Which complete endodontic diagnosis may be entirely asymptomatic yet still requires endodontic therapy?

Correct answer: A. Pulpal necrosis with chronic apical periodontitis

• A. CORRECT. This is the silent combination. The pulp is dead, so there is no pulpal pain. The apical lesion is CHRONIC, so pressure is vented and there is no percussion tenderness. The patient feels nothing, but the tooth is infected and will not heal without root canal treatment. These are typically discovered on routine radiographs.
• B. The word ACUTE means symptomatic — this patient would present with pain on biting.
• C. Reversible pulpitis is managed by removing the irritant and placing a restoration. It does not require endodontic therapy.
• D. A normal pulp does not produce apical periodontitis of endodontic origin — and acute apical periodontitis is by definition symptomatic on percussion.

Note: Chronic apical periodontitis = necrotic pulp + apical radiolucency + no symptoms. It is the single most common incidental finding that mandates root canal treatment.