Somebody give me a microphone, because I’m about to get on my soapbox! I recently had a conversation with a general dentist who I love, but something she said made me nearly fall out of my chair. She told me she never does a cold test. This is endodontic blasphemy!! It’s so important for you to perform a cold test on teeth, and I want to tell you why today. I hope, when you finish reading this blog post, you’ll feel as strongly as I do about this!

First of all, let’s talk about what a cold test is actually FOR. Cold tests help you actually make and understand your diagnosis. Your diagnosis becomes your roadmap, so you know how to guide your treatment plan and help your patient. You do not need to be doing the root canal to be doing endo. Say it again with me: You do NOT need to be doing the root canal to be doing endo. Diagnosing your patients’ pain is endodontics, too! Knowing your diagnosis will guide your patient through the referral process. And if you are doing the root canal, it will help you anesthetize, medicate, treat, and follow up with your patient. And when you act as the diagnosis pro who can guide your patient through the process, they will continue to love and trust you forever. My friends, this is how you build strong relationships that last with your patients!

So with that context, how can you possibly help your patients without doing (and knowing how to do) a cold test — aka knowing your diagnosis? You honestly can’t diagnose anything without doing a cold test, period. This is why I always say cold testing isn’t just for endodontists, it’s for ALL dentists. In fact, that’s why I plan to give out a big basket of Endo Ice to all my referrals this Christmas. Okay, okay, I’ll throw in some festive holiday chocolates, too. 😊

Still not convinced about the importance of doing a cold test on every tooth you treat? Let’s have a look at a few examples that happened to show up to my practice a few weeks ago.

Tooth Story 1: Cold Test on Tooth Without Pain

What do you do when you see a Texas-size lesion that encompasses multiple teeth? Which tooth is the culprit? Do you treat all the teeth, or do you believe that none of these teeth are no longer saveable? (I really hope it’s not the latter! Please, give teeth a chance!)

My findings were as follows:

All probings in the quadrant were within normal limits. There was no pain to percussion. In fact, the patient had no pain at all. Teeth #3, 4, and 5 all responded normally to cold, but tooth #2 did not respond to cold. Aha, that’s some good information! So, my diagnosis was Necrotic Pulp and Asymptomatic Apical Periodontitis #2.

Knowing that all the other teeth in the quadrant were vital, I knew that this lesion belonged solely to tooth #2. It was the culprit, and the other teeth were fine for now.

So, I treatment planned him for a root canal on #2, and we will see what happens from there.  Hopefully, he won’t need any other treatment beyond that, but I always prepare my patients who present like this for a possible surgery, since this could be a cyst. The plan is to follow up with him in 6 months and see if this lesion shrinks.

Tooth Story 2: Lesion Present, but Teeth Test Vital

What do you do when you see a lesion, but then the teeth test vital? (Hint: you will only know if you do a cold test!) 

Here is another patient who literally could be the previous patient’s twin, when it comes to their tooth stories. But there is one key difference.  

This second patient presented with a large lesion around teeth #14 and 15. He was asymptomatic, had no pain to percussion, and all his probings were within normal limits. But here’s the difference: this time, both teeth responded normal to cold, and #14 and 15 were vital.

When I did the cold test, I was very surprised to see that both teeth #14 and 15 were vital. My assistant even looked at me with big eyes. 

This lesion is NOT of endodontic origin, and so that means that it needs to be biopsied. I couldn’t tell you if this was an odontogenic keratocyst or metastatic cancer, but this patient needs to be seen by an oral surgeon, not an endodontist.

Do you see how a simple cold test could save this patient so much money and time? Not to mention, it will build trust in you for making the proper referral! There was no need for this patient to walk through my door for this evaluation. They need OMFS, stat!

Important Note: Using Endo Ice

Anytime you see a lesion, your first instinct should be to pick up the Endo Ice. Keep that simple rule right in the forefront of your mind. Just get yourself a few bottles and use it. 

Don’t try any shortcuts or to use anything else, like freeze anesthetic carpules or get dry ice or even use regular ice. I’ve seen it all, but I swear by the good stuff. Endo Ice is super controlled and friendly, so please use it. It really is your best friend as a dentist. And use it properly, with a cotton pellet on a college plier. (Seriously, please click this link to read about how to do a proper cold test.)

When you check vitality, you are performing a really important step! You are making sure that this isn’t something else, like metastatic cancer.

Tooth Story 3: Different Variations of Normal

One of my referring dentists sent me this image and asked me what I would do. They only sent me this image with no other info.

What other information do you think I might need in addition to this radiograph? Maybe a history of previous trauma, some percussion test, or you guessed it… a cold test?? That’s exactly what I asked about!  

I reached out to the dentist to find out if the teeth responded to cold. He replied that, yes, they do. 

Then I asked him if this was an African American female in her 40s. He messaged me back and said, “Yes, it is! She is 42!” 

Well, knowing that, I can make the differential diagnosis that this patient has Periapical Cemental Dysplasia, since I learned in dental school that this happens more commonly in this specific population.

I told him if he feels more comfortable getting a second peek at this patient, then he should send her to an oral surgeon and not an endodontist. Do you see how this can save your patients loads of money and time? And then guess what? That means they will have more money to spend on that crown on another tooth you so desperately want them to get. 

Tooth Story 4: Swelling and a Vital Tooth

I’m eager to share this tooth story, because it really might not be obvious to everyone! This patient was swollen in the submandibular area, and it was getting serious. She was honestly on her way to having a Ludwig’s angina. She really didn’t have time to waste seeing multiple providers to get the right answer. She would be hospitalized before long if she wasn’t treated.

So I started with a diagnosis. As I did my testing, I found that all the teeth in the quadrant tested vital. I was so confused because anytime I see swelling, I always think it’s of endodontic origin.  And if it is, you should be looking for a necrotic tooth.

In this case, I even felt that my testing wasn’t right. Why was she still feeling cold? I didn’t trust myself, so I had my colleague come into the room to re-test and check behind me. Guess what?  He obtained the same result; those teeth were vital!

I took a CBCT and found a radiolucent area lingual to tooth #18.

But the CBCT didn’t show me any pathology in the periapical area.

It was all coronal, as you can see on this coronal slice of the tooth.

I determined that this tooth could be cracked, it could be a periodontal issue, or it could be something else. So once again, I referred the patient to an oral surgeon.

Cold Test on Teeth to the Rescue

So I hope you’re taking away from this pearl of wisdom: When you design your treatment plan based only on the radiograph, and you don’t truly understand what is happening to the patient and the etiology of the problem, you can make a major mistake. 

Would you want that to happen to you? Would you want to get the runaround from a bunch of providers? Of course not!

And look, I understand you might think it’s okay to not know how to properly do a cold test, or to know the information that comes from a cold test because you don’t do oral surgery or endodontics in your practice.

But you still have to make a referral, right? You still have to get that patient to a provider who can help them!

And if you send them to the wrong specialist, you’ve wasted your patient’s time and money. This understandably makes them lose faith in you. They may not have enough trust in you to return to your practice. If you’ve misguided them once, how do they know you might not again?

There’s an easy way to prevent this, though: Do a cold test! Your patients will thank you. The specialists you refer to will thank you. Your practice’s bottom line will thank you. It’s so important!

Stay tuned for a future post where I’ll be talking about how you can really understand and interpret your cold test to help you achieve diagnosis mastery.

Want to Take Your Knowledge to the Next Level?

Let’s be honest, there are some details and advanced skills that dental school doesn’t have time to cover, no matter how excellent a program is. I would love nothing more than to be your endodontic coach, so you can learn directly from me, and I can help you be more confident in your endodontic skills. And as a bonus, your knowledge will help you make your practice more profitable and your career brighter. 

Whether or not you officially “do endo” in your practice, you’re using endodontic knowledge every day. This stuff is SO important.

I invite you to sign up for the E-School LIVE waitlist for my 4-day live, hands-on endodontic CE course where you’ll perform root canals on real patients. And I’ll be there to help guide you in real-time. 

There’s no cost to join the waitlist; it’ll just give you first dibs on signing up. Please note E-School with Coaching is a prerequisite for E-School LIVE. Sign up for the waitlist, and you’ll get all the details in your inbox when I am ready to open up registration for the next session.

Pulpal and Periapical Diagnosis Checklist (because performing a cold test is part of the diagnosis process)