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Key Takeaways:
- It may feel like the most boring part of endo, but getting the right pulpal and periapical diagnosis is crucial, whether you take on the case yourself or refer it out to a specialist. Not only does it help you guide your patient’s treatment plan, but it also ensures you cover your butt and avoid litigation later on.
- You should be performing pulpal and periapical tests for every single tooth you treat, making sure to document the results clearly in your patient’s chart. Like its name suggests, pulpal tests help you understand the status of the pulp, while periapical tests help you identify inflammation or infection around the tooth’s root.
- The combined results of your tests will determine your diagnosis. For example, a tooth with no response to cold indicates a necrotic pulp, while a tooth that is tender to percussion indicates Symptomatic Apical Periodontitis.
Let’s talk diagnosis. I’ve got pulpal and periapical diagnosis on the brain after revisiting a few cases that really made me examine the importance of getting the right endodontic diagnosis, along with clear documentation and proactive communication with our patients.
An endodontic diagnosis may be tricky—but that isn’t an excuse to skip it! Before you ever open a tooth, you need to know its diagnosis, so you can explain why you accessed the tooth to begin with. Point blank. Period.
I know what you’re thinking. “Sonia, this is such a booooring part of endo.” But it’s totally at the heart of what we do—and it’s straight up how you cover your butt and avoid litigation later on. Not to mention (and most importantly!), an accurate diagnosis leads to the right treatment decisions for your patients!
From diagnosis to documentation—this stuff is so important to avoid legal trouble, support specialists you refer out to, and give your patients A+ care.
Let’s get into it.
Pulpal and Periapical Diagnosis: Start Here
It’s essential that you always have a pulpal AND a periapical diagnosis for every tooth that you treat—plus this should be documented clearly in the patient’s chart along with your diagnostic tests. The diagnosis sets the stage for how you treat and manage your patient and make sure all their teeth remain healthy.
I like to start by nailing down my pulpal diagnosis.
So, let’s examine the symptoms in more detail, shall we?
Pulpal diagnosis is essentially what your cold test is testing for—it’s helping you get a sense of the status of the pulp. Do not skip this step. It is SO very important.
| Tooth feels cold and heat with no lingering pain → Normal Pulp | The tooth has a normal response to cold and heat. It feels the temperature, but then the sensation goes away after a few seconds. A tooth that has a normal pulp could still need a root canal for restorative reasons, like a post in order to retain the core. You’ll see this pulpal diagnosis for teeth that need elective endo. |
| Decay into the pulp, but no pain → Asymptomatic Irreversible Pulpitis | The tooth needs a root canal and still feels temperature, but there is no real pain associated with the hot or cold stimulus. I usually see this in teeth with a large carious lesion that has already reached the nerve. It’s asymptomatic because the patient doesn’t have pain, and it’s irreversible because the bacteria has permanently damaged and exposed the pulp. |
| Exaggerated response to cold or heat → Symptomatic Irreversible Pulpitis | This diagnosis always means trouble for our patients, who generally are having a ton of pain and walk in as an emergency. It doesn’t always need to be a “hot” tooth, but this type of pulpitis has an exaggerated response to cold or heat. When I do a cold test, and the patient has a stronger or lingering response to cold (the amount may vary from patient to patient), this will be their pulpal diagnosis. |
| Tooth has no response to cold → Necrotic Pulp | This is a really easy one to diagnose! |
| The tooth has had a root canal started, but it hasn’t been finished → Previously Initiated | I see this one when one of my referring dentists starts the endo, gets stuck, and then sends it to me to finish up. This also happens when the patient moved from another location, or they never returned to finish treatment. |
| Tooth has had a completed root canal → Previously Treated | Note the difference from the Previously Initiated diagnosis, and make sure you distinguish this clearly. |
Phase one complete! But we need a pulpal AND a periapical diagnosis, so our work isn’t done yet.
On to the Periapical Diagnosis!
The periapical diagnosis comes from your percussion test (or your bite test) and your radiograph.
The percussion test and radiograph are every bit as important as the cold test is for a pulpal diagnosis. Make sure you do all of them–yes, all of them!
Here are your options when it comes to diagnosis:
| Everything’s normal → Normal Periodontium | We love to see some normal periodontium! Here, the tooth will have no pain to percussion, and the apex looks pristine on the radiograph. It has normal alveolar bone, a normal PDL, and an intact lamina dura. |
| A periapical radiolucency is visible with no pain to percussion → Asymptomatic Apical Periodontitis | I call this “the silent lesion.” It’s not great, but at least the patient isn’t experiencing lots of pain. |
| The tooth is tender to percussion → Symptomatic Apical Periodontitis | It may or may not have a periapical radiolucency. |
| The tooth has a sinus tract → Chronic Apical Periodontitis | The abscess indicates the presence of pus, and the “chronic” part means that it’s an infection that has been there for some time. Most of these patients don’t have pain, but they can still be a bit tender to percussion. When I see a sinus tract, the diagnosis of Chronic Apical Periodontitis (CAP) will trump that of Symptomatic Apical Periodontitis (SAP). And don’t forget you can have a sinus tract that drains through the sulcus, too! This stuff is tricky, so pay attention. |
| The patient is swollen → Acute Apical Abscess | Sometimes they have significant facial swelling, and sometimes it’s a small vestibular swelling, so bear in mind there are a variety of ways this can show up. Again, the abscess signifies the presence of purulence. Your patient may have little pain or a lot of pain when it comes to percussion, but the diagnosis of Acute Apical Abscess (AAP) will always trump that of SAP. |
From Theory to Application
Let’s look at three cases. I’ll provide some background information and then radiographic imaging.
Here’s your task: From the information provided, what are your pulpal and periapical diagnoses?
Don’t worry, I won’t hold out on you—just scroll to the bottom of the blog post for the correct answers.
CASE #1: This patient has no response to cold on tooth #30, but does have severe tenderness to percussion. What are your pulpal and periapical diagnoses?
CASE #2: This patient has no pain on tooth #30, but there was a pulp exposure while doing the crown preparation. The tooth responded normally to cold and was slightly tender to percussion. What are your pulpal and periapical diagnoses?
CASE #3: Tooth #18 has no response to cold and no pain to percussion. However, there is a 9mm probing on the disto-buccal. What are your pulpal and periapical diagnoses?
Let’s See How You Scored on Your Pupal & Periapical Diagnosis!
Pulpal Diagnosis: Necrotic Pulp
Periapical Diagnosis: Symptomatic Apical Diagnosis
Pulpal Diagnosis: Asymptomatic Irreversible Pulpitis
Periapical Diagnosis: Symptomatic Apical Periodontitis
Pulpal Diagnosis: Necrotic Pulp
Periapical Diagnosis: Chronic Apical Periodontitis
Note: This tooth is totally saveable! Don’t get fooled by the amount of bone loss and the probing depth. It’s just a sinus tract draining through the sulcus.
How’d you do?!
Endo diagnosis isn’t easy stuff, so don’t be hard on yourself if you didn’t come up with the correct answer in every case.
And if you’d like a little more support, grab my free diagnostic checklist, print it out, and put it to good use starting today!
I hope this post has made you feel more confident in your diagnostic skills so you can better understand and explain to your patients their pulpal and periapical diagnoses and come up with the right treatment plan together.
Sonia
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34 Comments
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Thank you SO much Megan! I appreciate you helping me spread the word!
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-Sonia
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Thank you Del – I appreciate you helping to spread the education!
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honestly, i learn so much from your blog and your knowledge and ease of explaining difficult concept cease to amaze me. Thank you, doctor. I can never thank you enough as a current struggling dental student. I hope to mentor others and strive for excellence for my patients in the future.
Best,
HS
Thank you so much for your kind words. I have no doubt you’ll become an excellent mentor in the future!
-Sonia
Thank you so much for reading, and for your kind words.
-Sonia
I’m glad it’s helpful!
-Sonia
Thank you for that informative post.
I have a small doubt from case 2. Could you please explain how the pulpal diagnosis is irreversible pulpitis since the sensibility test was normal? Is it because the apical periodontitis cannot occur without a pulpal cause or there was the long-standing pulpal exposure from the crown prep?
Hi AC. Many times, when there is decay into the pulp or a pulp exposure, there is no pain. It’s irreversible pulpitis because the bacteria has landed in the pulp, but it’s asymptomatic irreversible pulpitis because they don’t have any pain at all and these patients test normal. Hope this helps!
-Sonia
Hi! Why is it on case no. 3 not ASSYMPTOMATIC apical periodontitis? Why did you also not mention the the diagnostic term CHRONIC Apical Periodontitis on your disscusion about periapical diagnosis? And hie does CHRONIC Apical Periodontitis differ from ASSYMPTOMATIC Apical Periodontitis? Thank you! Nice blog by the way🙂
Hi there. Case #1 is symptomatic Apical Periodontitis because there is tenderness to percussion. The definition of Chronic Apical Abscess is the presence of a sinus tract. Apical Periodontitis has been split up between Asymptomatic and Symptomatic Periodontitis to differentiate when there is tenderness to percussion. These terms have been amended over the years.Thank you.
-Sonia
Thank you for the incredible effort
I have a question regarding case 3
Why the apical diagnosis is asymptomatic periodontitis not abscess even though there is a sinus tract and the pus is draining through the sulcus ?
Hi Fenowchi, thank you for your question. The diagnosis for case #3 is necrotic pulp and chronic apical abscess due to the sinus tract. -Sonia
Pretty! This has been an incredibly wonderful article.
Many thanks for providing these details.
Thank you for reading!
-Sonia
hello, can a tooth have a diagnosis : Pulpal Diagnosis: Irreversible Pulpitis
Periapical Diagnosis: Chronic Apical Periodontitis
Hey there. No you can’t. You need a dead nerve to have a Chronic Apical Periodontitis. Hope this helps.
-Sonia
I think so, but I read a article about periapical radiolucency in teeth with Irreversible pulpitis https://www.researchgate.net/publication/233404062_Evaluating_the_Periapical_Status_of_Teeth_with_Irreversible_Pulpitis_by_Using_Cone-beam_Computed_Tomography_Scanning_and_Periapical_Radiographs
Can You explain it to me? And in case of pulp polyp with periapical radiolucency. Thank you very much!
Hello doc wat if there was a trauma to a central incisor with a minute pulp exposure but tests normal to thermal tests but has sensitive touch. Wat is the diagnosis to this case?
Sounds like it would be asymptomatic irreversible pulpitis and symptomatic apical periodontitis. I would do a MTA Vital pulp therapy and see what happens, so make sure to follow up this patient.
-Sonia
Pulpal Diagnosis & Symptoms of Pulpitis Very well Explained. Looking forward to more Such informative Stuff.
Thanks for reading!
-Sonia
Oh my god ..just i understand how to solve diagnosis questions ..thank u very much for this amazing way in explaining
Thank you for reading!
-Sonia
It is very useful Pulp & Periodontial diagnosis.
Hello. This really helpful article but I have a question.
Is there a possible diagnosis “Asymptomatic Irreversible Pulpitis & Normal Periodontium?
Case: No pain and No response for cold test, but there was deep decay closed to the pulp. EPT test is positive and no pain on percussion.
How would you diagnosis this patient?
Thanks!!
Julia,
That absolutely can be a diagnosis! You are exactly right!
-Sonia
Hi Sonia, thank you so much for the helpful post! It really helps to clarify a few things. As a relatively new graduate, I sometimes find it challenging to make a diagnosis, especially when the patient’s pain history isn’t very clear. I was wondering if it’s possible to have a pulpal diagnosis of symptomatic irreversible pulpitis (exaggerated response to endo-frost) along with symptomatic periapical periodontitis (small apical pathology visible on the radiograph and tenderness to percussion). I was told that if an apical area is present on the radiograph, the tooth wouldn’t respond to the cold test.
Hi Sophia, there is always a spectrum of irreversible pulpitis, so keep that in mind. The more time the tooth has been exposed to that infection, the bigger that lesion will be. Not every radiolucency you see will be due to a necrotic tooth and could be pathology so keep doing your cold testing. And not every necrotic tooth will have a radiolucency at the time of your evaluation. Remember there is always a spectrum and that is why our testing and our interpretation of those tests are so important.
Great read, Dr. Chopra! You’re so right that diagnosis can feel like the “boring” part, but it’s honestly the foundation everything else stands on. I’ve seen too many cases where skipping a proper pulpal test led to an unnecessary access or a missed referral. Clear documentation and walking the patient through *why* we’re testing really does save headaches later. It also makes me think about how much we rely on systematic checks—almost like exploring an unknown map. Sometimes you need a little extra resource to make sense of the territory, kind of like how I use a reference guide for less familiar cases, similar to checking a handy palworld element chart when I’m stuck. It keeps me thorough and consistent. Thanks for the reminder that diagnosis isn’t just paperwork—it’s patient safety and legal protection in one. Looking forward to more posts like this!
You’re very welcome! Loved your comment 💜