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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