Anyone who knows me knows that diagnosis is my “thing”. Saving teeth is SO important to me. Why? Because of my own personal tooth story (to read more about it, click here).  I was born without eight teeth, and after a young life 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 their dental experiences, as if they were my own.

This case I’ll discuss here truly broke my heart when it came into my office.  This was a repeat patient of mine. He had seen me before for a retreat, we had success in the past, so he was back for treatment on another tooth.

Here are his preoperative radiographs…

Root of Diagnosis 1

Root of Diagnosis 2


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 restored with a crown.  

The patient currently had no pain — this was an incidental finding at his last cleaning.  The patient actually referred himself! The treatment plan that was suggested to him by his general dentist didn’t sit well with him, and he wanted to get my opinion before he took any action.  Before I tell you what that treatment plan is, let me walk you through the rest of my findings.

With ANY incidence of a previous root canal, I take a cone beam. So here are some images…

Root of Diagnosis 3

The axial shot shows that the disto-lingual canal has been “missed” since it doesn’t appear to be as radiodense as the other canals.  At least this canal wasn’t cleaned all the way to working length.

Root of Diagnosis 4

The sagittal view shows 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.  

So, now I will tell you what his dentist told him to do.  This was his treatment plan:

  1. Root canal #31
  2. Extraction and Implant #30

Since the patient had a retreatment from me in the past, he knows that this is a thing.  He knows that retreatment is 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 based on a practice’s limitations, especially when he knows that other people know 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 test!

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 normal to cold.  And percussion was normal on all the teeth. So based on this, what would be your diagnosis now?  

. . . . . .

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:

  1. 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 than his dentist’s.  So I took a minute to explain to him my reasoning (that I just stated) and logic based on my findings. He totally understood and thanked me for wanting to save his tooth. 




  1. Don’t just make a diagnosis from the radiograph alone
  2. Don’t forget about what your diagnostic tests are telling you
  3. 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
  4. Treatment plan based on what you would do as if it was YOUR tooth!!




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