Proper case selection and accurate diagnosis can help practitionersavoid the calamities associated with these high-level procedures.

We have all experienced endodontic volatilityduring our careers. Endodontic volatility iswhen a potentially profitable procedure dete-

riorates into a disaster. Conversely, it is also when a rootcanal is resurrected from a disaster into a predictable, lessstressful, profitable procedure — a winner.

All dentists want to perform endodontics predictably,stress free, and profitably. When an endodontic proce-dure begins to degenerate, potential disaster looms.Here’s how to avoid it.

The key to avoiding “endodontic disaster” involvesmultiple factors: proper case selection, accurate diagnosis,

profound anesthesia, straight-line access, and avoidingiatrogenic incidents. In our first article we will examinethe first two factors, and address the others in an upcom-ing article.

The first way to avoid a “disaster” is through propercase selection. You must be honest with yourself anddecide whether or not you can properly treat the case. Itis smart dentistry to decide that a case is beyond yourexperience and refer that patient to a specialist. This isnot just about complex dental anatomy but also historyand patient management. If the patient is merely anxious,make certain that you fully explain things before begin-

by Kenneth Koch, DMD, and Dennis Brave, DDS

DISASTER!

How to avoid your worst endodontic

photo FPG Int’l.

AVOIDING ENDO DISASTERS

ning the procedure. Informing patients about what youjointly are trying to accomplish will increase their toler-ance of the procedure.

Also, let patients know that they do have some controlover the situation. For instance, if something is painful,and they raise their hand, you will stop. Many anxiouspatients will actually test you on this accord. Work withthe patient, not against them, and you will find yourtreatment progressing more smoothly.

The American Association of Endodontists hasaddressed the problem of case selection through the pub-lication of a difficulty assessment form. Through a num-bering system, based on difficulty, dentists are given a“heads-up” about the difficulty of the case they are aboutto treat. At first, such a system almost seemed tantamountto a “1-800-ENDO” concept. However, it rapidllybecame apparent the system can be a great aid in identi-fying very difficult cases. We recommend that every den-tist who performs root canals get a copy and understandits contents. You can obtain this document by contacting

the AAE at (800) 872-3636, or by visiting their Web site,www.aae.org.

The AAE has performed a real service for the generalpractitioner. If filled out properly, the assessment formoffers a defense to the endodontic legal nightmare.Should you find yourself giving testimony about why youfelt capable of doing a particular case, you can rely on thecase selection difficulty form to support your position.Your reply, if questioned, would be “I used the AAE RiskAssessment Form to evaluate the case before I started.The case presented none of the risk factors, so I felt per-fectly comfortable treating Mrs. Jones.” Talk about avert-ing a potential disaster!

Once you have made the decision to treat a case, thenext key is to confirm the diagnosis. Making the correctdiagnosis and treating the condition appropriately isvitally important. To ensure accuracy, do not hesitate totake a second, angled X-ray. Also factor in the patientmanagement issues, such as whether or not the patient is“difficult.”

Diagnosis is universally regarded as the most difficultpart of endodontic treatment. To make the routine lessstressful, you must become comfortable with a pre-dictable method of diagnosis. The following is a list of esome helpful diagonostic recommendations.

Real world diagnosis tipsThrough the use of key questions, we can obtain vitalinformation from patients:

? How long has this tooth been hurting? (Helps todifferentiate between acute and chronic.)

? Does this pain wake you up at night? (Endo paindoes; perio pain usually does not.)

? Do hot or cold liquids make the tooth hurt? (Coldpositive usually indicates some type of pulpitis while heatsensitivity can indicate a degenerating pulp.)

? Is the pain spontaneous? (Endo pain is mostly spon-taneous )

? Does the tooth hurt when you bite down? (Indicatesinflammation in the PDL;also indicates a necrotic toothor an occlusal discrepancy)

? Have you had any swelling? (Can indicate a possiblenecrotic tooth.)

Tip # 2: Take a second X-ray at a different angle

Following the initial discussion, we take an X-ray or X-rays of the suspected tooth. Taking two X-rays of thesame tooth, with one X-ray angled (in excess of 15degrees), assists with an accurate diagnosis. The angledX-ray will often show unusual anatomy that may bemissed in the standard radiograph. Also, remember the“SLOB” rule: Same, lingual/opposite, buccal. If youmove the cone head either mesial or distal, that part ofthe tooth (or canal) that goes in the same direction is tothe lingual. If it moves opposite to the cone head, thatobject is buccally placed.

The second angled X-ray is one of the keys to avoid-ing an endodontic “disaster.” Always look for ligamentswhen evaluating X-rays. This is critical to remember. Bytracing these ligament spaces, you can diagnose multipleroots, figure eight canals, bifurcated roots, or teeth withstrange anatomy. A perfect example of this is themandibular premolar. Endodontists agree this tooth —usually a necrotic lower bicuspid — causes the most angstfor the general practitioner.

Here is a typical scenario: The patient comes to youroffice and presents with a necrotic lower first bicuspid.Initially, the case appears simple. It is only one canal;since it is non-vital, anesthesia should not be a problem.You start to treat the tooth and your file goes down very

Making the correct diagnosis and treating the condition appropriately is vitally important.To ensure accuracy, do not hesitate to take a second, angled X-ray. Also factor in the patient

management issues, such as whether or not the patient is “difficult.”

nicely into the canal. Suddenly, after about 17 mm, thefile stops! You know from the pre-op X-ray that thelength is about 21 mm but you have now bottomed out atthe 17 mm mark. You begin to realize that something isnot quite right. The tooth is probably bifurcated. If thisnecrotic tooth flares up a little you might even get someswelling. If the swelling presses against the buccal nerve,this can lead to a potential nightmare, parasthesia. Oncepatients become parasthetic, they get upset.

The whole key to avoiding this disaster is proper diag-nosis and knowing the true anatomy of the tooth.Unfortunately, the majority of endodontic anatomy text-books in this country are out of date. This is because theoriginal studies, though beautifully done, were on cadav-ers from Germany during World War I. This group was,dental morphology wise, quite generic. Lower molarshad three canals, while lower bicuspids had one canal,and lower anterior teeth had single canals. Patients now-days are more diverse. In North America alone we areseeing many more Asian patients and people from the

Middle East. Asian patients often present with 4 canallower molars, bifurcated or double-canal lower bicuspids,and quite frequently C-shaped mandibular secondmolars. If you treat a large Indian and Pakistani popula-tion, you will also encounter many double canal loweranteriors. Remember Tip # 2. The key to preventing adisaster in such cases is a good angled X-ray and readingthe ligaments.

After the radiography is completed, we begin our clin-ical evaluation. Certainly, your office should have theproper equipment to conduct a basic endodontic evalua-tion. The basic endodontic setup consists of a mouthmirror, college pliers, combination periodontal probe andexplorer, cotton roll, “tooth slooth,” and “Endo Ice.”This simple setup can accommodate more than 98 per-cent of your diagnostic demands.

Tip # 3: Perform a percussion testThe first clinical test to perform is the percussion test,one of the two most important endodontic tests. Beginpercussion testing on an adjacent tooth or any tooth notfelt to be involved in the problem. Always begin withlight tapping, which you can increase as needed. Bybeginning on an uninvolved tooth, you avoid inflictingpain on the patient, who in turn retains confidence in the

outcome you recommend. Tap on the affected tooth witha mirror handle and also tap on multiple adjacent teeth,ensuring a thorough examination.

A percussion-sensitive tooth indicates inflammation inthe periodontal ligament. This pain can be the result ofeither a vital or nonvital tooth. Certainly, the inflamma-tion from a hyperemic tooth can go to the PDL, whichcan result in percussion sensitivity. Also, hyperocclusionin a perfectly normal tooth can transfer inflammation tothe PDL.

On the other hand, a necrotic tooth with bacteria andits by-products will often present with periapical involve-ment. This also will produce pain to percussion. Toobtain a proper diagnosis, combine the information fromthe percussion test with that of a thermal test.

Tip # 4 Perform thermal testingOnce we have determined that a particular tooth isindeed sensitive to percussion, the next step is to deter-mine the pulpal status of that tooth (vital or non-vital).

Without question, the method most commonlyemployed by endodontists is the thermal test and, in par-ticular, the cold test. Endodontists have used everythingfrom ice sticks to CO2 to computer refrigerant. Whenperforming a cold test, we strongly recommend using“Endo Ice.” “Endo Ice” is a refrigerant made by theHygenic company. It comes with a long nozzle in a greenand white box. Take the “Endo Ice” and the nozzle out ofthe box, insert the nozzle into the can, and cut the nozzleback so that only a short piece remains. We recommendthis to prevent the nozzle from flying off the can. “EndoIce” gets very cold and you simply spray it on a cottonball, give it a second to crystallize, and then place it on adry tooth. Endo Ice is so cold it will actually penetrate acasting. If there is no response from the cold test, youmust assume that the tooth is necrotic (nonvital). Youcan, however, test adjacent teeth to get a general sense ofthe patient’s response to cold. If other teeth respond tocold, but the specific tooth does not, assume that thetooth is nonvital. However, if the patient does respond tothe cold test, you must quantify the response. The key tothis evaluation is time. How long does the tooth continueto ache from the cold? Does it throb? If you place a coldpellet on the tooth and the patient goes “ouch,” what

AVOIDING ENDO DISASTERS

Always begin with light tapping, which can be increased as needed. By beginningon an uninvolved tooth, you avoid inflicting pain on the patient, who in turn retains

confidence in the outcome you recommend.

does this mean? A normal tooth will only take a few seconds for the cold todisappear but an inflamed tooth, with an irreversible pulpitis, will react withdiscomfort and throbbing that can continue for three to five minutes.

Therefore, the key to evaluating your patient’s response to cold is throbbingand its duration. Patients with an irreversible pulpitis generally will make aface, close their eyes, and start to roll their tongues. The tongue is warm andthe heat is comfortable.

Heat tests generally are not necessary. However, if you choose to performone, the best way is to isolate the tooth with a rubber dam and clamp (no anes-thesia), and flood the tooth with a hot liquid, such as coffee or tea. These liq-uids hold the heat better than straight hot water. Make certain you have high-speed suction ready to evacuate the liquid when the tooth starts to respond.This test is much kinder to the patient than placing hot gutta percha on thetooth. In fact, we recommend you avoid placing hot gutta percha on a tooth.

Heated gutta percha can be difficult to remove from the tooth, resulting inprolonged agony for the patient. Hot gutta percha is even more difficult toremove from a moving target! Remember, heat tests are rarely used byendodontists.Tip # 5: Know the limitations of EPT testingThe EPT(electric pulp tester) is probably the most common — and least accu-rate — piece of equipment the general practitioner uses for diagnosis.Endodontists rarely use EPTs. This tool can be used as an adjunct during diag-nosis, but its scope is limited. There are too many false readings associatedwith the EPT. A false reading can exacerbate an already anxious patient to nearhysteria. The only time it means anything to most endodontists is if it gener-ates no response. Then, we can assume that the tooth is either anesthetized ornecrotic. However, the percussion and thermal tests, when combined, are farmore accurate in determining a diagnosis.

These tips should assist you in making the correct diagnosis and avoidingthe nightmare of your patient saying, “Doctor, I think you treated the wrongtooth!” Talk about a disaster! This is one of the worst! Watch your fee goright out of the window. Also, how do you justify a fee now to treat the correcttooth? We have yet to mention the confidence lost by the patient and all theirfriends who could have been future patients.

Our next article will solve your worst disasters regarding cracked teeth andinadequate anesthesia. With proper information, endodontics can be profitableand pain-free — for you and your patients.

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AVOIDING ENDO DISASTERS