This endo case comes with SO many lessons! So, I had this patient come in to see me and his referral slip said that the root canal that I performed may have a reinfection, AKA failing! Anytime that happens, my heart sinks. I mean, nobody wants their work to fail, right?
When I asked this patient what his chief complaint was, he said “it really hurts me when I drink something cold.” So, what do you think went through my head at this point? If “cold” is his chief complaint, how can a root canaled tooth hurt him?
Lesson #1 in this endo case is listen to the chief complaint. And if your patient states that their chief complaint is cold, then you can rule out any of the root canaled teeth in the area as the culprit tooth. My first thought was “Phew, it’s not the treatment I did.” I took the preoperative radiograph to investigate further.
I am not going to lie, I was a little disappointed that the referring dentist would assume that there was a reinfection on tooth #18, especially since everything looked great on the radiograph. No doubt that my patient lost faith in me, and I had to spend extra time convincing him that our previous treatment was doing just fine.
Since the culprit tooth wasn’t the tooth circled on the referral slip, I had to investigate further with more radiographs. And as I evaluated the radiographs, I looked for teeth that could be culprits for cold sensitivity.
So, I did my testing and didn’t really come up with much — I couldn’t get him to jump out of the chair at all. All his teeth tested normal to cold except tooth #19, which had NO response to cold at all. It was slightly tender to percussion, but only ever so slightly. When I tested tooth #30 (it also had a crown), it tested normal to cold and then went away without any lingering pain. So, I assumed that tooth #19 was necrotic and that his nerve died, and what he was feeling was his nerve dying. And now that the nerve was dead, he no longer feels cold. At the time of the evaluation, he said he didn’t really feel that much pain, his pain level was rather low. So, I diagnosed him with Necrotic Pulp and Symptomatic Apical Periodontitis #19 and he was treatment planned for a root canal on #19.
A few days passed and he came back for his treatment appointment. My assistant brought the patient back and asked him how he was feeling. He said, “My tooth has really been sensitive to cold lately, worse than before.” Now hold up — what?! What a crazy endo case!
So my VERY SMART assistant (that’s her right there) reviewed his preoperative diagnosis, and saw that it said Necrotic Pulp, and that didn’t really jive with what he said his symptoms were. And the last time that he felt the cold was that same morning. So, she asked me to retest the tooth to make sure that I got the correct diagnosis. She knows that there is nothing worse than starting the wrong tooth!
Lesson #2: Always ask your patients how their tooth feels at the beginning of the appointment.
Lesson #3: Make sure you teach your assistants the why behind diagnosis so that they can have your back.
If it weren’t for her, I may have misdiagnosed and picked the wrong tooth and he would still have the same pain before AND after treatment. And that simply is NOT cool. I really hope that all of you are sharing with your team the knowledge that you learn through these blogs, and are allowing your team to help you with the endodontic process. They are an asset and fully capable of learning it as well as you.
In an endo case like this, I always retest my patients prior to the anesthesia to make sure that I agree with myself. Let’s face it, nobody’s perfect! That’s Lesson #3b!! When I retested him, we were inconclusive. #19 still had no response to cold, but that was not corresponding with his chief complaint. So, even if #19 is necrotic and a problem, it is not THE problem. And if he still had pain to cold once the anesthesia wore off, then he would be really mad! (Did I mention that he is a lawyer??)
So, you know what I did? I aborted the root canal. I didn’t move forward with it (and not just because he was a lawyer). The loss of production really doesn’t matter to me — I am more concerned about getting the right tooth, and I hope that you practice the same way. I will tell you, this act of retesting before anesthetizing is something that I do A LOT. I like to be 100% sure.
Lesson #4: Never start a root canal unless you are 100% positive of your diagnosis and that the patient’s pain is 100% localized. It’s ok to delay treatment.
So, when I retested his teeth, #17 was the most sensitive to cold. Now this may change his treatment plan. Why? I am not sure if #15 is restorable anymore and #17 is a wisdom tooth. The patient may want to just take #17 out if that is the culprit tooth. So how did I handle this? Well, I told him to go home and start functioning with the tooth to see what really troubles the tooth: HOT, COLD or BITING. You want to make sure that the patient does not avoid functioning on this side, make sure they use it so they can tell you what is bothering them.
Fast forward another few days — my patient’s pain got a little bit worse, and yes, cold was still his chief complaint, and it was definitely coming from #17. So, based on our radiographic findings, he has decided to determine restorability of #15 with his general dentist, and based on that decision perhaps extract tooth #15 with tooth #17.
Man, am I glad that I didn’t start treatment on #19! I am hoping that this endo case tooth story reminds you just how careful we need to be with diagnosing. A misdiagnosis can happen to the best of us, but it’s how we handle it that really matters.