Thanks to The Endo Blog for this. This new terminology hasn’t yet made it into the American Association of Endodontists’ glossary of endodontic terms, but it is much more practical than the terminology commonly in use today.

Endodontic diagnosis generally consists of both a pulpal and periapical diagnosis.

Pulpal Diagnosis:

• Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.
• Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.
• Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.

Additional descriptions:

• Symptomatic – Lingering thermal pain, spontaneous pain, referred pain.
• Asymptomatic – No clinical symptoms but inflammation produced by caries, caries excavation, trauma, etc.

• Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.
• Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments.
• Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).

Apical (Periapical) Diagnosis:

• Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.
• Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area.
• Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms.
• Acute apical abscess - An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.
• Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract.

Some new technology that’s being developed allows use of existing xray tubes to produce better images. Hopefully this will benefit dentistry as well. The original article is here.

I’ve been asked to comment on anaesthetic testing of teeth. This is a diagnostic test that’s done to try to localize pain to a particular area or tooth or to even rule out odontogenic aetiology as the source of pain.

While I was an endo resident I rotated through Mt. Sinai’s facial pain clinic and one thing that I’ll probably remember forever is a patient who presented with a nagging toothache. She pointed at the 16. I don’t remember her history, but for some reason her regular dentist suspected non-odontogenic pain. We suspected the same thing once we saw her and examined the area. My supervisor at the time recommended that we try an anesthetic test to see if we could rule the tooth in or out as a source of the woman’s pain. Muscle palpation in the area was unremarkable, so it wasn’t like the anesthetic would numb up active trigger points that were the source of the pain.

So I reclined the chair as I was telling her about the test I was going to do. I applied some topical anesthetic and told her we’d wait a little for that to take effect before I used the real stuff. After about a minute of letting the topical soak in, my patient looked at me and said that her chronic ache was gone. Hmm. Confused was I. But not my supervisor. Off to the neurologist our patient went.

Patients will often present with toothaches that they can’t localize to a particular tooth, or even point at a tooth that has nothing obviously wrong with it, and the responsibility falls on the dentist to diagnose the problem and treat the correct tooth.

Anaesthetic testing is most useful for eliminating quadrants as suspects rather than adjacent teeth (obviously). This however, can be a valuable tool, because referred tooth pain often does cross the horizontal midline.

Explanation by way of example:

A friend, K, called the office in tons of pain about 3 weeks ago. They were actually at their regular dentist and the dentist was pointing at 16 as the source of pain. K agreed.

I had seen her for the 16 about a year ago because of some pulpitic-type sensitivity she was having there. The problem turned out to be deep caries. I did some caries control and ended up with a pin-point vital pulpal exposure. I decided to pulp cap with MTA and see how things went. I also told her to have 48 extracted because it was partially erupted and picking up caries on the distal.

Everything settled after about a week.

With the phone call from the other office, it made sense that any current toothache had 16 as the likely source. My personal schedule (getting ready for the ProAm) didn’t allow me to see K quickly. Antibiotics and anti-inflammatories were of little help.

We managed to finally get K into the office. She hadn’t been sleeping well for about 3 days at that point. Again, she pointed at the 16, but said that the pain was pretty much on her whole right side at the back. Xrays of both upper and lower quads showed no areas consistent with apical pathosis. Because I figured we were dealing with an acute pulpitis, I didn’t want to torture K by cold testing the 16, but out of habit and instinct, I decided to test other teeth to try to definitively rule in 16 as the source of pain.

Cold testing was normal where it should have been except on 48. Cold applied to 48 provided some reduction in K’s overall pain level. Hmm. I decided to percussion-test the teeth. Both 47 and 48 were percussion sensitive relative to 16. Both 16 and 48 had been filled with resins by K’s dentist. Both fillings were falling apart.

So in comes the anaesthetic test. I gave 1/2 a cartridge of lidocaine as a buccal infiltration about 16. After 5 minutes, K indicated that she felt the pain still everywhere except for where I had given the freezing. The pain was practically the same intensity. This led me away from the 16 as the source, and to the 48 as the next likely candidate. A subsequent mandibular block eliminated the pain.

The problem turned out to be an irreversible pulpitis on 48. I didn’t go back and try cold-testing 16, but I’m assuming at this point that it’s pulpally ok…

When testing areas this way I usually start with inflitrations on top and save the lower block as the last injection. It’s much easier to control the field of anaesthesia on the upper arch than the lower. Field control is a good thing because the more we can isolate the anaesthesia to a particular tooth, the more information we glean from the test.

I’m posting an email conversation I had recently. If any of you have other opinions (doesn’t matter if you agree or disagree with mine) please comment. It’ll benefit us all, especially since general dentistry hasn’t been my field for a few years:

Paraphrased question:

I mainly just had a question about appropriate screening at dental check-ups. What is the standard of care? Is a panorex a legitimate screening modality?Also, my wife just visited a new dentist who found an area that needed repair. Without asking he snapped some digital pics to show her. He could see the area clearly without the need for the pictures, and she surely would not have asked for them, especially if he had told her that they would cost almost a hundred dollars and not be covered by insurance. Do you think this warrants any action on our part other than refusing to pay. Any thoughts in general?

My response:

Did the new dentist take the Pan on your wife? Were the digital pictures xrays or intraoral photographs?

Their response:

The Panorex was done by a tech before my wife saw the dentist. He told her it was just routine screening. The digital pics were intraoral photographs. She had a cracked tooth in the back.

My answer:

Pans are an appropriate film for new patients and patients who haven’t had a comprehensive radiographic survey for a number of years. You get less radiated from a Pan than from a full mouth series (16-18 films) and you get more peripheral information from a Pan than the FMX (TMJ, sinuses, jaw anatomy). Unfortunately, the resolution of a pan is generally not good enough to definitively diagnose some types of caries and some other tooth-related issues so we’ll target individual areas with more specific films if we see something suspicious on the Pan. In their defense, Pans, especially the newer digital ones are becoming sharp enough to see incipient caries as precisely as we are able to on bitewing films.Intraoral cameras are a great tool in helping patients trust that what their dentist is saying is wrong with their teeth actually is. Many times teeth that need work are asymptomatic and patients don’t actually know if the recommended work is really needed. I take pictures of some of my cases so that when I send the note back to the referring dentist they don’t think I’m bullshitting them. Same idea.

Intraoral shots are sometimes a good idea for records, but are generally more important for patient education and information. As with anything in medicine and dentistry, the equipment is expensive though and some dentists feel the need to recoup their costs. IO cameras help to recoup their own costs, because by being able to show pt’s problems in their mouth more directly, pt’s are usually more interested in getting something done rather than waiting for pain to develop (at which point you might not be able to do anything). I haven’t heard of any offices that charge for IO pictures for this reason. But that obviously doesn’t mean it doesn’t happen.

Your financial responsibility with an office is part of any informed consent. Prior to a procedure being performed, if you were not aware that you would have to pay for the procedure, I can’t see how the office can make you pay. Along this same vein, and just as unethical, is when a therapeutic procedure is started and proceeds to the point of being irreversible (eg. a root canal procedure is started) and the office then tells you how much you’re going to have to pay.

Unfortunately, most patients don’t want to rock the boat and don’t complain and pay they bill. They become wiser for next time.

In your wife’s case, I can’t see how you’d take the case any further than refusing to pay for the pics because the only neligence was not informing your wife of costs. No damage or physical error was done by the dentist. If reported to a state dental board, they might warn the dentist about the way he practices, but that would probably be the end. And I don’t know if he’d change…

This patient was bounced from her family physician to a dermatologist who, over the course of a couple of years, repeatedly cauterized this recurring pimple (probably thinking it was a sebaceous cyst or something similar). The patient finally ended up at a dental office where they found that the source was a tooth abscess.

This picture shows the tracer pointing to the apex of a tooth. Both the canine and lateral incisor were probable sources of infection, so the root canal was redone in the canine and a root canal was done in the lateral incisor.

This is the post op film. No recall pictures yet but the chin has healed with a little scarred dimple.