Why is it important to develop your endo diagnostic skills?
With enhanced endo diagnostic skills you can look forward to:
- Improved patient retention (You successfully resolve your patients’ concerns.)
- Greater production/collections (Increased confidence and being able to answer your patients questions makes you a rock star in your patient’s eyes, increases future treatment acceptance).
- More internal referrals (Patients appreciate how you listen to them and refer friends/family.)
- Reduced overhead (You quickly recognize when root canal is indicated rather than unnecessarily placing or replacing a filling/crown first.)
- Less stress, fewer emergency/after-hours calls (You can often resolve/predict toothaches before they occur.)
In the following sections, I have listed a brief outline of Endo Diagnosis 101 “Cliff Notes”. For a more complete synopsis of how to perfect your endo diagnostic skills, please look for our new YouTube videos coming out spring of 2018. The American Association of Endodontists website also has an excellent online article with diagnostic case examples that can be accessed at: https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/07/endodonticdiagnosisfall2013.pdf
The Basics of Endo Diagnostic Skills:
- Listen – Before you even pick up a mirror or look at an x-ray, it is important listen to your patient and gather a comprehensive history of their chief complaint. Diagnosis is as much an art as it is a science and requires patience, good listening skills, and understanding of dental physiology, in addition to a clinical evaluation. Start with finding out when the pain began and what makes it worse (hot, cold, biting, etc.) Listen for the important adjectives that describe endo pain such as: dull, aching, throbbing or lingering pain after the aggravating factor is applied.
- Gather and examine all the data (for example):
- Obtain high quality PA and consider a BW as well if restorability is questionable.
- Perform a thorough exam on both the tooth in question and the adjacent teeth assessing palpation, percussion, perio, mobility and cold.
- Establish a baseline on healthy teeth as a reference before assessing the suspected tooth.
- Reproduce the patients’ chief complaint, do not initiate treatment and never diagnosis strictly off the appearance of the radiograph.
- Additional things to consider:
- Dim lights and transilluminate to assess for cracked tooth etiology (a future blog posting).
- Refer to or consult with an endodontist if you aren’t able to arrive at a diagnosis or have questions (We love to nerd out on this stuff….REALLY!).
Once you have your diagnostic results from testing, ask any additional questions of the patient to formulate the pulpal and periradicular diagnosis. Remember, diagnostic categories have changed over the years! Now, diagnostic categories are based on the patient’s symptoms to determine what clinical treatment is indicated, if any. Feel free to use the diagnosis classification information on the following page as a reference.
Endo Diagnosis Classification Information
- Normal pulp when all diagnostic testing is normal ( + short to cold, perc and palp WNL)
- Reversible Pulpitis when the patient may complain of mild symptoms to cold or sweets that linger no longer than 1-2 seconds, but the dentist thinks that the symptoms will resolve following management of the etiology.
- Symptomatic Irreversible Pulpitis is based on symptoms that the vital inflamed pulp is incapable of healing and that RCT is indicated. Characteristics include sharp or lingering pain upon thermal stimulus, spontaneous and referred pain.
- Asymptomatic Irreversible Pulpitis diagnosis is usually associated with a direct carious exposure on a tooth with no subjective or objective symptoms.
- Pulp Necrosis indicates the death of the dental pulp. The pulp is non responsive to pulp testing and is asymptomatic. One must discern whether the pulp is truly necrotic, or not responsive due to calcifications or recent trauma.
- Previously Treated includes teeth where obturation material is present in the canals.
- Previously Initiated includes teeth that have a history of a pulpotomy/pulpectomy.
- Normal Apical Tissues are not sensitive to percussion or palpation. An intact lamina dura is noted.
- Symptomatic Apical Periodontitis represents inflammation at the root apex resulting in a painful response to biting or palpation. There may or may not be radiographic changes (PARL). SAP is highly indicative of a degenerating pulp, but hyperocclusion must be ruled out.
- Asymptomatic Apical Periodontitis occurs when there is no pain to palpation or percussion in the presence of periapical radiolucency (PARL).
- Chronic Apical Abscess diagnosis is noted in the presence of a draining sinus tract. There are commonly no symptoms in this case. Antibiotics should not be prescribed (see future blog on antibiotic usage….)
- Acute Apical Abscess is an inflammatory reaction to pulpal infection characterized by rapid onset, spontaneous pain, pain to biting and swelling of the associated tissues.
- Condensing Osteitis is noted in the presence of a diffuse radiopaque lesion representing a low grade inflammatory process.