Challenging endodontic diagnosis: making clinical decisions
Indications for RCT can be grouped into three categories; vital inflamed pulps, necrotic pulps and re-treatment. Endodontic diagnosis is straightforward enough, most of the time, but occasionally a diagnosis can prove elusive. This article was written to help the general practitioner diagnose vital inflamed cases efficiently with an eye toward predictable clinical management. Specific methods of examination and testing procedures will be addressed.
It is assumed that an adequate medical and dental history precedes any pulpal diagnostic procedures. In addition, as a starting point, teeth with significant periodontal disease are relatively poor candidates for endodontic procedures as the prognosis of RCT on a tooth with severe periodontal disease depends primarily on the long-term prognosis for periodontal condition.
Before pulpal tests are performed, an initial periodontal examination is critical. For the sake of brevity, a comprehensive periodontal examination will not be described, but at a minimum, the tooth should be probed as well as examined with multiple radiographs for the degree of bone support and mobility noted and these findings incorporated into the endodontic treatment planning.
If the periodontal condition of the tooth is questionable, or the tooth will require additional periodontal treatment beyond the endodontics, the patient must be fully informed and certainly consent to these procedures before starting. Using the above findings, the clinician should ask themselves two key questions: 1) Can the tooth be saved? 2) Should the tooth be saved? Success rates for endodontics can only improve if treatment is carried out on teeth that are restorable, free of vertical fracture and in teeth where the chances of later fracture are minimised.
An endodontic diagnosis is never made based on radiographic evidence alone. In the hierarchy of importance, the patient’s clinical history, subjective and objective findings are primary and radiographs are least important. A prudent diagnostician will never accept the patients word as to the offending tooth without performing all confirming clinical tests to reproduce the patients chief complaint. Relying on just on one objective test is also ill advised.
All objective tests should confirm one another. At a minimum, every tooth under suspicion, including control teeth, should be subjected to percussion, palpation, mobility, probing, cold testing and possibly testing with heat. Additional secondary tests, as needed, would include electric pulp testing, the bur test (entering a tooth without anesthesia to see if a response is elicited), selective anesthesia, transillumination and visualisation through the surgical operating microscope.
Patience is counseled; if one is not sure if RCT is indicated or which tooth is the offender, treatment is best delayed until symptoms localise. This is empowering. Many is the tooth that has been started under stressful circumstances in order to relieve a patients pain only to discover that the wrong tooth has been accessed. Conversely, many is the tooth that has needed treatment, which for a variety of reasons has been left to smolder painfully where treatment was indicated from the start.
Some perplexing cases defy diagnosis even after thorough subjective, objective, and radiographic examinations. Usually, these situations do not require immediate treatment and should be rescheduled for further evaluation or possibly specialist consultation. Such consultation is prudent to prevent misdiagnosis and mistreatment of these difficult cases.
In difficult diagnostic cases, the clinician should resist the temptation to feel compelled to immediately treat all patients with symptoms. Specialist consultation, tincture of time, repetition of tests can most often permit the correct diagnosis and appropriate treatment. Symptoms often localise to the offending tooth in a matter of hours to days. Even when in pain, most patients will usually accept this delay in the interest of making the correct diagnosis.
One of the inherent difficulties in endodontic diagnosis in the early stages of pulpal disease is the fact that few, if any, changes are visible radiographically. As a specialist, it is common for patients to arrive with lingering thermal pain of several days’ duration, which is worsening in intensity, duration and frequency and having been told that their radiographs are normal and that the tooth ‘should settle down’.
Early cases of irreversible pulpits will not have any radiographic signs of pathology. The history, subjective and objective examination is the primary indication for treatment, not the radiograph. As the pathology spreads from within the root to the apical bone, after approximately several weeks to months, radiographic changes will become visible. Recognising this subtle but important point can lead to more rapid diagnosis, treatment and ultimately pain relief.
Pulpal inflammation occurs in a coronal to apical direction. Virtually anything that is done to a tooth will, can and does inflame the pulp to one degree or another. The following factors are directly correlated with pulpal inflammation and are contributing causes of pulp death: caries, frictional heat, over drying, cleansing and sterilisation, solvents, acid etching, impressions, marginal leakage, insertion and cementations of restorations, bur cutting, lack of water spray, over drying an exposed dentin surface, vibration, heat, bases, liners, etching, temporary and permanent restorative materials of all types and pins.
Skepticism of manufacturers claims regarding their materials to the contrary is advised. In addition, techniques like placing sodium hypochlorite over vital pulp exposures to ‘sterilise’ the exposure and preserve the pulp prior to capping must be viewed cautiously in terms of their long-term effect on the pulp.
Finally, it has merit to view pulpal health and indications for endodontic therapy as a continuum from vital and completely free of inflammation on one end and non-vital on another. Somewhere in the middle of this continuum there is a line over which the pulp cannot heal due to the cumulative effects of the stresses and inflammation placed upon it. The pulp will progress on and die irrespective of whatever sedative filling or time is given to allow healing. This clear dividing line is the clinical finding of lingering pain to temperature, pain to chewing, spontaneous pain and pain which has been present for an significant period of time and is not improving, usually more than a day or two.
If these symptoms are present and can be reproduced with tests, the patient needs a root canal and should be treated immediately. Hoping that the patient will improve is ill advised and most often delays needed pain relief.
As an important aside, management of these clinical events in an efficient manner is worth a brief discussion. Early management of these issues is far simpler than waiting until the patient may be in severe pain or worse yet, swollen. If time is limited, at least being able to remove the coronal pulp is highly effective for relief of irreversible pulpitis. These clinical situations will often require the use of intraossesous anesthesia for profound anesthesia.
Once straight-line access is made into the pulp chamber, a clinician can often take an orifice opener into the straightaway portion of the canal approximately 3-4 mm or usually to the top of the middle third of the canal. I use the K3 orifice Shapers (SybronEndo, Orange, CA, USA) for this task because of their tapers (.12, .10, .08), tip size (25) and robust handling characteristics.
Most often, these shapers will be used in the presence of a viscous EDTA solution like File-Eze (Ultradent, South Jordan, UT, USA), which can hold the pulpal remnants in suspension until they can be flushed with sodium hypochlorite irrigation. Larger orifices will require the .12 taper, smaller orifices will require the .08 Shaper. Use of the K3 Shapers (Figure 1) in this manner can remove, by volume, a significant portion of the pulp and quickly and efficiently help relieve pain from irreversible pulpitis.
If the clinician has the time to finish a vital tooth in one visit, in general, there is no contraindication to doing so and treatment can proceed. If two visits are needed, the tooth can be sealed (without a medicament) until the next visit. In any event, using just one or perhaps two of the shapers can provide excellent clearance of the coronal third pulp and relieve the patient’s pain until definitive endodontic treatment can be provided.
In summary, a concise and clinically useful means of addressing pulpal diagnosis has been presented with a view towards rapid and effective pain relief. I welcome your feedback.