Anyone who knows me knows that diagnosis is my “thing.” Saving teeth is SO important to me, and endodontic diagnosis and treatment planning is the number one key to being able to achieve that.
Why do I care SO much? Because of my own personal tooth story. I was born without eight teeth, and after lots of early years filled with dental appointments, I had a dentist who extracted the wrong tooth. So, based on my own tooth stories, when I see a misdiagnosis, it really hits me in the heart. I view other people’s teeth and dental experiences as if they were my own.
A Case Where Endodontic Diagnosis and Treatment Planning Really Mattered
This case I’ll discuss here in this blog post truly broke my heart when the patient came into my office.
This was a repeat patient of mine. He had seen me before for a retreat, and we’d had success in the past, so he was back for treatment on another tooth.
Here are his preoperative radiographs…
I can see that there is a periapical radiolucency around teeth #30 and 31. Tooth #30 had a previous root canal and had been restored with a crown. Teeth #3, 5, and 31 had been restored with composite restorations. And tooth #4 also had a previous root canal and had been restored with a crown.
The patient currently had no pain — this was an incidental finding at his last cleaning. The patient actually referred himself! I have to say… I just LOVE that initiative. I am all about empowering patients to care about their own oral health.
The treatment plan that was suggested to him by his general dentist didn’t sit well with him, and he wanted to get a second opinion before he took any action. Before I tell you what that treatment plan ended up being, let me walk you through the rest of my findings.
What I Discovered
With ANY incidence of a previous root canal, I took a cone beam. So here are some images…
The axial shot showed that the disto-lingual canal has been “missed,” since it didn’t appear to be as radiodense as the other canals. At least this canal wasn’t cleaned all the way to working length.
The sagittal view showed a BIG periapical radiolucency around teeth #30 and 31.
Ok, now based on these findings alone what would your diagnosis be?
. . . . . .
That was a trick question. Don’t you dare make a diagnosis based on the radiograph alone. So, if you are doing that now, I need you to stop ASAP!!!
There is more to a diagnosis than just the x-ray.
This is what I preach, folks, and that is why I can’t tell another clinician what to do without seeing the patient as well. I want to teach YOU how you can make this diagnosis definitive, and I want to make you confident that you can do it YOURSELF.
What Led the Patient to Me
So, now I will tell you what his dentist told him to do. This was his treatment plan:
- Root canal #31
- Extraction and Implant #30
Since the patient had a retreatment from me in the past, he knew that retreatment was an option. So, he questioned his dentist and wondered why a retreatment of #30 was not a part of his treatment plan.
Well, my friends, this is the real kicker. According to my patient, his dentist said, “Well, that’s not something that I offer here.”
When my patient heard that, he knew he had to RUN. He knew he was sitting in the wrong chair. So, he kindly finished his appointment and left, and then immediately called my office for an appointment.
He didn’t want to get a treatment plan that was based on a practice’s limitations, especially when he knew that other dentists knew how to handle this type of treatment.
You know what’s funny is that he didn’t tell me this until I had completed my diagnosis and gave him my treatment plan. I’m glad I passed the endodontic diagnosis and treatment planning test he set up for me!
Reworking the Treatment Plan
I ran through my diagnostic tests and this is what I found:
Tooth #30 had no response to cold, and teeth #28, 29, and 31 all responded normally to cold. And percussion was normal on all the teeth.
So based on this, what would be your diagnosis now?
. . . . . .
Let me walk you through my thought process.
You MUST always correlate your clinical findings to your radiographic findings. You cannot rely on one without the other.
An endodontic lesion can only be associated with a tooth that does NOT respond to cold. So, if this lesion is around teeth #30 and 31, then my cold test is going to be SUPER important in my diagnosis. Since tooth #31 responds normal to cold, then I KNOW that tooth 31 has NOTHING to do with that lesion.
So, this was my treatment plan:
- Retreatment tooth #30
When I told my patient this, I couldn’t get over the look on his face. He was totally confused. He couldn’t understand why my treatment plan was so different from his dentist’s. I took a minute to explain to him my reasoning and logic based on my findings. From there, he totally understood and thanked me for wanting to save his tooth.
So, I retreated the tooth, and this is what I found… black stuff!
Phew, that is some dirty gutta percha that I took out of that tooth.
Once I completed treatment, this is what the tooth looked like, and it confirmed that more needed to be treated in that distal canal.
Fast forward two years, and this is how the patient healed…
Let’s look at the preop CBCT and the postop CBCT just to compare.
The Takeaways from this Case
I hope you’ve enjoyed this story! There are a lot of lessons to be learned here about endodontic diagnosis and treatment planning, and just plain ol’ taking care of your patients. Here are some of the biggest takeaways I hope you’ve learned:
- Don’t just make a diagnosis from the radiograph alone.
- Don’t forget about what your diagnostic tests are telling you.
- Don’t treatment plan based on what you can and can’t do. Remember your specialists are there to help you… so leave your ego at the door, and make that referral.
- Treatment plan based on what you would do as if it was YOUR tooth!!
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