As an endodontist I see referred pain all the time.  And it is my job to make sure that I confirm a diagnosis before I ever begin.  Both patients and referring dentists can get irritated when I insist on re-evaluating the patient before I start treatment.  Well, I have a case that shows you the EXACT reason why I re-evaluate, and why you should expect every endodontist to evaluate your patients again.

Some of the things I hear from patients are, “My dentist already told me I needed a root canal” or “My dentist already did this at their office, why are you doing it again?”  And some referring dentists are so confident in their diagnosis that they don’t want me to spend the time to go through the process again (if only I was a fly on the wall during their evaluation).

Well, I can tell you from experience that if I didn’t confirm the diagnosis in every case, I would have lost my license by now. I would have a ton of unhappy patients because I would have done a root canal and the patient would still have the same pain.  At least once a day I have to work through referred pain to find the culprit tooth.

Let’s look at this case. Here is the referral slip…

It clearly states to do a root canal on tooth #30, and when you ask the patient where the pain is coming from, even HE points to tooth #30.  His finger goes right to it. This guy was in so much pain that he could barely think and he hadn’t slept for two nights straight. Let’s take a look at the preoperative radiograph…. 



After reading the referral slip and looking at the radiograph, I agreed with the referring dentist and thought that tooth #30 could be cracked.  The patient had enough occlusal wear for that to be a possibility. But, when I did my testing of that quadrant, things just didn’t add up. I could NOT reproduce his pain.  So, that’s when I looked at the bitewing in order to see if there was any other possibility that it could be another tooth.



Tooth #3 had a deep filling, so I decided to repeat my testing on the maxillary arch.  Everything probed normally, but tooth #3 was really tender to percussion and had no response to cold.  Since I always want to be 100% positive, I performed the tests again to make sure I was in agreement with my initial assessment.  Yes, all of it lined up, so I was able to diagnose tooth #3 with a Necrotic Pulp and Symptomatic Apical Periodontitis. Then I took a new preoperative radiograph.



The patient was so confused at this point and he was in too much pain to concentrate.  So, I decided to get him numb, not only to have a conversation with him that he could pay attention to, but also to confirm my diagnosis.  So, a few minutes after infiltrating the area around tooth #3, he was able to open his eyes and concentrate on our conversation. His pain was gone. So now I knew with full confidence that his pain was originating from the maxillary arch.  

I proceeded to do the root canal that day because of his pain level.  I knew if I didn’t, he wouldn’t be able to sleep again. When I accessed tooth #3, I saw that there was some vitality, so he was in a late stage Irreversible Pulpitis. He was so happy to be numb that he snoozed the whole time.

Here is the completed case…


I called him the next day to see how he was doing.  He was so happy to be out of pain. He said he slept so hard that he didn’t wake up with his alarm!

So remember, your endodontist is doing an evaluation to confirm your diagnosis. Let your patient know that, and tell them to expect the specialist to repeat the same tests, but we will use our own interpretation.  This will soothe your patient and they won’t get so frustrated with the referral process.  It’s really up to us to educate the patients — all they want is to be informed.

I hope this case makes you understand why we as specialists have to do what we do.  If I followed the referral slip without checking for myself, the patient would still have his original pain even after treatment.  In my opinion, that would be the worst thing I could ever do.  So, if we take our time to make the correct diagnosis, we are saving both time and money for our patients.  And you should want your endodontist, and any specialist, to be your “checks and balances”.  



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