Periapical Diagnosis

When clinicians perform restorative or endodontic treatment, they often do not obtain a periapical diagnosis. However, making a periodontal diagnosis is especially helpful when a patient presents in pain. A study by McCarthy et al ¹² demonstrated that patients presenting with periapical pain can localize the painful tooth 89% of the time and that patients who present with tooth pain without periapical pain can localize the tooth only 30% of the time.

By objectively testing the periapical tissue, a dentist can best determine its gingival and periapical status. Below are the current periapical diagnosis terminologies.¹⁰

Normal periodontal tissue: Not sensitive to percussion or palpation testing. Also, radiographically, the lamina dura surrounding the root is intact.

Symptomatic apical periodontitis: The tooth has a painful response to biting and/or percussion. This may or may not be accompanied by radiographic periapical changes.

Asymptomatic apical periodontitis: The tooth has no pain on percussion or palpation. Radiography reveals a periapical radiolucency.

Chronic apical abscess: Radiography typically reveals a periapical radiolucency, but a periapical radiolucency is not required for this diagnosis. Clinically, there is a sinus tract present on the gingival tissue. The draining sinus tract should be traced with a gutta-percha cone and then confirmed radiographically (Figure 5 and Figure 6).

Figure 5.

Figure 5.

Clinical confirmation of the periapical diagnosis—chronic apical abscess on tooth No. 19. The tooth is not sensitive to percussion or palpation. A gutta-percha cone is inserted into the sinus tract.

Figure 6.

Figure 6.

Radiographic confirmation of periapical diagnosis—chronic apical on tooth No. 19. Note the tracing of the inserted gutta-percha to the etiology.

Acute apical abscess is an inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation, and swelling of associated tissues. There may be no radiographic signs of destruction.

Condensing osteitis is a diffuse radiopaque lesion in the periapical region. The opacity represents a localized osseous reaction to a low-grade inflammatory stimulus.