Wanna know a secret?
As an endodontist, I don’t treat every tooth that gets referred to me. Scandalous, I know. But I think that makes me special, even if it upsets a lot of people when I don’t schedule them to meet and treat.
I stand my ground though, because for every 10 patients I see, only about 7 of them actually need a root canal. If I just scheduled an hour and a half for every patient I met because I assumed a root canal was needed and warranted every time, I would be way less productive. This is a huge business lesson. I’ve learned many things over the years, and seen time and again how I have to be responsible for my own diagnosis. I can’t just go with what’s written on the referral slip. I feel like I can own the fact that I have a gift when it comes to endodontic and tooth pain diagnosis.
I want to share an example of a case I would refer back to the GP for more care before I ever committed them to a root canal. Because I’m sending them back to where they were referred, this means everything you read in this blog can (and should!) be done by the general dentist in their practice. It’s an area where I see patients are often frustrated, something we must do our best to avoid.
The Problem with the Cracked Tooth Diagnosis
In this industry, it’s common knowledge that cracked tooth syndrome is really difficult to diagnose. Just knowing the pain could be from a cracked tooth diagnosis is the first step, but then you must find the culprit tooth and decide if it needs a root canal, a crown, or both.
These are some serious decisions that every good dentist should master in a cracked tooth diagnosis, and exactly why I spend a lot of time on this topic in E-School. We see this stuff every damn day in our practices. Right?
I teach effective endodontic systems in the hopes you also master this craft. The outcome? We help people the right way and you grow your practice as a result. When I listen to my patients, I hear the tooth story, and that story gives me the clues I need to determine what’s troubling them. I’ve also practiced the art of interpreting my diagnostic tests enough that I can make a solid treatment decision for the patient and feel confident with that decision.
That is what I want to share with you. My goal in everything is to help my patients—to help them save their time, their money, and their teeth. I want that to be the same for you.
The Tooth Story
Let’s learn more about this tooth pain diagnosis from the tooth story. This patient presented to me with sensitivity to cold and some pain while biting. Her general dentist was adamant she needed a root canal and they even instructed me to perform one. But after I did my testing, I just wasn’t convinced. Things didn’t add up. She wasn’t that sensitive when I compared her testing to a normal tooth. Here are her preoperative radiographs…
Sure, she had slight sensitivity to cold, but nothing that lingered. And yes, she was a bit tender to biting, but again, nothing too intense. I felt like it just wasn’t enough to warrant a root canal. I believed she had what we call a reversible pulpitis.
In these instances, I prefer the treatment to start with the restorative phase first. My reasoning is that whenever you do a root canal, you always need to do the crown, but you don’t always need to do a root canal to place a crown. This is what I tell my patients: 50% of the time the crown will actually make the you feel better. The other 50% of the time, you’ll need both the root canal and the crown, because your symptoms will either not get better, or get worse. I think those are some pretty good odds, which is why I don’t dive right into a root canal. This is a perfect example of a possible reversible pulpitis. I like to give that tooth a chance. Just make sure you warn your patient about all the postoperative possibilities before you start the crown, so they don’t get mad at you and point the finger when their tooth starts to hurt!
I mean, a molar root canal can cost anywhere from $1,500 to $2,000, depending on where you live. At this point, if I did a root canal on this patient, I would be stealing her money, and homie just don’t play that. My mama always told me to treat others how I would want to be treated, and I would be pissed if someone did something to me that was completely unnecessary.
So, she went back to her dentist after my cracked tooth diagnosis, they prepped the tooth for the crown, and we gave the patient about one month to function on that tooth to see how it was responding to treatment. The crown was placed in temporary cement and she came back to me for an evaluation. It’s important that the patient really runs that tooth through the gauntlet: trying out hot things, cold things, and crunchy things to see if any of them trigger the sensitivity from before. If they avoid the tooth for any reason, we won’t get the information we need.
The patient was ecstatic that her pain completely went away! Of course, I always re-test to confirm nothing went necrotic over the time I didn’t see them, so it’s important they don’t cancel this appointment when they become symptom-free. I feel better going through my standard diagnosis protocol and making sure the tooth tests vital and has no lingering pain. We then green light the patient to return to their general dentist to permanently cement the crown.
Always Do Diagnostic Tests
I truly believe referrals like these can be minimized for the benefit of the patient. General dentists are fully capable of performing these tests and feeling confident in their interpretation of the results to make this decision for their own patients.
Think about it: if you can save your patient the cost of having an endodontic consult of even a few hundred dollars, they will love you for it, and it may even allow them more funds to spend on additional treatment in your office. I’m all about saving people’s time and money!
On the flip side, this will also open up your endodontist’s schedule so they can see more patients with real endodontic pain, and your patients don’t have to wait weeks for an appointment.
Do you see how this education can truly impact your patients and your practice?
What Can We Learn From This?
Now, some takeaways:
- Find the chief complaint. Is it sensitive to cold or biting? It’s usually one of the two.
- Do your diagnostic tests to find the culprit tooth. Don’t assume the referral is right or even what the patient is telling you is right.
- Think about how you interpret your tests. This is super important because when a cracked tooth diagnosis starts to come onto the scene, the difference in the culprit tooth from a normal tooth can be very subtle. Pay attention to these things so they become more obvious to you with time and your diagnostic acuity can grow sharper.
- Once you find the culprit tooth and the symptoms are not far outside normal limits, start prepping the tooth with a crown first.
- Allow the patient to function in a temporary crown for about one month to see what happens to their symptoms. It’s also important to make sure the patient does NOT avoid chewing on the problem side or else you may not get the answers you’re looking for. (Warning: some patients will be a bit more sensitive initially, but then their symptoms will calm down.) It is important to also know how to interpret between normal postoperative pain and actual endodontic pain.
- Re-evaluate all diagnostic tests at one month and see if they have resolved, stayed the same, or gotten worse. The latter two will need root canal therapy prior to permanent cementation of the crown.
So how about you? Was there a time your patient expected one solution, but you were able to help them find another? I’d love to hear about it in the comments!
Hi Sonia, instead of prepping the tooth for a crown, could placing a stainless steel band give you the same information ?
In these cases, you need cuspal coverage in order to prevent crack propogation.
I am a General Dentist in. community Health Center with a lot of love for Endo. I came across a patient with a cracked tooth syndrome a couple weeks ago and I was happy to learn her symptoms went away after the RCT was finished.
Keep up with your page and congratulations!
Thanks Jack. So happy you had a great outcome!
Thank you for this insight Dr. Sonia! I love your conservative approach. I have basic questions and I am glad I can ask these anonymously – how did placing the crown alleviate the symptoms of reversible pulpitis? Also would you think these patients may need a longer time before following up? I I have not practiced as a dentist enough to encounter patients like this but I personally myself had my molar cracked after eating hard nuts which rendered in symptoms of reversible pulpitis, had a crown placed, then THREE months later, I developed irreversible pulpitis and now need a RCT. I am assuming over time the crack propagated underneath. Would you please share your thoughts?
The reason for the symptoms is due to bacteria getting into the pulp through the crack. It becomes a doorway for bugs. You have to look visually too and see the extent of the crack or if there is any staining. It’s always a mix of tests and treatment that will drive you to your proper outcome. I think really paying attention to symptoms while the patient is in a temp crown is important. I am sorry that you need a root canal after 3 months.
Your blogs are a great source of information for patients such as myself.
A few weeks ago, an endodontist advised me tooth 36 had a significant crack extending across the distal-marginal ridge. Endodontic treatment was performed and “the distal crack was visualised extending into the pulp chamber”. The diagnosis is “an irreversible pulpitis and a symptomatic apical periodontitis”.
I’ve been advised the “long term prognosis is poor”. It’s been three weeks since the procedure and I haven’t experienced further pain or discomfort. I would prefer to complete the RCT and crown rather than an implant but I don’t know if this is an viable option.
It’s totally a viable option. You can always extract that tooth at any time. I would ask your dentist if there is any harm to monitoring the tooth for some time.