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May 2001 – Endo or Perio Lesion?
A 58 year old female in good health arrived in my office, having been referred to me for toothache associated with tooth # 36. The tooth was an important abutment of a 3 unit bridge #36-35-34.
The patient's current complaint was buccal gingival swelling, increased mobility and pain to occlusion. The tooth was noted to be slightly high in occlusion as marked with articulating paper. The patient claimed to have had intermittent problems in the area for about one year. She did not mention thermal sensitivity as a problem.
Periapical radiography (Fig. 1) showed a furca radiolucency with no obvious pathology at the root apices. Periodontal probing showed a Cl II buccal furca involvement and drainage from the furca, The tooth was percussion sensitive. No other significant periodontal findings were noted in other teeth in the quadrant. I did note some other possible furca involvements in the contralateral tooth and in the Maxillary molars. The patient had no history of referral to Periodontist. The question remained: Was this a Perio or endo lesion ? Did the case need endodontic treatment or was the patient doomed to lose the bridge? If we did perform endodontic treatment on the tooth, would it be to any benefit?
After a brief interview, I asked the patient if any thermal tests had been done at the referral dentist's office. She told me that none had been attempted. A cotton pellet sprayed with Endo Ice was applied to the occlusal surface. The tooth was mildly positive but I was still unconvinced. I again used the Endo Ice on a smaller pellet and applied it to the distobuccal area ( in an area of gingival recession) where I was able to see the crown margin dentin. The patient responded sharply and immediately.
The tooth was vital. Endodontic treatment was contraindicated and would be of no benefit to the patient because the lesion was entirely periodontal in etiology. After consultation with a periodontist, we agreed that the tooth should be extracted and further efforts should be made to address the patient's generalized periodontal problems.
The speed of my diagnosis was somewhat upsetting to the patient. Endodontists can sometimes be placed in a very difficult position when such diagnoses are obtained with such rapidity and ease. Why ? Because I am often asked : " Why didn't my dentist put cold on the tooth like you did? It only took you 30 seconds to make the diagnosis." (The patient may have waited or suffered quite a long time with this problem).
There is no reason why reliable cold tests should not be part of the dentists routine diagnostic armamentarium. The cold test as performed above is accurate, fast and inexpensive. Occasionally, such cases do not respond well to cold tests as applied with Endo Ice and a cotton pellet. This is because of the possible insulating effect of the crown or pulpal recession as a result of secondary dentin deposition. (Isolation with rubber dam and use of cold water applied to an individual tooth by syringe is also an alternative.) Had there been any doubt, I would have immediately placed a rubber dam and performed a cavity test to establish the presence of a vital pulp.
Cold tests are essential when evaluating a case for possible endodontic involvement.
||Periapical Radiolucencies can be of endodontic and periodontal origin.
||Suspected necrotic teeth should always have pulp tests to ensure that the diagnosis is correct. When in doubt, perform a cavity test.
||Performing endodontic treatment in the case above would be of no benefit to the patient. It could result in unnecessary treatment directly attributable to diagnostic error.