Managing Endodontic Cases

Intake Questions

1. Can the patient localize the pain to a specific tooth, or is it diffuse?
2. What triggers the pain — cold, hot, biting, spontaneous, positional?
3. How long does the pain last after stimulus removal (seconds vs. minutes vs. continuous)?
4. Is there swelling, and if so, is it localized (vestibular abscess) or diffuse (cellulitis)?
5. Has the patient experienced trauma to the area, and if so, when?
6. Has the tooth had previous endodontic treatment?
7. Is the patient taking bisphosphonates (risk for MRONJ with surgical procedures)?

Step 1 — Diagnostic Testing Protocol

Perform systematic pulp testing on the suspect tooth and control teeth (contralateral and adjacent).

• Cold testing (preferred): Apply Endo-Ice (1,1,1,2-tetrafluoroethane) or refrigerant spray on a cotton pellet to the middle third of the buccal surface; record response as normal, exaggerated/lingering (> 10 seconds after removal), diminished, or no response; always test a control tooth first to establish the patient's baseline
• Electric pulp testing (EPT): Apply to dried enamel surface; record threshold reading relative to control tooth; higher threshold suggests decreased vitality; no response suggests necrosis; EPT indicates nerve function, not blood supply
• Heat testing: When symptoms are triggered by heat; apply heated gutta-percha or warm water via syringe; isolate suspect tooth
• Bite/percussion testing: Tap along the long axis (axial) and perpendicular to it (lateral); tenderness to percussion (TTP) indicates periapical inflammation or PDL involvement, not necessarily pulp necrosis
• Palpation: Apply firm digital pressure over the root apex buccally and lingually; tenderness indicates periapical pathology extending to the cortical plate
• Selective anesthesia: When pain cannot be localized, use infiltration or PDL injection to isolate the offending tooth systematically
• Transillumination: Fiber-optic light to detect cracks in dentin (crack line interrupts light transmission)

Step 2 — AAE Pulpal Diagnosis

Assign one of the following AAE-standardized pulpal diagnoses.

• Normal pulp: Responds normally to cold and EPT testing; no spontaneous symptoms; serves as the baseline for comparison
• Reversible pulpitis: Exaggerated but brief response to cold (resolves within 1–2 seconds of stimulus removal); no spontaneous pain; indicates inflamed pulp that can recover if irritant is removed
• Symptomatic irreversible pulpitis: Lingering response to cold (> 10 seconds), spontaneous pain, pain to heat, may be exacerbated by positional change; pulp cannot recover — RCT or extraction indicated
• Asymptomatic irreversible pulpitis: No clinical symptoms but pulp exposure from caries or mechanical exposure exists; pulp cannot recover due to extent of inflammation
• Pulp necrosis: No response to cold or EPT; pulp is non-vital; may present with or without periapical pathology; discoloration may be present
• Previously treated: Tooth has had prior endodontic treatment; evaluate quality of fill and periapical status
• Previously initiated therapy: Endodontic treatment was started but not completed (e.g., pulpotomy, partial instrumentation)

Step 3 — AAE Periapical Diagnosis

Assign one of the following AAE-standardized periapical diagnoses.

• Normal apical tissues: Tooth is not sensitive to percussion or palpation; radiograph shows intact PDL and lamina dura; periapical structures appear normal
• Symptomatic apical periodontitis: TTP present; PDL may be widened radiographically; patient can localize pain; no radiographic radiolucency (or early widening only)
• Asymptomatic apical periodontitis: No symptoms; periapical radiolucency present on radiograph; non-vital pulp test; represents chronic granuloma or cyst formation
• Acute apical abscess: Rapid onset, spontaneous pain, TTP, swelling (localized or diffuse), possible systemic symptoms (fever, malaise, lymphadenopathy); may or may not have radiographic radiolucency depending on duration
• Chronic apical abscess: Intermittent drainage through sinus tract; usually asymptomatic between episodes; periapical radiolucency present; trace sinus tract with gutta-percha cone and radiograph to confirm origin tooth
• Condensing osteitis: Focal radiopacity at the apex representing reactive bone formation in response to low-grade pulpal inflammation; usually associated with a vital tooth with large carious lesion

Step 4 — Treatment Decision and Planning

Determine treatment approach based on diagnosis, restorability, and strategic value.

• Restorability assessment: Evaluate remaining tooth structure; determine if post-endodontic restoration (core buildup + crown) is feasible; ferrule effect requires minimum 1.5–2 mm of sound supracrestal tooth structure circumferentially
• RCT indications: Irreversible pulpitis, pulp necrosis with or without periapical pathology, when tooth is restorable and strategically valuable
• Retreatment indications: Previously treated tooth with persistent or recurrent periapical pathology, separated instrument, missed canal, short fill, strip perforation
• Apicoectomy indications: Failed conventional retreatment, post with complications precluding retreatment, suspected vertical root fracture requiring surgical exploration, biopsy of periapical lesion
• Extraction indications: Non-restorable tooth, vertical root fracture confirmed, root resorption destroying > 1/3 of root, periodontal-endodontic combined lesion with hopeless prognosis
• Referral criteria: Calcified canals, complex anatomy (C-shaped canals, dens invaginatus), retreatment with separated instruments, surgical endodontics, teeth requiring CBCT evaluation — refer to endodontist

Step 5 — Treatment Documentation

Record endodontic procedures with procedure-specific detail.

• Access and canal discovery: Number of canals located, method of location (microscope, CBCT guidance, ultrasonic troughing), MB2 canal status in maxillary molars (found/treated or not found after exploration)
• Working length determination: Method (electronic apex locator brand/model, radiographic); record length in mm for each canal (e.g., MB: 21.0 mm, DB: 20.5 mm, P: 22.0 mm)
• Instrumentation: Technique (rotary NiTi system name and sequence, reciprocating, hand files), master apical file size per canal, taper
• Irrigation protocol: Solutions used (NaOCl concentration typically 2.5–6%, EDTA 17%, CHX 2% if used), delivery method (syringe with side-vented needle, EndoActivator, passive ultrasonic irrigation), volume per canal
• Obturation: Technique (warm vertical condensation, lateral condensation, single cone with bioceramic sealer), master cone size and taper, sealer type, quality assessment (radiographic fill to within 0–2 mm of apex, dense fill without voids)
• Intraoperative complications: Ledge formation, perforation (location, size, repair material — MTA or bioceramic putty), separated instrument (type, location in canal, management decision), hemorrhage control

Step 6 — Outcome Assessment and Follow-Up

Evaluate treatment success at follow-up intervals.

• Follow-up schedule: 6 months, 12 months, then annually for 4 years per AAE recommendation; periapical radiograph at each follow-up
• Success criteria (AAE): Absence of symptoms, resolution or reduction of periapical radiolucency, tooth in function with no sinus tract
• Healing classification: Complete healing (resolution of radiolucency), incomplete healing (radiolucency reducing but not resolved), uncertain healing (no change), failure (persistent/enlarging radiolucency, recurrent symptoms, sinus tract)
• Retreatment trigger: Persistent radiolucency > 4 years, enlarging radiolucency at any follow-up, recurrent symptoms, new sinus tract development

Checkpoint B — Case Documentation Review

• Pulpal diagnosis assigned using AAE terminology
• Periapical diagnosis assigned using AAE terminology
• All diagnostic tests documented with results (cold, EPT, percussion, palpation) including control teeth
• Pre-operative radiograph in chart with interpretation
• Restorability and strategic value assessed before treatment
• Working lengths recorded for all canals
• Instrumentation technique and master apical sizes documented
• Irrigation protocol documented with solutions and delivery method
• Obturation technique and quality assessment documented
• Post-operative radiograph in chart showing fill quality
• Follow-up schedule established and communicated to patient

Quality Audit

Guidelines

• Always use AAE standardized pulpal and periapical diagnostic terminology — never use informal terms ("hot tooth," "dying nerve," "infected") in clinical documentation
• Test at least one control tooth (preferably contralateral) before testing the suspect tooth for cold and EPT
• Never perform endodontic treatment on a tooth that cannot be restored; assess restorability before initiating access
• MB2 canal must be actively sought in all maxillary molars — document the search effort and outcome regardless of whether the canal is found
• CBCT is indicated per AAE/AAOMR when 2D imaging is inconclusive for canal anatomy, resorption, root fracture, or periapical pathology characterization — document the specific clinical question the CBCT will answer
• Irrigation is as important as instrumentation — document solutions, concentrations, volumes, and activation method
• Post-operative radiograph is mandatory after obturation to assess fill quality before dismissal
• Teeth with completed RCT must be restored with a coronal seal (core buildup + crown) as soon as clinically feasible to prevent recontamination; document the restorative plan and timeline
• Document referral to endodontist when case complexity exceeds GP scope; include specific clinical question and diagnostic findings in the referral