Endodontic Diagnosis: "Pot of Gold"
Well, today I have a very interesting topic and we could entitle this topic today, “The Pot of Gold”. We probably all have heard the expression that at the end of the rainbow there is the proverbial pot of gold. Actually, I’m going to talk to you about where there is a pot of gold and you’re not really finding it is my impression.
Let me support my assertion. Almost any dentist, anywhere in the world, regardless of their ethnicity, the country that they practice in, the school that they went to; we’re all taught to do an endodontic examination. If you will, let’s be more specific, we’re taught to all do a general examination on any new patient that matriculates into our office. We might not accomplish the complete examination in the first visit, maybe not even the second visit, but generally in the first few visits we gather all the information such as: We look at the occlusion; we have patients slide into work and balance and protrusion to see how their gnathology is; we look for carries; we look for existing restorations and do they have good marginal adaptation, are they esthetically pleasing, and is there a good biological width and soft tissue response to the restorative.
Further, we’re taught to probe every tooth and we’re looking for perio-defects and pocketing and everything perio that would suggest a problem. Further, we’re looking for missing teeth. You’re looking for dark teeth… And, in general, you’re doing a complete full mouth examination. This includes looking in the oral pharynx, under the tongue and the fornix of the vestibules. You’re looking for fistulous tracks in the attached gingiva, in the lining mucosa, and yes indeed, through the sulcus.
You do all these things faithfully, yet how many of you routinely perform an endodontic examination as part of the comprehensive general examination? My assertion is, virtually none of you do… and here’s what’s at stake when you don’t. Let’s just make an assumption very quickly. You can make the numbers fit precisely in accordance with your practice, but in this assumption I’m going to make today, I’m going to assume that all of you have 1,000 active patients. If you’re new and out of school, you might not have 1,000 active patients. If you’ve been practicing for more than five years, you have a lot more than 1,000 active patients, but that’s my assumption.
Let’s assume that those 1,000 patients have only 20 teeth per patient. They could have 32 teeth, that would be a whole compliment of teeth. They could have just a few teeth left. But, let’s assume they all have 20 teeth. So, 20 times 1,000 patients means you’re the custodian of 20,000 teeth. My question to you is: Do you know the status of the pulp within the teeth that visit you daily? Do you know where that pulp is on a continuum that ranges from total health to gangrene necrosis? Are you aware of the status of that pulp before you pick-up the handpiece and ever touch the tooth for a restorative or prosthetic procedure? My assertion is that you don’t… because you don’t do an endodontic examination.
What is the endodontic examination? Well, the endo examination is comprised of three things. It’s the vital pulp testing, it’s gathering the clinical findings and finally, it’s the radiographic examination. These three things, in concert, reveal the status of the pulp and let you know if the pulp is totally healthy, if the pulp is sick and potentially irreversible, or if the pulp is irreversible and it’s marching down through, you know, inflammatory responses that would include ischemia, infarction, necrosis and pulp death. So, if you aren’t doing a full mouth endodontic examination on these 20,000 teeth, then you have no clue what the status of any given pulp is, on any given procedure, you might be entertaining to do today or at the next visit.
So, what I want to say is, I’m going to now tell you more about the “Pot of Gold”. If you were to actually do vital pulp testing, with emphasis on first establishing a baseline, and gathering confidence between you and the patient between what is normal for them, then we typically would run cold or hot tests. If a patient says it hurts to cold, we’d run a cold test. If they say it hurts with hot, we would run a hot test. If we gather clinical findings such as: mobility percussion, palpation, probe the sulcus…
If we did all these things and more, you would begin to have a profile of this tooth. And then if you gathered films, even including more than one single, well-angulated radiograph, if you actually move the cone a few degrees horizontally from straight-on, you would have a wonderful series of information pieces that would come in that would help you either put the pulp either towards health or you need to do root canal or extract the tooth. Since you’re not doing this, you’re missing an enormous opportunity because out of these 20,000 teeth you’re taking care of, if you’re not even pulp testing, then nobody can even argue with me. But, let’s just assume for fun, between colleagues, that you’re missing 5% of all endodontic diagnostics. You’re failing to find irreversibly involved teeth.
I’m not talking about the toothache… you find the toothache. I’m talking about are you finding irreversibly involved quiescent pulps? So, if you miss it 5% of the time, I guess I’m going to ask you to do some homework for me. What’s 5% of 20,000? It turns out to be 1,000 teeth. There’s 1,000 teeth that you’re failing to do root canals on that ethically need treatment or extraction. Well, what if you were to get $500 for all root canal procedures? Okay? It could be an anterior, bicuspid or molar. You can plug your own fee in, in your geographical region, but I’m just assuming low-ball that it’s a $500 procedure. So, $500 times 1,000 is $500,000. That’s a half a million dollars of work you’re failing because you’re not looking for it. You’re not ethically diagnosing and helping your patients get a good chance to move towards optimal health.
Well, the good news is, for a dentist anyway, maybe perhaps the patient doesn’t feel this way, but what do all endodontically treated teeth typically get post-treatment? They get restorative… usually a new crown. Let’s just assume, again, it’s a low-ball number… that all crowns, whether they’re tooth-colored castings or whether they’re all gold castings, let’s just assume that all crowns cost $500. There’s another $500,000.
So, if you add together the missed endodontic diagnostics at $500,000, the missed opportunity to restore an endodontically treated tooth for $500,000; that’s $1,000,000 of undiagnosed treatment that’s slipping through your hands on a day-to-day basis. We’re not saying to do aggressive endodontics. We’re not saying to do unethical endodontics. We’re saying to do the due diligence, the ethical pulp testing, and then to decide and talk with your patients what is best for them. So, you can see, my friends, that out of all the people that are walking into your office, you’re picking up handpieces, you’re constantly doing all kinds of restorative and comprehensive crown and bridge procedures, but what’s missing is, you don’t know the status of the pulp.
So, there is a “pot of gold” at the end of the rainbow and my assertion is: There is a pot of gold and it’s within the teeth that visit you daily. If you’d like to have more information on how to do pulp testing, you can go to my website and you can download for free, articles I’ve written on endodontic diagnosis which perfectly explain the vital pulp testing schemes, how to gather the clinical findings, and the importance of two or three well-angulated, different horizontally-viewed films so we can be real clear on endodontic diagnosis. This means you’ll be carrying out your treatments with greater confidence and skill.
