When patients present with urgent endodontic problems, coming up with an accurate diagnosis is not always a straightforward process. Whether you are faced with a distressed patient with toothache or an asymptomatic patient presenting with vague symptoms, it is important to have a systematic approach to arriving at a final diagnosis.
Symptoms and clinical assessment
To begin, it is important to empathise and establish trust. Open questions are essential to allow the patient to share their complaint and to procure an accurate history (as well as get an indication of the patient’s attitude towards dental treatment). A popular mnemonic used by clinicians to gain a precise pain history is ‘SOCRATES’; site, onset, character, radiation, associations, time, exacerbating/relieving factors and severity. Any cases with a history of trauma will require more information regarding the time, date, location, loss of consciousness, medical history and any emergency treatment carried out.[i]
Extraoral examination will identify any facial asymmetry or swelling, and the patient’s general condition including fever, difficulty swallowing, difficulty breathing or malaise could point to spreading infection. Clinicians must be aware of cases which require hospital referral. Intraoral examination will identify the possible dental cause of the presenting complaint. Soft and hard tissue assessment will benefit from the use of good lighting and magnification.i
Special tests for suspected endodontically affected teeth
When the teeth are potentially endodontically affected, there are a number of initial tests that may be used to identify the affected tooth/teeth, and indicate the diagnosis.
Thermal testing should be carried out with a cold (refrigerant spray) or hot (warm water, heated probe or heated gutta percha stick) stimulus first to a ‘control’ tooth located far from the suspect area to establish a baseline, and then to the suspected tooth. The responses from all the areas tested should be recorded (including lack of response) to help inform later diagnosis and severity.i
Another widely used test is the electric pulp test. This uses a probe which applies an electrical stimulus to a tooth at varying intensities, and gives a digital reading which can help inform pulp vitality. It should be noted, however, that electric pulp tests are accurate when testing vital teeth, but not when testing non-vital teeth.i
When it is difficult to locate the source of the pain, selective anaesthetic testing may also be appropriate. This is a diagnostic test that aims to localise the source of pain by progressively excluding areas of the dentition until the suspect tooth is found. For example, if the pain is poorly located between the upper and lower jaw, selective anaesthetic testing may be carried out to localise the source.i
When carrying out these tests, there are a few things to consider. Clinicians must ensure that the stimuli mentioned above are applied to sound, and dry tooth structure along with isolation and that they avoid contact with restorations for the most accurate outcome. Additionally, an optimal response can be achieved when the stimulus is applied to the thinnest enamel area, or exposed dentine.i
Diagnostic imaging
To ensure an accurate diagnosis, radiographic imaging must be used when justified following clinical examinations and special testing. This is in line with the ALARA principles, to ensure patients receive lower doses of radiation. As such, a conventional periapical radiograph should be taken first to assess for periapical pathology. If there is insufficient information gleaned from this, 3-dimensional imaging (Cone Beam CT) can be considered.i
Never stop learning
All clinicians will be involved in the diagnosis of endodontically affected teeth; therefore it is essential to keep up to date with the latest developments in the field, and solidify your understanding. By becoming a member of the British Endodontic Society (BES) clinicians join a group of likeminded dentists with an interest in endodontics, and a commitment to providing excellent treatment and furthering their knowledge. The BES values education, running a number of useful events for clinicians at all stages of their careers including the Spring Scientific Meeting, Regional Meeting, and Early Career Group Meeting, along with workshops aimed to help members expand their knowledge. The BES has also published its Guide to Good Endodontic Practice, to ensure the clinicians have a reliable document to refer back to when making decisions.
Utilising all of the information gathered through clinical assessment, special testing, and radiographic imaging, clinicians are able to effectively form an accurate diagnosis and treatment plan accordingly.
For more information about the BES, or to join, please visit the website www.britishendodonticsociety.org.uk or call 07762945847
[i] BES. Guide to Good Endodontic Practice. https://britishendodonticsociety.org.uk/news/39/a_guide_to_good_endodontic_practice
