Early referral is always the best option in this instance. That said, for a host of reasons, referral may not always be possible (if the patient has been seen late at night, over a holiday, or based in a rural area etc).
Unfortunately, many is the tooth that has been started under stressful circumstances in order to relieve a patient’s pain only to discover that the wrong tooth has been opened. Conversely, many is the tooth that has needed treatment but, for a variety of reasons, has been left to smoulder painfully where treatment was indicated from the start.
As a result, when referral is not possible and the diagnosis is not immediately apparent, the clinician must make certain that they have gathered the correct and comprehensive history of the patient’s chief complaint and all subjective signs and symptoms, plus objective findings.
At a minimum, aside from recording the subjective symptoms and taking a complete history, in every such case irrespective of its challenge, the clinician should observe the patient’s percussion, palpation and mobility. Probing of the teeth in the offending quadrant (if not also the opposing arch) must also take place, along with cold, and when needed hot and perhaps electric, pulp testing, as available through a unit like the Elements Diagnostic unit, which also doubles as an electronic apex locator (SybronEndo, Orange, CA, USA).
In addition, taking the required radiographs, preferably with a digital radiography system like Dexis (Alpharetta, GA, USA), can yield the optimal information upon which to complete the diagnosis. Ideally, there will be three such images – one each from the buccal, mesial and distal. A comprehensive examination often makes what might otherwise seem confusing and uncertain fit together like the pieces of a puzzle, and gives the clinician the correct diagnosis obviating the need for delay or referral.
Even after all necessary subjective, objective and radiographic examinations have been completed, some difficult cases defy diagnosis and explanation. In such instances though, as a guiding principle, referral is almost always the best option. Such consultation with others is essential as many times a periodontal and/or TMJ issue overlaps the possible endodontic problem.
Patience is always advised. If referral is not possible, treatment is best delayed until symptoms localise, assuming that the aforementioned examination is not conclusive. A rush to judgment is unproductive. Symptoms from an odontogenic problem become isolated to the offending tooth in time. Most patients accept a delay in treatment if it is clearly communicated what is known and unknown with regard to their diagnosis and until a definitive one can be made.
If referral is not immediately possible and the patient is in extreme discomfort, as a very last resort the patient can be given a choice as to whether they want RCT initiated on the basis of the practitioner’s best educated opinion, or if they’d prefer to wait until symptoms localise or referral might be available, case dependent.
I welcome your questions and feedback.