Many of us got into the practice of dentistry because we wanted to help people. I can safely say that it was an endodontist that got me out of pain and helped me live a fuller life back when I was in college. That aspiration to help people can make it all the more frustrating when a patient comes to us in pain—and the radiographs show nothing. The tests are inconclusive. And we’re not sure what to do with our failed dental x-rays and all the possible causes of our patient’s troubles.
How do we get to the right diagnosis and right treatment plan for our patients? I’ve got some ideas.
The tale of a failed dental x-ray: A Tooth Story
This patient was a 56-year old woman, and her official diagnosis was Necrotic Pulp and Asymptomatic Apical Periodontitis (read a little more on pulpal and periapical diagnosis here).
At this point in my career, it is a quite normal occurrence to have radiographs that give me no signs of what to come. Yet despite a failed dental x-ray, or one that really shows nothing amiss at all, the patient is still in pain, just like this woman.
She was referred by her dentist after a heavy dose of pain meds and some antibiotics. By the time I saw her, she could not indicate which tooth was giving her trouble, and I had nothing to go by from the periapical radiographs. Which meant this would be a tough case. Time to put on my detective cap!
Teeth #2-5 had no pain to percussion, and the only tooth in the quadrant that felt cold was tooth #2 (#3-5 had no response to cold). I couldn’t assume that all three teeth were necrotic. Which tooth was it? She described having a few days of excruciating pain and then it started to subside. Her claim of having a painful episode like this one is usually a sign that a nerve has died somewhere, but I knew I needed proof.
Getting an accurate diagnosis
We all know that periapical radiographs can be great, except when they’re not. What a failed dental x-ray shows or doesn’t show, combined with a heaping helping of pain, can be a nightmare for diagnosing accurately.
At this point, I was frustrated and the patient was frustrated—so I opted to employ the ol’ cone beam. I no longer have to wait for my patient’s pain to return and localize, which is a blessing for both of us! I can see right through the buccal bone, without waiting for the bony breakdown of the cortical plate to occur. Which meant that I could treat this patient right away and get to work on relieving her pain.
I took a cone beam to see if I could determine the etiology of her pain. I looked carefully through the planes, seeking any irregularities in the teeth and any resorption of bone. Everything looked normal … until I got to tooth #3. I could see a small radiolucency around the disto-buccal and palatal roots.
You can see the thickened sinus membrane in the next image as well (green arrows). This was the sign I needed that tooth #3 was necrotic. Despite all the difficulties in getting there—from the failed dental x-ray to the patient’s spreading pain— I gave her a confident diagnosis and told her that we could proceed with treatment right away.
The ins-and-outs of CBCT
I am a very thorough tester—which counts for a whole lot! And this is a clear example of a case where the traditional methods just didn’t cut it. (I mean, compare those first radiographs to what showed up using the cone beam!)
I am embracing the technology of CBCT because it helps me accurately diagnose my patients and expedite their healing journey, especially when the dental x-rays fail and the normal tests don’t work. I know the CBCT is not foolproof (see my blog on cone beam and cracks), but it does help me diagnose cases more accurately every day, and get my job done—and that job is to save teeth!
I’d love to hear about your experiences with the CBCT. Tell me: Where has it helped you out? And where has it failed you? I want to hear your honest responses.
Leave your comments below because they will help other dentists in our group shorten the learning curve for this powerful technology!
In the meantime, I’d love to offer you my free Pulpal and Periapical Diagnosis Checklist, which can help you get to the root (haha, get it?) of your patients’ pain, every time!
– Sonia
Your method of diagnosing is quite innovative…. With the use of CBCT I mean
nice!
Hi Doctor Chopra,
I have started to love the cbct for diagnosis as well. I had a pt. scheduled for a retreat #30 which was treated 15 years ago. There was a crown on the tooth and the pt. had no problem with it untill suddenly he developed pain on a Monday. He was seen immediately and the doctor attending him that day took a pa and saw a rl on the mesial root where the rct was short and there was a weird bend in the fill. He was diagnosed with a periapical abscess and scheduled for a retreat with me. The pain had dulled till he reached the office on friday but I was curious as to what caused this sudden pain after so many years. Asked a few questions, did a bite test and took a cbct. Lo and behold found a fracture on that mesial root right next to the weird bend. Felt like Sherlock that day.
It’s interesting how the body works and how long it can let an infection sit there and then one day it just flares up. I don’t have a scientific answer for you, I just know that this happens all the time. I do have one question for you, did you find the fracture in the tooth using a microscope or did you visualize it on the CBCT. If it was the CBCT, I want you to be careful since more often than not, you cannot diagnose the fracture from the CBCT and what you are seeing is simply artifact. Did the tooth have any probings in that area?
-Sonia
It’s not a “failed” x-Ray. It’s simply a tool and in this case it has limits to what it can tell us.
Tim,
I appreciate the feedback and apologize if you took it with a different intention than I had. Maybe I can eliminate that part and just keep “What to Do when your radiographs aren’t enough.”
-Sonia
Did you test with an electronic pulp tester? This normally differentiates vital from non-vital with no ionizing radiation. I would want the results of that test before going on to CBCT.
Doug,
Thank you for your feedback. Sometimes this test is not reliable and I most certainly cannot use on a tooth that has already been treated with a root canal. I use my CBCT for several applications during the evaluation and the procedure itself. So, I see the value in using this technology consistently. However, I can see this may not resonate with you. I always welcome this type of conversation because your experience could help others who do not have a CBCT. I would love it if you shared more. Thanks.
-Sonia