We’ve all had the same patient in the chair, whether you’re a general practitioner or endodontist. A molar was prepped and temped uneventfully a few weeks or months ago (see Figures 1-3). The patient presents for the crown delivery appointment and the rest can vary.
Sometimes the crown was just cemented and placed after being prepped and temped uneventfully and the patient never reported any symptoms or discomfort (see Figures 4-6). Often during crown treatment planning, (newer) PAs are not taken and the crown gets prepped and temped based on the FMX from years earlier.
So, the crown was prepped and temped based on the recent BW from the previous year (they are often taken every two years). Unknowingly without a “recent” PA, periapical pathology likely existed even before the crown was prepped and temporized.
Three scenarios to consider
Scenario 1: At cementation, the dentist notices a small draining parulis (pimple, sinus tract) and assumes periodontal involvement since the patient is asymptomatic. The dentist explains the situation to the patient, drains the abscess, adjusts the bite and writes a prescription for antibiotics and, maybe, refers the patient to a periodontist.
Scenario 2: The patient is symptomatic after the prep and temporary appointment. They call the office to report cold-like symptoms but when they present, the symptoms are not reproducible or remarkable and both patient and dentist agree to go ahead and cement the crown since the symptoms come and go for the most part, but have been less since the patient's first call.
Scenario 3: The patient returns asymptomatic and delivery goes well. Several days/weeks/months/years later, the patient returns with either symptoms of throbbing pain or with a facial swelling and asks you how this happened.
Dentists may ask if there was anything they could have done differently. Patients often ask this of endodontists.
Each scenario could result in a different flowchart, but as an endodontist, my suggestion is first and foremost to take a periapical film before any crown is planned, even if the crown is going to be replaced. I suggested this recently to an audience of general practitioners and a dentist with 24 years of experience responded that they always “have a recent film of the tooth” in question. I asked that dentist to define “recent.”
Insurance guidelines suggest BW every two years and FMXs (PAs) every five years, so how recent is the “recent” PA you’re referring to? Why not take a very recent PA (within the past two months) of any tooth with a large restoration (three surfaces or more) that is about to be replaced, added to, or crowned?
A recent PA, with the BW that you might already have, will provide essential information about that tooth. Are the pulp chambers uniform and evident? Meaning, can you see the pulp chambers? Are they grey? Or are they sandwiched and shrunken (aka calcifying or calcified)?
Can you cold test the tooth? If it is calcified, it might not respond to cold, so then how do you assess? Is the cold response the same intensity as all the other teeth? Can you percuss the tooth? Is it different in how it feels versus the adjacent teeth or virgin nearby teeth (if applicable)? If not, might you be able to suggest an endodontic consultation?
In Scenario 1, if the periodontist also does not test the tooth for pulp vitality and the true origin is endodontic in causation, misdiagnosis can continue since most endodontic symptoms resolve temporarily with antibiotics. The tooth that most likely needed endodontic therapy then might unnecessarily receive periodontal therapy and/or may later become a bigger problem with fewer or less optimistic treatable solutions.
In Scenario 2, the symptoms have falsely disappeared or “resolved.” Likely, pulpal necrosis will continue and eventually symptoms and/or an abscess/swelling may eventually appear in time.
In Scenario 3, pulpal necrosis (likely present prior to crown cementation) progressed, which resulted in facial swelling. But each scenario could have likely been avoided with the suggested limited testing in conjunction with a PA film and an endodontic consultation to be sure.
As a side note, it usually takes approximately three months for radiographic changes of pulpal necrosis to become evident with a periapical lucency, for instance, and please remember these lucencies aren’t always clear or evident.
Room for improvement – the year of the PA
I’m a systems-type person. I like flowcharts and checklists. These two suggestions below will decrease your post-crown cementation complications and prevent many patients from becoming disgruntled about their symptoms or having you or an endodontist create access through their beautiful and costly new crown.
In Figures 7-9, each patient was asymptomatic but clearly all had medium- to large-sized restorations.
Many patients present to endodontists by saying their dentist told them their (now symptomatic) tooth "might need endo" (several years ago). Why are we so timid and fearful about this important conversation, and why are patients still so scared of endodontics?
I speak to many practitioners who still admit they cannot comfortably deliver the “you need a root canal” conversation with their patients. Let’s embrace this. Let’s step up our patient conversations and educate them so that they can avoid unnecessary pain and discomfort. Let’s script this, rehearse and change the dialogue to make it a positive conversation – preferably in advance and possibly during the treatment planning. My first suggestion would be something like:
"Hey, Mr. Smith, this is a very large filling. It would be best if you had a [root canal] before we place the crown (though you could also say endodontic or pulpal therapy to minimize the patient's negative response). It would avoid potential discomfort or having to drill through the beautiful new crown after it’s placed. I know it’s not what you might want to hear, but it would really save you time, money and discomfort in the long run."
If the patient wants to hear a bit more about the biology and why, feel free to elaborate. To patients with and without symptoms, I explain:
“The nerve inside the teeth is a very delicate tissue and, unfortunately, the nerve tissue does not like cavities or fillings getting to close to it. Over time (or suddenly) we have gotten too close to the nerve tissue and it is likely going to be harmed. Unlike the rest of your body, it won’t be able to recover or heal itself, and that is why endodontics is indicated. I’d like to offer you to have it done sooner so that you can avoid the symptoms, discomfort or ruined weekend or holiday, since it can surprise you anytime and even land you in the emergency room.”
Some patients will opt to gamble. But knowing this, I’d like to think you’ll get more “takers.”
My second suggestion is to introduce your patient to your endodontist via an in-office tablet, or pamphlet if that’s easier – essentially to confirm that the specialist you’re referring them to is an experienced clinician with a successful practice. Introducing your patient to your endodontist and their team is highly comforting to patients. Otherwise, they are most likely to fold up your referral slip and wait for symptoms and default to one of the aforementioned scenarios.
I also advocate that you educate your front desk and other team members. If you are inclined, ask your endodontist about key phrases to listen for when patients call to report pain. With this awareness, your office and the patient will both be relieved to avoid wasted time and resources. Perhaps you and your staff would like the patient to go directly to the endodontist? Decide as a team and embrace this new system. If anything, try it out for a few months.
Likewise, dental hygienists should also be empowered, since they often have the closest relationships with the patients. Have every hygienist ask patients about dental discomfort or pain during each visit. Have them selectively take PA films on heavily restored teeth. When they probe, if there is isolated pockets or purulence or a sinus tract, be sure to take a PA film and have them notify you. This is an important indicator of potential/likely endodontic disease.
Many dentists tell me, "I told the patient they needed (endo)." With a bit of confidence and rephrasing, endodontics doesn’t have to be so negative, and your patients will have a better grasp of how endodontics helps save teeth and eliminate pain.
Judy McIntyre, D.M.D., M.S., is a contributor to Spear Digest. Follow her on Instagram @drjudyendo.