Endodontic Diagnosis And Documentation

Consider the following scenario: A patient was treated yesterday by a new associate for a direct restoration on tooth #3. The patient returns to the office the next day upset, as she was not able to sleep last night due to severe pain that began after treatment. She had been told the restoration was deep, but that the pain should resolve in a few days. The patient is upset and does not understand why she is in so much more pain after the procedure than prior to treatment. Another associate dentist at the office evaluates the patient and diagnoses tooth #3 with irreversible pulpitis and symptomatic apical periodontitis.

The patient is informed that the tooth will require root canal therapy (RCT) and a new indirect restoration. The patient is again upset and asks why the RCT was not initiated yesterday and questions if it is only necessary now because of something that was done inappropriately during yesterday’s care. The second dentist refers to the notes for more information, but is dismayed to only find details about the procedure that was completed (#3 MO composite). There is no documentation of her symptoms or objective evaluation to establish a diagnosis for the patient, who presented with mild pain and an associated tooth with a large caries lesion. This unfortunate situation could most likely have been prevented with proper diagnosis and accurate documentation.

The primary purpose of the dental record is to facilitate correct and appropriate care. Clear and accurate records convey and document the what, why, and how behind clinical decision-making. The dental record allows other clinicians caring for the patient to understand the thought process and diagnostic conclusions reached; in turn, this helps them to  provide the proper treatment. Documentation also offers legal protection for the patient and practitioner in case of disagreement or disputes over the care received. A dental record must include sufficient information to justify the diagnosis and support the treatment plan and care ultimately provided.

In this hypothetical scenario, perhaps the pulpal and periapical status were assessed prior to treatment and the therapy provided was the appropriate course of care; however, there is no documentation this took place.

IMPORTANCE OF ACCURATE RECORDS

Keeping accurate and complete records is critical because the general healthcare community subscribes to the American Dental Association principle: “If it is not written down, it did not happen”¹ The quality of the records is presumed to reflect the quality of care delivered.

Patients with endodontic disease frequently present with pain associated with infection and/or inflammation. Although most orofacial pain is of odontogenic origin, there are occasions where non-odontogenic pain may originate from the jaws, sinuses, ears, temporomandibular joint, muscles or salivary glands. Therefore, diagnosing the pain’s source is the critical first step of treatment. Therapy depends on the diagnosis, and an incorrect diagnosis will result in inappropriate care. Proper diagnosis is based on the presenting symptoms, history of the symptoms, diagnostic tests — including imaging — and clinical findings. If a diagnosis cannot be established, treatment should not be initiated until further evaluation is done.² Reevaluating the patient within a few days to several weeks may be necessary to arrive at an accurate pulpal and apical diagnosis.³

To simplify documentation, using Subjective, Objective, Assessment and Plan (SOAP) notes is an accepted method for structuring the treatment record to ensure that all pertinent information is included. This also supports clinical documentation in an orderly, well organized and thorough manner.⁴ Commonly used in healthcare settings, the SOAP format enhances communications and provides a clear and concise way of documenting patient information. This approach can be readily followed by the next person providing treatment and allows operators to find the information they need quickly.⁵ When a provider is looking for specific information, such as objective test results, it will be easy to find in the treatment notes.

SUBJECTIVE DATA

The “S” in SOAP represents subjective data. This includes the chief complaint, which is defined as having patients describe the signs and symptoms in their own words. Since treatment is centered around the specific patient, the SOAP note begins with the subjective information. It also includes the past and present history of the illness, as well as any other significant dental history.⁶ Sample questions include:

• How long have you had the problem?
• What are the intensity and frequency of the pain?
• What triggers — and what relieves — the pain?
• How long does the pain last?

Spontaneous or lingering pain is generally associated with irreversible pulpitis. Pain described as burning and electric is usually not of odontogenic origin, but throbbing, sharp, or dull pain is typically used to describe pain of odontogenic origin.⁷ Answers to these questions help the clinician form an initial diagnosis and plan the objective tests to be performed. One of the goals of objective testing is to reproduce the patient’s symptoms.

The subjective data is the starting point. Even if a patient reports only mild, fleeting pain, objective tests are necessary to arrive at a diagnosis. It is incumbent upon the clinician to evaluate the teeth and not assume a diagnosis based solely on the patient’s symptoms or radiographic appearance.

If an asymptomatic patient presents with a deep caries lesion, the status of the pulp and apical tissue should be evaluated prior to caries removal. Often, necrotic teeth are asymptomatic, but objective tests reveal pain to biting. Diagnosing prior to treating results in more efficient and effective care. Although the need for an endodontic procedure may be determined after caries removal, it is advantageous from a professional and patient management standpoint to anticipate the required treatment before initiating therapy. Treatment may change as it progresses, but the initial approach should be supported by the original diagnosis.

OBJECTIVE OBSERVATIONS

The “O” in SOAP represents objective information. It is a result of observations, as well as tests conducted by the dentist. These tests will usually, but not always, correspond with information obtained from the patient in the subjective history. The objective examination includes:

• Extraoral and intraoral examinations covering the hard and soft tissues. (For example, large caries lesions, fracture lines, tooth discoloration, sinus tracts, and redness or swelling of the surrounding tissues.) A dental etiology for the pain should be apparent clinically or radiographically.
• Palpation, percussion, bite and pulp testing, and radiographic evaluations should be performed. The percussion and bite tests detect possible periapical or periradicular inflammation. Palpation is also done in the periapical area of the teeth to feel for tenderness and possible swelling or expansion. Inspection of the tooth with high magnification and illumination is always recommended. If cracks or crown-originating fractures are suspected, transillumination may prove useful.

Although these tests are objective, the patient’s interpretation of the sensation is subjective. Therefore, clear guidance and explanation should be provided. For example, patients should be asked to indicate when they feel a sensation with the cold test, not necessarily pain, as some individuals do not feel pain with the cold test. Bear in mind that although these are objective tests, the patient’s response is subjective (that is, it is how the patient perceives the sensation).

When noting the patient’s response in the chart, providers need to be clear and specific. If the response to the cold test is noted as “no sensitivity,” it is not clear as to whether there is no response to the cold stimulus or if it is a normal, nonpainful response. The result of the test should not be ambiguous. A result of “no response” will be clear to everyone reading the notes the patient had no response to the cold test. Of course, in reaching a diagnosis, the results of each objective test will be considered in the context of other clinical and subjective data.

As there is no established normal response to the pulp tests and periapical tests, inclusion of control teeth is essential to differentiate between the offending tooth and the deviation from the patient’s normal.³

Always test the adjacent and contralateral “normal” teeth first, and then test the tooth in question for comparison. This allows the clinician to establish what normal is for each patient and also allows the patient to understand the objective test in order to provide useful information.⁸

Patients with irreversible pulpitis are typically not good at locating the source of pain since initially there is no periapical inflammation. As the disease progresses, apical inflammation will ensue and be expressed in pain to percussion, biting and palpation. Once this occurs, the accuracy of locating the offending tooth will increase.⁹

The endodontic diagnosis consists of a pulpal diagnosis and periapical diagnosis. Pulpal diagnosis is the clinical condition of the pulp, as evaluated by ice, cold and electric pulp test assessments. The periapical or periradicular diagnosis is the clinical condition of the periapical tissues, as evaluated by the biting, palpation and percussion tests.

ASSESSMENT

The “A” in SOAP represents assessment. It is a diagnosis based on the clinical data. A proper endodontic diagnosis will include pulpal and apical (periapical or periradicular) diagnoses.¹⁰

According to the American Association of Endodontists’ (AAE) Diagnostic Terminology,¹⁰ the status of the dental pulp is classified as either:

1. Normal Pulp: A clinical diagnostic category in which the pulp is free of symptoms and normally responsive to pulp testing.
2. Reversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating the inflammation should resolve, and the pulp return to normal.
3. Symptomatic Irreversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain or referred pain.
4. Asymptomatic Irreversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms, but inflammation produced by caries, caries excavation or trauma.
5. Pulp Necrosis: A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponse to pulp testing.
6. Previously Treated: A clinical diagnostic category indicating the tooth has been endodontically treated and the canals obturated with various filling materials other than intracanal medicaments.
7. Previously Initiated Therapy: A clinical diagnostic category indicating the tooth has been previously treated by partial endodontic therapy (e.g., a pulpotomy or pulpectomy).

According to the AAE Diagnostic Terminology,¹⁰ the status of the apical tissues can be classified as follows:

1. Normal Apical Tissues: Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform.
2. Symptomatic Apical Periodontitis: Inflammation, usually of the apical periodontium, producing clinical symptoms, including a painful response to biting and/or percussion or palpation. It may or may not be associated with an apical radiolucent area.
3. Asymptomatic Apical Periodontitis: Inflammation and destruction of the apical periodontium that is of pulpal origin; it appears as an apical radiolucent area, and does not produce clinical symptoms.
4. Acute Apical Abscess: An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.
5. Chronic Apical Abscess: An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.
6. Condensing Osteitis: A diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at the apex of the tooth.

PLANNING TREATMENT

Finally, the “P” in SOAP represents plan. It is what the healthcare provider will do to alleviate or correct the condition that has been diagnosed. If RCT is indicated, the plan should also include the final restoration.

Good record keeping provides evidence of the level of skill, care and attention the patient received. Each step in the procedure needs to be properly documented. Tooth isolation with a dental dam is the standard of care in endodontics and should be noted in the chart, especially when a clamp is not visible in the working radiographs.¹¹ The description of the status of the pulp upon entry into the pulp chamber should also be noted, as this is the more definitive pulpal diagnosis.³ Treatment may need to be modified if the clinical diagnosis does not match the initial preoperative diagnosis. This further serves as documentation supporting the treatment ultimately rendered.

The prognosis, as explained to the patient, and restorative recommendations should also be documented. An informed consent is part of the record, as are all consultations. Prescriptions should be recorded, as well.³ In addition, any deviations from normal should be documented. By way of example, an instrument separation or inability to treat a portion of the root canal system should be noted, as should the follow-up plan. Will the case be retreated, or is the outcome not ideal but acceptable? This should also be noted in the treatment record.

The patient’s response to therapy also needs to be evaluated.³ When a patient presenting with an acute apical abscess returns to complete RCT, the subjective and objective findings at the second appointment must be recorded. When the patient reports a significant improvement in symptoms, and a resolution of the swelling occurs, this is a good indication that he or she is responding well to treatment and that RCT can be completed. However, if swelling is still present, it may be preferable not to complete RCT at this appointment. That noted, the only way to support the decision to complete treatment or continue therapy at a later visit will be through documentation.

KEY TAKEAWAYS

• The primary purpose of the dental record is to facilitate correct and appropriate treatment.
• A patient’s record needs to include sufficient information to justify the diagnosis and support the treatment plan and care ultimately rendered.
• Documentation also provides legal protection for both the patient and practitioner in case of disagreement or disputes over the care received.
• Using Subjective, Objective, Assessment and Plan notes is a clinically accepted method for structuring the treatment record to ensure that all pertinent information is included.
• Good record keeping provides evidence of the level of skill, care and attention the patient received.

CONCLUSION

Accurate and thorough documentation of care is a fundamental professional obligation. Comprehensive, timely record keeping reduces the opportunity for treatment errors, minimizes communication problems, and helps prevent issues with dissatisfied patients. Furthermore, it preserves important patient data, facilitates the sharing of vital information (both within and outside the dental office), and protects against malpractice litigation. While this level of record keeping may initially seem daunting and time intensive, using the SOAP note format provides a logical approach to clear, precise and thorough clinical documentation.

REFERENCES

1. American Dental Association. What and How to Write, or Change, in the Dental Record. Available at: https://www.ada.org/resources/practice/practice-management/writing-in-the-dental-record. Accessed April 11, 2023.
2. Ingle JI. Diagnostic acuity versus negligence. J Endod. 2002;28:840–841.
3. AAE Clinical Practice Committee. Guide to Clinical Endodontics. 6th ed. Chicago: American Association of Endodontists; 2013.
4. Berman L, Rotstein I. Diagnosis. In: Berman LH, Hargreaves KM, eds. Cohen’s Pathways of the Pulp. 12th ed. St. Louis: Elsevier; 2021.
5. Podder V, Lew V, Ghassemzadeh S. SOAP Notes. Available at: https://www.ncbi.nlm.nih.gov/books/NBK482263/. Accessed April 11, 2023.
6. Ingle JI, Heithersay GS, Hartwell GR, et al. Endodontic Diagnostic Procedures. In: Ingle JI, Bakland LK, eds. Endodontics. 5th ed. Lewiston, NY: BC Decker; 2002.
7. Rosenberg PA. Endodontic Diagnosis. In: Endodontic Pain Diagnosis, Causes, Prevention and Treatment. Heidelberg, Germany: Springer; 2014.
8. Sui H, Lv Y, Xiao M, et al. Relationship between the difference in electric pulp test values and the diagnostic type of pulpitis. BMC Oral Health. 2021;21:339.
9. McCarthy PJ, McClanahan S, Hodges J, Bowles WR. Frequency of localization of the painful tooth by patients presenting for an endodontic emergency. J Endod. 2010;36:801–805.
10. American Association of Endodontists. AAE Consensus Conference recommended diagnostic terminology. J Endod. 2009;35:1634.
11. AAE Clinical Practice Committee. Dental Dams — AAE Position Statement. Available at: https://www.aae.org/specialty/wp-content/uploads/sites/ 2/2017/06/dentaldamstatement.pdf. Accessed April 11, 2023.

From Decisions in Dentistry. May 2023;9(5):18-21.