Inside Dentistry
December 2017
Volume 13, Issue 12

When to Refer

Diagnosis and case difficulty assessment in endodontics

Katherine A. Thomson, DDS, MS

Diagnosis and case difficulty assessment form the cornerstone of referrals. While evaluating tooth pain, general practitioners are often faced with vague symptoms and inconclusive test results. There are times when practitioners start endodontic treatment on teeth only to find out during the treatment that the case should have been referred to an endodontist. How does one make the decision to treat or refer? Which cases are treated is dependent on the general practitioner's experience with both diagnosis and treatment modalities. Patients and practices are best served when a clear referral algorithm is set.


Diagnosing teeth suffering from pulpal and periapical disease is as much an art as it is a science. Symptoms of pulpal disease can range from absent to excruciating, spontaneous pain. Painless pulpitis leading to pulp necrosis occurs in 40% to 60% of cases. Moreover, periapical disease can present with a wide range of subjective and objective symptoms, including pain on percussion, swelling, or radiographic evidence in the form of periapical radiolucencies that are consistent with bone loss. Sometimes, these radiolucencies can only be visualized with 3-dimensional radiography  or cone-beam computed tomography (CBCT). Recognizing the need for root canal therapy in these cases requires systematic and thorough diagnostic testing. The cold test, percussion, palpation, periodontal probing, bite test, and mobility test make up the foundation of endodontic testing. The results are interpreted to reach a diagnosis for the pulp and periapical tissues based on the latest American Association of Endodontics (AAE) classification of pulp and periapical conditions.

Level of Difficulty

Once an accurate diagnosis has been made, one should ask, “Is this a case that can be treated successfully in the general practice setting?” Cases that are deemed to present a significant challenge should be referred to an endodontist. An excellent tool in assessment is the AAE Case Difficulty Assessment Form, which can be obtained from the AAE website (www.aae.org/caseassessment).

This Case Difficulty Assessment Form provides criteria and subcriteria that aid in assessing level of difficulty. The diagnostic and treatment considerations section includes diagnosis, radiographic difficulties, position in the arch, tooth isolation, crown morphology, canal and root morphology, radiographic appearance of canal(s), and resorption. For example, position of the arch lists anteriors and premolars as being minimally difficult. These are general guidelines, and of course there are outliers. Oftentimes, general dentists say they do all their own anterior and premolar cases while sending out the molars, but clearly, all anterior and premolar cases are not straightforward. Some can be especially technically sensitive.  For example, a retreatment of a tooth with an open apex requires specific cleaning and obturating techniques, illustrating the importance of removing existing gutta percha without extruding the softened material, then properly obturating with the appropriate biocompatible materials. Unfortunately, some dentists believe that lower premolars only have one canal; however, in 25% to 30% of cases, they actually have two or three canals. These cases are much more technically sensitive, requiring more time to treat, microscopic magnification, and a CBCT study.

Endodontic diagnosis combined with a restorability assessment is used to recommend treatment options to patients and aid in clinical decision-making. The final decision should incorporate the best scientific evidence, clinical expertise, clinical capabilities, and patient values to ultimately provide the optimal patient-centered outcome. As a general practitioner, one should be proficient in performing diagnostic testing, interpreting results, presenting treatment options, and selecting the most appropriate treatment. With the proper assessment tools and experience, clinicians can rely on the information gained through a thorough examination to guide them in their decision to personally treat a case or refer the patient to an endodontist.


Katherine A. Thomson, DDS, MS, maintains a private practice limited to endodontics in La Jolla, California. She practiced for many years as a general dentist before specializing in endodontics.

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