Diagnosing dental pain can be a challenging task, especially if tooth pain is being mimicked by non-odontogenic conditions. Without a proper diagnosis, it’s difficult for the dental healthcare professional to provide the patient with appropriate treatment options and definitive care. In addition, delays in a timely diagnosis can lead to prolonged pain, unwanted patient/provider frustration, repeat appointments, excessive chair time and profit loss. Like many other skills, practice, patience, perseverance and education prove to be the best path for diagnostic proficiency.

During the evaluation visit, it is crucial to ask the patient the “right” questions to get that right diagnosis. The first things we like to know are the patient’s “Chief Complaint” and history of present illness. Remember, we are diagnosing pulpal and periapical disease.

Questions to Consider:

What provokes the pain? Cold/hot/chewing/pressing on tooth/ pain when lying down? Does drinking cool water provide relief? A positive response to any of these should raise red flags for pulpal and/or periapical disease.

How long does it last and what is the intensity? A patient who reports mild pain for a few seconds might not yet be a good candidate for endodontic care; however, a patient who reports pain lasting for over 10 seconds to minutes or hours might have pulpal/periapical disease. Also, ask the patient to grade the pain on a scale of 1-10. The higher the score on the scale, the more likely pulpal/periapical disease has set in.

What kind of pain is it? Throbbing, intense, sharp pain can be a tip off to pulpal disease. A low-grade dull ache can be more consistent with periodontal pain.

When did it start? Possibly after a recent dental visit? If the pain is manageable and decreasing over time, I typically give the patient about 3-4 weeks to see if the pain abates.  Even then, it is recommended to have the patient return for pulpal testing to confirm that the episode was reversible. Obviously, patients who have increased pain or if that pain is affecting the quality of their life (not chewing on affected side or avoiding cold/hot liquids) should be called back in for further pulpal and periapical testing.

Has the discomfort lasted days/weeks/months? For those of us who have experienced tooth pain, we know and most likely agree that it is one of the worst pains we can experience.  With that said, few of us can last weeks or months with pulpal/periapical disease. Usually, tooth pain is a hard hitter, but some patients can weather the storm for some time.

Do you grind or clench? Grinding and clenching can certainly precipitate pulpal inflammation and pain. If recognized and corrected early, it can be a reversible state; however, if it is in more chronic stages, it is most likely an irreversible event.   

Is it that tooth? A patient may be fully convinced that a specific tooth is causing pain and point to that tooth. Remember, dental pain can refer and radiate. Our complex neuronal anatomy in the head and face can sometimes send us mixed signals. A patient who points to tooth number 14 could be mistaken, and the culprit causing the pain could actually be tooth number 13 or 15.  A best practice is to test at least the teeth on either side of the one to which the patient pointed.  For posterior teeth, pain can refer to the opposite arch, so be mindful of taking a peek “upstairs and downstairs.” For radiating pain (e.g., when a patient reports ear pain), I typically look at the lower second molar. When a patient reports temporal pain and/or headaches, I look to the upper molars.

It’s very important to establish a baseline when testing teeth.  What’s “normal” for one person might be very different for another. Be open to testing several teeth, even in other quadrants, to determine that patient’s baseline. Count in your head how long it takes for the thermal response to completely disappear. That means no pain or linger! So, if you cold test five teeth and one lingers for 20 seconds while the other four resolve after 3-4 seconds, you can bet the tooth with the longer linger is the culprit.  Teeth that linger to thermal stimulus are usually the ones responsible for the patient’s pain.

Be mindful that certain teeth might be more responsive to thermal testing than others. I typically notice that bicuspids respond slightly less than molars and anterior teeth to thermal testing.  Also, if a patient is taking pain medications and/or antibiotics for tooth pain, test results may be masked. If that is the case, have the patient return in a week or two to retest and compare results.

During the evaluation, check for decay, abfraction lesions, occlusal wear to the pulp chamber and gingival recession, as these chronic conditions can precipitate pulpal inflammation and/or necrosis.

A tooth that is non-responsive to thermal stimulus could be necrotic, calcified or simply non-responsive. If we feel it is necrotic, we should consider endodontic care or extraction.

Cold testing tests peripheral A-fibers; heat testing tests the core C-fibers.  During this phase, it’s important for you as the provider to clearly communicate to the patient what you are doing and what feedback you are looking for from the patient. I ask the patient to let me know if and when they feel cold or pain with Endo Ice and then to tell me when it is completely gone so there is no residual cold, linger or pain.  A linger is suggestive of an irreversible pulpitis. Be suspicious of a very intense response without a linger, as it too may suggest a diseased pulp.

I personally do not recommend using a Q-Tip for cold testing, as wood can absorb cold and lead to inaccurate readings. For best results, I always use Endo Ice, a cotton pellet and college pliers.

Considerations with cold and heat testing

• Test facial/buccal of all teeth in question
• Establish the baseline! 
• What is normal for that particular patient?  Look for the tooth that is the outlier
• Consider the occlusal surface if the buccal surface is not providing an accurate response, especially on teeth with crowns

Considerations with heat testing

• Use of flame with Gutta Percha and plastic instrument
• Besides a linger with heat, a delayed response with linger is typically suggestive of an irreversible pulpitis

 Radiograph Considerations

Be liberal in obtaining different angled x-rays to help increase the chances of detecting apical pathology. Sometimes one angle might show an apical or lateral radiolucency better than another. If a CBCT is available, use it as it can make the radiographic diagnosis much easier!  Also, just because there is a radiolucency associated with the apex or other portions of a root, it does not mean that tooth needs endodontic care or extraction.  Be mindful of other non-odontogenic radiolucencies and consider thermal testing findings when making your diagnosis.

Percussion and Palpation Considerations

With percussion and palpation, we are testing for inflammation of the Periodontal Ligament (PDL), root apex and surrounding tissues. For percussion, we gently tap the incisal/occlusal surface of the tooth with the back end of a mirror. With palpation, we are palpating the area where the apex should be. When palpating the apex, look for the root eminence as a guide and follow it apically. A positive response to percussion or palpation is indicative of periapical disease.

Cracked Tooth Syndrome

• With a tooth sleuth, we are testing for cracks that might be leading into the pulp chamber. A positive response indicates this situation. Also, consider using a wet cotton roll
• A positive response is telling us that a crack most likely does lead into the chamber
• Cracks can act as a passageway for bacteria to the pulp and/or cause inflammation of the nerve when stimulated
• Depending on the pulpal response to cold/hot, consider RCT vs. temporary crown and retesting. A tooth with a normal pulpal response would be a better candidate for a temporary crown and retesting versus a lingering response or intense response to thermal stimuli

Deeper Crack Considerations (Root/Floor of Chamber)

• When reviewing x-rays, look for a vertical defect of the crestal bone. This can be indicative of a root fracture. In addition, furcal radiolucencies and J-shaped radiolucencies can be indicative of a crack/fracture as well
• Isolated deep pockets with or without bone loss in the area could be due to root fracture
• Evaluate craze lines of the mesial and distal marginal ridges with a close eye.  In addition, I tend to notice that lower second molars and maxillary bicuspids can be more prone to fractures in these areas.

Non-odontogenic Considerations

Non-odontogenic ailments can also mimic tooth pain.  When performing your evaluation, be mindful of the following disorders:

• Sinusitis – Is there pain with palpating the maxillary area extra orally in a general area? Does the patient have a history of sinus issues? What season is it? Has this particular patient been seen by you at the same time a year ago?  Look for similarities.
• TMJ Disorder – Pain with opening and closing? Is the patient pointing to the TMJ area? Are they stressed? Do they have a history of TMJ disorders?
• Neuralgia – Are there triggers to their pain? Is it located on one side? Is the pain brief and intermittent?
• Grinder/Clencher – Any history of this? Do they notice pain at night? Do they wear a nightguard? Any stress in the patient’s life? Do you notice occlusal wear facets?
• Myofascial Pain Syndrome – Any stress in the patient’s life? Is there pain with palpating the masseter or temporalis muscles?

Like many other facets of dentistry, diagnosing is a skill and an art.  Take the time to listen to the patient’s history of present illness and communicate well to the patient when testing. Sometimes it can take a couple of minutes for you and the patient to be in sync, but have patience, as it will save you time in the long run.