Today we’re tackling radiolucent lesions and talking through endodontic treatment planning that can not only save a tooth—but might just improve a life.
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 do that more often.
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.
Diagnosis and Proper Endodontic Treatment Planning: A Case Study
This case 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 re-treatment on a different tooth, and we’d had success, so he was back for treatment on another tooth.
Here are his preoperative radiographs…
I could see that there was 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 were restored with composite restorations. And tooth #4 also had a previous root canal and was restored with a crown.
The patient currently had no pain—this was just an incidental discovery during his last treatment. And the patient actually referred himself! I love, love, love to see an empowered patient taking initiative and owning their health! It inspires me.
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 action on any endodontic treatment plan —especially one that he had his doubts about. Before I tell you what that treatment plan was, let me walk you through the rest of my findings on this case.
What the CBCT Showed
If a patient has already had a root canal previously, I always kick off my initial evaluation with a cone beam, so I can understand the whole tooth story.
Here are the 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. What’s more, this canal wasn’t cleaned all the way to working length (see the preoperative periapical radiograph above).
The sagittal view showed a BIG periapical radiolucency around teeth #30 and 31.
Based on these findings alone what would your diagnosis be?
That was a trick question!
You simply cannot make a diagnosis based on the radiograph alone. So, if you ARE doing that—I beg you!—STOP!
There is more to a diagnosis—especially one that will guide your whole endodontic treatment plan—than a few x-rays.
I’m all about being thorough so that you can make a definitive diagnosis and grow your confidence to tackle even the toughest cases!
The Patient’s Journey
I’m going to share with you what this patient’s 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 this plan of attack.
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 was sitting in the wrong chair. So he kindly finished his appointment, then immediately called to make another—at my office.
And thank goodness for that!
He didn’t want to get a treatment plan that was based on a practice’s limitations, especially when he knew other dentists were able to approach his case with the goal of saving teeth before extracting them.
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!
An Empowering Endodontic Treatment Plan
I ran through my diagnostic tests and here’s the results:
Tooth #30 had no response to cold, and teeth #28, 29, and 31 all responded normally to cold. 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 normally to cold, I KNEW that tooth 31 had NOTHING to do with that lesion.
So, this was the thorough and thoughtful outcome for my endodontic treatment planning for this patient: retreat 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.
Saving teeth is what I do! And I’m so glad he and I were on the same page
Check out the radiographs below from the patient’s two year recall! Do you see what I see? He got all his gone back! Those are pretty incredible results—especially considering the original treatment plan he received involved one step only: extraction.
I am so impressed with patients who take charge of their health. I’d love to hear some stories of your patients who did the same.
Drop one of your inspirational client stories in the comments below!
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Great case, Sonia! I would love to see the post re-treat image, after the lesion heals. Thank you!
Thank you!! I will make sure to post the recall when I get it. I start this case next week, so we will have to wait 6-12 months to see any changes on the radiograph. Stay tuned!
Thank you for sharing this case; so important one understands the importance of the clinical findings!! Thanks for highlighting this.
Could cold test on tooth #31 be a false positive? Can tooth #31 become non-vital due to spread of infection from #30
I always teach that your cold test MUST be obvious. And sometimes I repeat it just to make sure and I am always comparing it to the contralateral tooth against a known normal. If I see the patient levitate in the chair, I can be confident that they are feeling it. So, make sure you are not shy with your cold test and don’t be afraid of “hurting” your patient to get your diagnosis. I don’t believe that the infection in #30 can spread into #31, the periodontal ligament is a great barrier. Hope this helps!
Surprised the other dentist recommended rct for #31. If #30 was completely asymptomatic and the periodical lesion was stable over years, would you still retreat?
That lesion is far too large to leave alone for my comfort. He was asymptomatic for years, but I know that was an active infection. Don’t let the presence of no symptoms fool you.
Good article…so Dr. Chopra, in your opinion, what is the long term prognosis for #31, after it’s mesial root and furcation being involved in the periapical lesion? Is it possible to see pulpitis occur in #31 after this bacterial exposure? Thanks. Dr. Rowe
Thank you for your comment. The prognosis for #31 is excellent since there is no bacterial etiology associated with the tooth. This is all contained within #30. I would not expect a pulpitis to occur in #31 due to this infection on #30. Once #30 is treated, the bone will regenerate and that root will be covered again. Don’t let the pattern of bone loss confuse you :). I promise to track this case in order to repost the recall in the future.
That was a great story and educational.
Thanks for reading Steve!
Post endodontic restorations also decides longevity of tooth
Can u put some cases on this
You are exactly right!! I will add this to my list of topics to discuss on the blog. Thank you for the recommendation. Talk soon.
very basic question, but what is the best method/protocol to cold test? I feel like I get false positives often. Thank you
I use a cotton pellet with endo ice. Make sure that you are not using a cotton tip applicator. And make sure you are testing a normal tooth on the other side to assess THAT patient’s normal. Then it is all in how you interpret the cold test. Don’t be timid with it because you don’t want to make them uncomfortable. You need to get your diagnosis, so make sure you have a really cold cotton pellet to get your definitive diagnosis. Hope this helps.
Great case . Thanks for sharing . I have had couple of patients who get really upset with the cold sensation of endo ice . I have tried explaining them but they clearly hated the whole thing , few patients had completely denied the test . How would you handle that ?
Denying the test is simply not an option in my practice. I let the patient know that I need to make a diagnosis and without it, I cannot do my job. I let them know that if I don’t do it, I could pick the wrong tooth. And if they still have pain after treatment then they will need another root canal on another tooth. Most of the time, they understand that. If not, then perhaps I am not the best person to provide their care. Remember, it is your practice and your license. You need to protect that.
So the diagnosis for the #30 would be previously root treated for pulpal and chronic apical abscess for apical ?
There was no sinus tract, so the diagnosis would be Previously Treated and Asymptomatic Apical Periodontitis. Hope this helps.
Dr. Chopra, excellent material. Regards the cold test, do you recommend to use the cotton pellet on a specific surface of a tooth?
I usually go on the direct buccal, but sometimes I do switch it up and use the lingual surface. If there is a crown in place, I try to get as close to the margin as possible.
Really nice case study and informative too. Thanks:)
Thank you Jaon, more to come!
Thanks for the information this endo case study and tips really helpful.
Thanks Jaon – this is such a common issue we have, and I’m happy to help bring clarity!
Did you send this patient back to the dentist that made the original treatment recommendations?
I always complete the cycle of the referral process. I send my report back to the dentist so that they know the status of the patient and the treatment delivered. It is up to the patient to make the decision on who they want as their provider.
Did you complete this RCT in 2 phases? If so how long did you leave the CAOH
Yes I did and I typically let the CaOH soak in the tooth for about 3-4 weeks.
A Great case! I learned a lot and I can’t tell you how much I am happy for that patient!
Thanks so much for reading!
That looks great on recall radiograph! Thank you for sharing !
Sonia ! Can you please review some cracked tooth stories and best way to manage those. How can we save teeth with deep cracks? Do you have any recommendations/protocols?
I have seen many cases (especially with bruxism) causing cracks. Sometimes a full coverage crown resolves patient’s symptoms. But one case , I saw after crown : 3 months patient was fine ( tooth was normal pulp, normal periapical) and than symptomatic again. I have sent her to my endodontist for evaluation .
The crack line was mesial to distal in the mid of tooth#37.
I will do my best to find some cases on cracked teeth.
Great story. The Dx is everything!