Hi.
I'm David Landwehr, an endodontist at Capital Endodontics in Madison, Wisconsin.
As a dual-trained oral & maxillofacial pathologist and endodontist,
I often get asked by my referring colleagues
to consult on cases when the endodontic diagnosis is not clear.
As a result, I see several cases a year
where the radiographic and clinical findings don't confirm the diagnosis.
Over the next several minutes,
I would like to describe some clinical scenarios
that suggest a referral is in the patient's best interest.
For example,
when the preoperative and post-operative findings don't agree.
This really isn't a worry for me if
I'm debating between the diagnosis of an irreversible pulpitis
and a necrotic pulp.
However,
it is definitely an issue
if there is a periapical radiolucency
and a vital healthy appearing dental pulp is discovered in the chamber.
This suggests the radiolucency is not due to a pulpal origin,
but is more likely due to a non-inflammatory etiology and may be neoplastic.
If the patient has pain as a complaint
prior to the root canal,
a one to two week recheck to determine if the pain is subsided
would be a reasonable first course of action.
However,
referral to an oral and maxillofacial surgeon for biopsy
to determine the exact etiology of the radiolucency
would be the most prudent course of action,
especially if symptoms are unchanged following the root canal treatment.
Atypical or aggressive clinical behavior is another indication for referral.
Significant bone destruction with resorption of the roots
suggests a possible non-inflammatory etiology
and referral for further diagnostic workup would be a good idea.
This is an example of an osteomyelitis
that presented one year following root canal treatment.
This look is not typical of a failing root canal
and lymphoma metastatic disease
and a primary malignancy were also considered
in the differential diagnosis.
Inconclusive clinical findings and pulp testing
may also suggest a referral.
If a patient has pain as a chief complaint
and the pain doesn't have the typical triggers
that suggest an endodontic issue,
like cold and heat sensitivity,
pressure or biting sensitivity,
then my concern for a non-dental etiology begins to rise.
My level of concern is further elevated
if the dental history and pulp testing
are not consistent with an endodontic cause.
This is an example of temporal arteritis
in a 70 year old female
with the chief complaint of increasing pain when chewing.
The pulp testing with cold did not identify a culprit tooth
and there was no percussion or tooth sensitivity
to reproduce her chewing symptoms.
There was no indication of an occlusal issue
and there was slight tenderness to palpation
of the temporal area
and the superior attachment of the masseter muscle.
The radiology findings were not diagnostic
as the periapical films and the CB/CT did not reveal any changes consistent
with a bacterial cause.
As a result,
the clinical findings did not confirm a dental cause
and the patient was referred to her medical doctor.
A simple blood test indicated an elevated erythrocyte sedimentation rate
consistent with the diagnosis of temporal arteritis.
A timely diagnosis is critical in this disease,
because blindness may result if left untreated.
And in rare instances, it can be fatal.
Multilocular radiolucencies are a reason for immediate referral.
Periapical cysts and granulomas are most often several millimeters in diameter
and are either well or poorly defined radiographically.
They can get larger.
It is not unheard of to have a periapical cyst
of more than two centimeters in some cases.
However,
even in the largest periapical cysts,
the growth pattern should be unilocular.
If there is a multilocular radiolucency,
the lesion should be considered non- inflammatory until proven otherwise.
Referral for further radiographic evaluation
to an oral and maxillofacial radiologist would be a reasonable
first step.
However, referral to an oral surgeon for biopsy
would be another possible course of action.
In some cases,
the radiographic findings will be suggestive of a systemic disease.
That doesn't mean that a patient in pain doesn't have an endodontic etiology,
but before endodontic treatment is initiated,
I will discuss the findings with the patient
to ensure appropriate follow-up and management
Here's an endodontic case that I treated several years ago
for a necrotic tooth number 30.
The pulp testing indicated
necrosis and this was confirmed at the time of treatment.
The canals were disinfected and sealed without complication.
The patient presented for a routine six-month follow-up
and was asymptomatic with no history of pain.
However,
radiographic examination revealed a symmetrical widening
of the periodontal ligament spaces
associated with multiple teeth.
This finding is consistent with systemic sclerosis
and the patient was referred to his medical doctor
and the diagnosis was confirmed.
Other systemic conditions
that could be identified by radiographic examination include,
but are no means limited to, Gardner's syndrome
with multiple osteomas,
Paget's disease of bone with a cotton-wool appearance
or fibrous dysplasia with a ground-glass trabecular pattern.
I have shown several case examples where
referral for further diagnosis and management is indicated.
From my perspective, the treatment of some of the pathologies we encounter
will require a team approach
and I think it is important to remember
that not all radiolucencies that present
at the apex of a tooth are endodontic in origin.
It is important that the clinical findings and chief complaint
are supported by the dental history and pulp testing.
When this is not the case,
it is important to consider a non-pulpal etiology
and referral may be indicated.