Sneaky Referred Pain in Endodontic Evaluation and Diagnosis

As an endodontist, I see referred pain all the time. It’s my job to ensure I can perform an endodontic evaluation and diagnosis before I proceed with treatment.

Both patients and referring dentists can become irritated when I insist on re-evaluating the patient before I start treatment. I don’t feel bad about that, because I have a case that shows exactly why I re-evaluate, and why you should expect every endodontist to evaluate your patients again.

Some of the things I hear from patients include: “My dentist already told me I needed a root canal” and “My dentist already did this at their office, why are you doing it again?” 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💢).

I understand why this process frustrates people, but it’s not as frustrating/dangerous as operating off a wrong diagnosis!

If I didn’t confirm the endodontic diagnosis with a proper evaluation in every case, I would have lost my license by now.😱 I would have a ton of unhappy patients because those patients would still have pain, even after a root canal.

At least once a day I have to work through referred pain to find the culprit tooth.

Let’s look at this case. Check out this referral slip:

It clearly states to do a root canal on tooth #30, and when you ask the patient where the pain is 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. This guy was in so much pain that he could barely think and he hadn’t slept for two nights straight.

But does the pre-operative radiograph line up with that assessment?

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.

I knew I needed to do more digging.

So, that’s when I looked at the bitewing, just to check my boxes and see if there was a possibility another tooth was responsible.

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

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 himThe patient was so confused at this point, and he was in too much pain to concentrate. I decided to administer a numbing agent, not only so we could have a focused conversation, but also to confirm my diagnosis. 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.

 Now I knew with full confidence that his pain was originating from the maxillary arch. He was in so much pain, I proceeded to do the root canal that day. I knew if I didn’t, he would be unable 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, after ensuring proper endodontic evaluation and diagnosis.

 I called him the next day to see how he was doing. ✨TA-DA! No more pain!✨ He said he slept so hard that he didn’t wake up with his alarm, haha!

Please keep this in mind when your endodontist is evaluating 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.  With the right expectations, 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. If we take our time to make the correct diagnosis, we are saving both time and money for our patients. You should want your endodontist, and any specialist, to operate as your “checks and balances,” so you don’t lose face, too.

-Sonia

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