot of students are getting their pulpal diagnosis mixed up.

This is a nice flow chart I stole from the rather fantastic endo blog that might help you figure them out. Getting this provisional diagnosis right will make your final diagnosis far easier. You will know what to look for in the mouth, the radiograph and what treatment to offer.

Ideally you should know what pulpal diagnosis you’d expect to see from your history and what kind of situations to look for.

Reversible:  Sharp transient pain with hot/cold. Usually for a few weeks before patient gets it checked, often in a well kept mouth. It can be interproximal caries, a loose filling, lost filling or fracture. It can even be a cracked tooth presentation so check with tooth sleuth or cotton wool to test it.

Cotton wool test is bite hard as possible on cotton wool roll then let go quickly: if painful suspect crack.

Irreversible: Severe pain, spontaneous or after a cold/hot drink. Lasts for about an hour after it starts. Unable to locate source of pain but feels one side rather than the other. Painkillers ease pain. Worse at night (this is because lying down the blood pressure rises in inflamed pulp). At late stage cold can actually help as it restricts blood supply to pulp.

This is likely to be a recently placed deep filling, filling lost a few months ago, deep interproximal caries (these are the sneaky ones). Check with ethyl chloride and radiograph!

pulpaldiagnosisperiapicaldiagnosis

Please note you should reach a provisional diagnosis before taking your radiograph and it should be one of the above. If there is a huge swelling and a chroinc apical abscess you don’t need to tell the person you present to the tooth is necrotic it will be obvious. The disease is already a few more rungs down the ladder of disease progression.

Also I still call symptomatic apical periodonitis, acute apical periodonitis and I think most people do. It probably means we’re out of date but better to be out of date and have the people who mark you understand than not!

Also for fun here are some additional features.

Reversible pulpitis only occurs if there is fairly significant primary decay so you really need a radiograph to exclude it. It is too easy to think they might have a dentine hypersensitivity.

Irreversible pulptits can be easily located to the correct side but often confused upper or lower so get your ethyl chloride out and try both arches. Take radiographs and be sure. If it is irreversible it will need an access don’t join the ledermix liner brigade. Basically if you do you kill the pulp slowly (mainly painlessly) making a future inevitable sclerotic root canal in 3-5 years very difficult.

Don’t forget about perio. This can cause tenderness; spreading pain and even sensitivity like symptoms if it doesn’t fit check the gums. If it isn’t the tooth it’s often the gingiva. Get your BPE probe out and check them, it will save you a lot of heart ache.

Hope this helps!

Chris

P.S If any 5th years have any questions they want to go over on the blog then let me know (Or if your at Newcastle you will find me on DEC until April)  and I’ll try to get round to covering them. I know you’ve all suddenly got very interested in dentistry… I wonder why!

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