CLINICAL INSIGHTS

PRESENTED BY

ESCONDIDO ENDODONTICS

Robert J. Hanlon, Jr. DMD
Charles E. Jerome, DDS
Fundamental Considerations in Endodontic Diagnosis

 
                Endodontic diagnosis can often be complex.  Findings may not always be consistent, and the process of arriving at a diagnosis depends on our critical interpretation of the findings.  We have to rely on the patient’s subjective data reporting that is often clouded with multiple complaints and can present the following scenarios:

 
PATIENTS ASSUME THAT PULPAL PROBLEMS CAN BE SEEN ON A RADIOGRAPH
 
               
Radiographs present the least accurate data for diagnosing irreversible pulpitis.  If the pulp is still vital and there is no percussion sensitivity then there is no apical extent of inflammation.  Even in the presence of  osteolytic inflammation, 50% of one of the bone cortices must be resorbed to observe a lesion on the radiograph. The radiograph can, however, provide clues to pulpal problems by observing caries and restorations. In this respect, a bite-wing radiograph is an excellent endodontic diagnostic tool.
 
THE TOOTH DOESN’T HURT ANYMORE WHY DO I NEED A ROOT CANAL?
 
                Patients often experience the intense pain of irreversible pulpitis that then diminishes by the time they seek treatment or are referred to a specialist.  The most reliable test for the apical extent of pulpal inflammation is the simplest – percussion. The pulp has no proprioceptive nerve fibers but bone does.  Once inflammation escapes apically, the specific tooth will be identifiable. Pulp testing with a thermal agent such as carbon dioxide snow (dry ice) is an important part of diagnosing non-vital pulp and assuring the patient that they need endodontic treatment before the necrotic tissue causes an infection.  Having the patient observe testing in a mirror is great for providing feedback and education.  Explain that they are no longer having pulpal pain because the pain conducting fibers have been destroyed but they have “traded” that pain for the pain of bone inflammation.  Once again, in the early stages of this process a lesion may not be present radiographically.
 
I HAD A ROOT CANAL  BUT IT STILL HURTS WHEN I DRINK COLD THINGS
 
                This is one of the most common and confusing complaints and definitely requires patient convincing and education.  Over 90% of all pulpal nociceptive fibers terminate in the coronal pulp and pulp horn areas. Even incomplete endodontic treatment e.g. partial pulpotomy or pulpectomy will render the tooth completely insensible to cold.  Even if a canal was missed during previous endodontic treatment, there will be insufficient tissue present to react to a cold stimulus.  Generally, the patient is implicating a adjacent tooth that probably has cervical dentin exposure, most likely from toothbrush abrasion.  Remember, tooth structure is not conductive to temperature at the same rate that the patient perceives a temperature change. The pulp perceives temperature change simply by the movement of tissue fluid within the dentinal tubules in the presence of intact a-delta pain fibers that line the pulp chamber. Any stimulus that causes fluid movement causes pain. Research has proven that a temperature stimulus has to be placed on tooth structure (in a constant state) for approximately a minute in order to measure a temperature differential on the pulpal side of the tooth structure. Patients don’t stimulate their teeth with hot or cold foods and liquids for that constant period of time.

 
                Use water ice to reproduce a chief complaint of cold sensitivity but use carbon dioxide snow or Endo Ice spray to test for intact nerves.
 
                Temperature sensitive teeth do not have apical lesions. Conversely, endodontically treated teeth cannot be temperature sensitive.  Teeth with large apical lesions cannot be temperature sensitive.

 

 
 
ESCONDIDO ENDODONTICS  488 EAST VALLEY PARKWAY SUITE 307 ESCONDIDO, CA 92025

(760) 739-1400   FAX (760) 739-1100   www.escoendo.com