The interpretation of pulp and periapical diagnoses in endodontics reveals a notable divergence among clinicians, as highlighted by recent surveys. This lack of uniformity underscores potential inadequacies within the current diagnostic terminology framework, particularly when applied to diverse clinical scenarios. The ambiguity in definitions and the evolution of endodontic procedures since the inception of the consensus paper by Glickman (2009) may contribute to this diagnostic variability. Despite a modest response rate typical of online surveys, a substantial number of participants, evenly distributed between North American specialists and international practitioners, provided valuable insights, enabling a robust comparison between these clinician cohorts.
This survey was meticulously structured to evaluate the efficacy of diagnostic terms advocated in the AAE consensus paper and to assess the consistency among clinicians utilizing this diagnostic system. The findings demonstrated a strong agreement, with 82% to 96% of responses converging on a single answer across nearly all control conditions. Notably, no significant differences emerged in the diagnostic term selections for ‘controversial conditions’ between the North American and international groups across all teeth examined. These results affirm that participants engaged thoughtfully with the questionnaire and possessed a solid understanding of AAE diagnostic terminology. A minor deviation occurred in only one control condition within the ‘International Practitioners’ group, where a secondary term exceeded the 10% threshold. This anomaly may be attributed to an ambiguity in ‘Case 3’s description, specifically regarding the presence or absence of clinical swelling, suggesting a minor limitation in the survey design.
The accuracy of pulp and periapical diagnosis is paramount, directly influencing endodontic treatment planning and the necessary level of intervention. Misdiagnosis can lead to inappropriate clinical decisions and potential legal ramifications. Consider ‘Case 1’ from the survey, where 31% of participants diagnosed tooth 21 with ‘pulp necrosis’ based on its non-responsiveness to cold testing and delayed response to electric pulp testing. Clinicians arriving at this diagnosis, or their referring dentists, might anticipate endodontic intervention for a tooth deemed non‐vital, necrotic, or diseased. Conversely, approximately 56% diagnosed tooth 21 as having ‘normal pulp,’ likely due to the absence of an obvious etiological factor (like caries or fracture), its response to electric pulp testing, and radiographic evidence of pulp space recession without periapical radiolucency. This group would likely opt for ‘no treatment.’ Both diagnostic conclusions are defensible based on pulp testing, yet the pulp’s state is definitively either normal or necrotic, not both. Similar diagnostic dilemmas arise in trauma cases or in patients undergoing head and neck radiation, where neural responses can be temporarily altered while pulp vitality remains intact (Bastos et al., 2014; Gupta et al., 2018). Furthermore, the phenomenon of ‘silent pulpitis,’ where pulp deterioration occurs without pain, further complicates the accurate labeling of pulpal conditions (Michaelson & Holland, 2002).
While advanced tests like laser Doppler flowmetry and pulse oximetry offer more reliable assessments of pulp vitality (Ahn et al., 2018a, 2018b; Mainkar & Kim, 2018), their widespread adoption in daily clinical practice is hindered by their technique sensitivity, cost, and limited accessibility (Ghouth et al., 2019; Mainkar & Kim, 2018). In ‘Case 1’, the narrative indicated that access preparation was attempted on tooth 11 by the referring dentist, but canal location and subsequent pulpotomy or pulpectomy were not achieved. According to AAE diagnostic terminology, ‘Previously initiated’ denotes a clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g., pulpotomy, pulpectomy) (Glickman, 2009). The current definition excludes access preparation alone, which may explain the divided pulpal diagnoses for tooth 11, with participants choosing between ‘pulp necrosis’ (52%) and ‘Previously initiated’ (45%).
Regenerative endodontic treatment, encompassing revascularization and revitalization, represents a relatively recent advancement in endodontics, gaining broader acceptance post-AAE consensus paper (Glickman et al., 2009). This novelty may explain the pronounced diagnostic discrepancies observed in ‘Case 2’, involving a patient with a history of regenerative treatment. A majority of participants based their diagnoses on pulp sensibility responses—non‐responsive (tooth 11) or responsive (tooth 21)—to classify the pulp as ‘pulp necrosis’ (38.5%) or ‘normal pulp’ (50%). The remaining participants used ‘previously treated’ (31%–39%) or ‘previously Initiated’ (10.7%–16.9%). The existing definitions of these terms somewhat justify their application in describing pulp status post-regenerative treatment. Diagnosing ‘normal pulp’ for a tooth ‘symptom‐free and normally responsive to pulp testing’ or ‘pulp necrosis’ for a tooth ‘not responding to pulp testing’ aligns with current AAE definitions. ‘Previously treated’ is also relevant, given the tooth has undergone definitive endodontic treatment, despite the absence of root filling material radiographically. ‘Previously initiated’ could also be argued, considering a pulpectomy was performed without radiographic evidence of root canal filling material. While each term has some justification based on AAE definitions, none fully and accurately encapsulates the pulp status after regenerative treatment.
Apical periodontitis typically arises as a consequence of pulp disease, stemming from inflammation or infection within the root canal system (Kakehashi et al., 1965). Consequently, apical periodontitis (symptomatic or asymptomatic) is typically diagnosed in teeth with periapical lesions associated with necrotic or previously treated pulps. However, ‘Case 3’ posed a perplexing scenario: can apical periodontitis (symptomatic or asymptomatic) be diagnosed in a tooth with a normal, healthy pulp? In this case, 82%–94% of participants identified the pulp condition of teeth 11 and 21 as normal, based on normal pulp testing responses. Yet, the periapical diagnosis varied between symptomatic and asymptomatic apical periodontitis depending on clinical presentation. While apical disease from a healthy pulp is biologically implausible, labeling the condition as ‘normal apical tissue’ in the presence of periapical radiolucency is also clinically inaccurate. This case highlights the limitations of current diagnostic terms in reflecting the understanding that periapical disease is a sequela of pulp pathology.
According to AAE terminology, reversible pulpitis is A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to ‘normal’ (Glickman, 2009). Subjectively, sensitivity to cold is indicative of reversible inflammation. Objectively, clinical and radiographic signs of caries serve as evidence, as confirmed by histological studies (Ricucci et al., 2014). In Case 4, diagnostic discrepancies emerged for tooth 46, which presented with radiographic caries but lacked clinical symptoms. Despite normal pulp sensibility tests, 73% of participants diagnosed ‘normal pulp,’ while 23% opted for ‘reversible pulpitis,’ likely influenced by the radiographic caries evidence. Tooth 44 also showed diagnostic variability, with clinicians distinguishing between reversible (27.3%) and irreversible pulpitis (70.5%) solely based on lingering pain duration. This inconsistency may reflect a lack of consensus on the duration of lingering pain post-thermal testing that definitively indicates irreversible pulp damage. Ricucci et al. (2014) demonstrated that 16% of cases clinically diagnosed as symptomatic irreversible pulpitis were histologically reversible. Similarly, Dummer et al. (1980) found weak correlations between clinical signs/symptoms and histologically confirmed pulpal disease. These findings emphasize the need for further research to establish clearer criteria for pain duration following cold testing to improve differentiation between reversible and symptomatic irreversible pulpitis.
Further limitations of the original study warrant consideration. Restricting access to Endolit database users and direct invitations introduces a sampling bias toward internet and social media users, despite the platform’s extensive membership. Additionally, non-English speakers were less likely to participate, potentially skewing the representation.
