My TEDx Talk about the Modern Root Canal Procedure
November 9, 2021
The Ruddle Show: On Endodontic Education, Balancing Work and Life, and Overcoming Challenges
December 14, 2021
Your run-of-the-mill dental postoperative sensitivity is nothing new. We even tell a lot of patients to expect sensitivity, regardless of whether it follows a filling or a crown.
But sometimes a patient will come back complaining about sensitivity long after it should have faded. When this happens, how long do you wait until you make a referral? And what are your steps before you make that referral?
Do you rule anything out, like occlusion?
While you think that over, I have a tooth story for you to consider:
Was it Normal Dental Postoperative Sensitivity?
It was the day after Christmas and everything was off to a peaceful start. I was trying to get ahead of my end-of-the-year cleaning, and while I was organizing my desk, a team member asked if I could see a patient for an emergency evaluation. Because I didn’t want anyone to suffer over the holiday, I told them I’d take a look.
As you might have guessed, the patient informed me that she had a new crown completed just over a week ago, and now anything cold was unbearable to taste or bite down on.
When I asked her what her pain level was, she reported a 6 out of 10. Knowing that it could just be normal postoperative sensitivity, I went ahead and diagnosed her to figure out what was causing her pain. Just in case.
Diagnosing the Pain
My diagnostic tests confirmed her symptoms of cold sensitivity with lingering pain, along with pain to percussion and the bite stick. Her occlusion was totally normal. I noted the mesial and distal decay on tooth #19 and diagnosed her with Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis.
Since she was in a good bit of pain at the evaluation, I offered to open her tooth right then and there. I was concerned that her pain could get worse over the remainder of the holiday weekend.
I gave her a treatment plan and the associated fees, but she decided upon checkout not to stay for treatment. She explained to me that her insurance had maxed out, and she wasn’t willing to go forward, even with the ongoing pain.
The Passage of Time
Fast forward a few weeks into the new year. After her insurance benefits renewed, the patient was back on my schedule for treatment. I was really surprised that she could tolerate the pain for so long!
When I walked into the room and asked her how she was doing, she said she was “fine,” and honestly, she was almost TOO fine to be in my chair. I asked if she’d been functioning on that side. Her response was that she only had a little pain to heat but that she could now chew on that side, so I decided to retest her. She responded normally to cold with no lingering pain and she no longer had any pain related to percussion.
Um…what?
A False Positive
I stopped my testing and informed the patient we could do the root canal at any time, but I added that, if the passage of time was making her feel better (just like with normal dental postoperative sensitivity), then perhaps leaving things alone and giving her MORE time would help her recover even more.
One piece of the puzzle that I didn’t know initially: she had a bite adjustment from her GP a few days before she came to my office the day after Christmas.
Apparently, she’d insisted on a referral to my office based on her previous experiences with tooth pain. I wasn’t aware of this until her second visit, since she said her pain was initially an 8, then after the bite adjustment a 6, and then down to a 3 (no wonder why I didn’t notice that her bite was off at the time of the evaluation—it was already adjusted).
At this point, she had no pain at all, though all of her initial tests indicated she needed a root canal. I know now, because we waited, that her testing was a false positive.
So maybe time doesn’t heal all wounds, but it definitely works for some. This is something you need to always consider, just as with normal dental postoperative sensitivity.
The Rest of the Story
When the patient found out she wasn’t going to have a root canal, she gave me a look of complete gratitude. Yes, her buildup was deep, but so were some of the restorations on her other teeth, so perhaps she can tolerate deep restorations.
Since the crown was on with permanent cement already, I wanted to wait for more definitive symptoms. Yeah, I lost some production that day, but it’s better for me to do it this way. I always want to treat my patients right. Man, am I glad that we waited for her treatment!
It just makes me wonder, how many root canals are we doing because we are not giving the patient the chance to recover from the normal postoperative period?
Normal Dental Postoperative Sensitivity vs Something More Serious
I often give the patient what I call a “two week check.” If a patient comes to me and has either symptoms that are not too bad or are localized—or they recently had some dental work that could be the culprit—I usually have them wait before we start treatment. I then schedule to see them again at no additional charge (and I tell them beforehand so they will actually come back).
At that point, I re-evaluate them and go through my diagnostic tests again, comparing the findings to my initial tests. If they get better, then awesome! We move on! But if their symptoms are not better, then we initiate treatment knowing that treatment is really necessary.
This is something you can implement in your practice today!
Have you ever had a case like this? I’d love to hear your thoughts or lessons learned from this tooth story in the comments.
Takeaways:
- Always give your patient time in order to decipher between normal postoperative sensitivity and a tooth needing a root canal.
- Don’t underestimate the power of a bite adjustment.
- Make sure your treatment is warranted. Re-test if you’re not sure! It may mean you don’t go through with the treatment.
-Sonia
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14 Comments
Great tips .THANK YOU
And thank you for following!
-Sonia
Thanks for sharing! I always try to give our patients a chance at most conservative treatment. It’s nice to have this feedback as well 🙂
Thank you for all of your support Suzie!
-Sonia
I always give time to heal. But it gives me great sense of relief that I am doing write since reading a blog from the expert . Thank u for sharing
Great job Payal! Thanks for reading –
-Sonia
Great tip! Thanks for sharing.
Dr. Chopra, what specific methods do you use to check a tooth for cold and hot sensitivity? And what big of a difference does it make if a tooth is crowned? Thank you very much.
Hi Khalida – glad it’s helpful and thanks for reading!
-Sonia
Hi Stephen – I don’t see a difference at all if there is a crown on the tooth. I simply use a cotton pellet on a college plier with some Endo Ice to do my cold test. I don’t really do a heat test, instead, that is something that the patient tells me.
-Sonia
How would you avoid a false positive diagnosis of irreversible pulpitis knowing what you know now? Would you say that many rct we’re done with a false positive irreversible pulpitis?
Great story. I have a patient going through something along the same vein. I completed some composite restorations the first of November. The patient called us 3 weeks later complaining of possible lost filling with one tooth with pain. The patient returned complaining of pain to temperature and brushing x the past 3 weeks. I didn’t see any obvious defects, the original preparation was not deep , her response to percussion was positive then negative, there was positive reaction to exploration over the restoration area. I advised patient that we would remove the restoration apply a desensitizer and replace the restoration. Pt advised if symptoms continued and/or progressed endo treatment might be needed. We didn’t hear from her so I thought ok great. We decided to reach out just as a follow up only to hear that she was still experiencing pain. She could never say if she definitively felt better or worse however she was planning on traveling so she deferred returning to the office for follow up. I don’t like to jump to endo in situations like this especially. I plan to retest with Endo Ice . Thanks Dr Sonia for so many good tips and tricks.
Chandra,
These stories happen all the time. Thank you for your patience with this patient. Diagnosis can be hard sometimes.
-Sonia
Jianqiang,
There are definitely RCTs done that don’t need to be done. This is why I take my time with diagnosis. Nobody is perfect, but we need to slow down and make sure what we are doing is the right thing and sometimes re-test over and over again.
-Sonia