I truly believe that any dentist can be great at root canals with proper technique and practice. What separates from good endodontists to great endodontists is making correct diagnosis. Incorrect diagnosis can lead to patients spending extra time figuring out what is causing the pain and worse drilling the wrong teeth, leading to headaches in your practice.
Making improper diagnosis can impact how a root canal can shift from a profitable, predictable procedure to a stressful disaster—or vice versa. The goal for every dentist is to perform endodontics efficiently, stress-free, and profitably. To avoid potential failures, clinicians must focus on proper case selection, accurate diagnosis, profound anesthesia, straight-line access, and prevention of iatrogenic errors. This article emphasizes the first two: case selection and diagnosis.
1. Proper Case Selection
A critical first step in preventing endodontic complications is selecting cases within one’s skill and comfort level. Recognizing personal limits and referring difficult cases to specialists demonstrates sound clinical judgment. Complexity is not limited to anatomy—it includes patient behavior and medical history.
For anxious patients, explaining the procedure and giving them control (for example, stopping if they raise a hand) builds trust and cooperation.
The American Association of Endodontists (AAE) provides a Case Difficulty Assessment Form, which helps clinicians evaluate procedural risk levels. Using this tool protects both the patient and the practitioner; if legal issues arise, the completed form can justify the clinician’s decision to treat a case.
2. Accurate Diagnosis
Correct diagnosis ensures appropriate treatment and minimizes stress. Always confirm findings with a second, angled radiograph, following the SLOB rule (“Same = Lingual, Opposite = Buccal”). Angled X-rays reveal hidden canals, bifurcations, and unusual anatomy—especially in teeth like mandibular premolars, which frequently present with complex morphologies in diverse populations.
3. Clinical Testing Protocol
A proper diagnostic setup includes basic tools—mirror, explorer, probe, cotton rolls, Endo Ice, and a tooth slooth—and systematic testing:
Tip #3: Percussion Test – Begin gently on uninvolved teeth to prevent startling the patient. Sensitivity suggests inflammation in the periodontal ligament, which may stem from pulpal or occlusal problems.
Tip #4: Thermal (Cold) Test – The most reliable vitality test. Using Endo Ice on a dry tooth helps distinguish between reversible and irreversible pulpitis. Pain that lingers or throbs indicates irreversible pulpitis; absence of response implies necrosis. Heat tests are rarely necessary and should not be performed with hot gutta-percha.
Tip #5: Electric Pulp Tester (EPT) – Use only as an adjunct. EPTs produce many false readings and are less reliable than percussion and thermal tests. A lack of response may confirm a necrotic or anesthetized tooth.
This case for example, was sent from a general dentist to retreat #12. Teeth was percussion positive and maybe that’s why the general dentist referred me to redo the root canal.
But I referred this tooth to perio - why? There’s no PARL, probing depth was fine, and tooth fracture was ruled out with tooth slooth. Over treating these teeth or making incorrect diagnosis can lead to headache and once again run an unsuccessful practice.
Key Takeaway
Most “endodontic disasters” stem from poor case selection or incorrect diagnosis. Employing the AAE assessment form, obtaining angled radiographs, and relying on percussion and cold testing are essential steps in preventing mishaps—especially the dreaded “wrong-tooth” treatment. With systematic evaluation and informed decision-making, root canal therapy can remain predictable, profitable, and comfortable for both dentist and patient.
