This is why endodontic diagnosis begins with the dental hygienist

Dental hygienists play a big role in the prevention of disease. Read more here.
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The curriculum for dental hygiene programs rarely includes a course on endodontics. Unlike periodontics, which RDH students thoroughly study, root canal treatment seems all but irrelevant to a dental hygienist's daily practice. This is unfortunate and likely to change in the future delivery of oral health care.

Changes driven by changes

Several changes are making it necessary for changes to occur in the practice of dentistry.

  • Prevention. Patients look to health care providers, not only to treat their disease but increasingly for the prevention of disease. Research linking oral health and systemic health is causing an acute awareness of the importance of regular dental visits.

Early diagnosis can help prevent severe endodontic infections associated with an abscessed tooth. There is a substantial benefit when the dental hygienist detects a small draining sinus tract in the gum before any symptoms develop. The patient benefits by avoiding swelling, pain, multiple dental visits, and prescription medications. The dental practice benefits by avoiding the challenge of managing an endodontic emergency in the middle of an already busy schedule.

  • Aging population. As the population ages, the need for complex dental procedures in periodontics, endodontics, and restorative dentistry increases. A root canal treatment saves many teeth that in the past required extraction. Older patients are now taking advantage of modern endodontic treatment to help them keep their natural teeth for a lifetime.

Another issue less frequently discussed is the time needed for appointments. This is due to the dental complexities and the more complicated medical histories of older patients.

These patients often have multiple chronic diseases requiring several medications. This affects the flow of the practice’s workday. An RDH proficient in endodontic diagnosis is a great asset to the dentist and the entire office staff. Detecting and educating a patient about an endodontic issue saves time for the patient and the dentist.

  • Access to care. Government and the dental profession recognize the current dental access crisis. As the call to action grows louder and the solution gets closer, changes to the delivery of care will become essential. One of these changes will be the delegation of more duties by dentists to dental hygienists.

The future of dentistry is likely to follow the path of the medical profession. To provide more care to their patients, physicians now rely heavily on the physician assistant. Dental hygienists can confidently assume a more active role in dentistry to deliver high-quality dental care to the increasing number of patients. One area that RDHs can enhance their careers and their role in dentistry is in the field of endodontics.

Including dental hygienists in endodontics

There are multiple reasons to offer more training in endodontics to dental hygienists, including:

  • Knowledge. RDHs are highly knowledgeable dental professionals with training in subjects such as head and neck anatomy, oral pathology, and periodontics. 
  • Skills. Dental hygienists have all the skills necessary to actively take part in endodontic diagnosis.
  • Role. Dental hygienists are often the first dental care provider to examine and treat new patients. On subsequent exam and cleaning visits, the RDH remains in this primary role and sees the patient before the dentist’s examination. Occupying this role of being the first clinician to see the teeth, gums, and patients ideally places the hygienist for diagnosing endodontic problems.
  • Endo-perio lesions. Dental hygienists already see and treat many cases of periodontal disease. Many times, periodontal disease and an endodontic infection become intertwined and difficult to distinguish the cause from the effect. However, once there is an endodontic component, treatment becomes necessary for the best periodontal outcome. The hygienist's early endodontic diagnosis can save the patient from unnecessary periodontal treatment and bring quicker resolution to the lesion.

An introduction to endodontic diagnosis for the RDH

Below are six components to endodontic diagnosis that require very little time to complete. Recording any significant findings is important to a thorough diagnosis.

  • Questions and answers.

The answers to a few questions can supply invaluable information and help focus attention on a potential endodontic issue, such as:

  • Do any of your teeth hurt? If yes, can you point to the tooth?
  • Does it hurt to bite on any tooth? If yes, can you point to the tooth?
  • Do you have hot or cold sensitivity? If yes, how long does it last?
  • Have you noticed any swelling in your gum? If yes, identify the location.
  • Oral exam.

RDHs are experts in focusing on one tooth at a time along with its surrounding gingiva, which is a very beneficial asset when it comes to endodontic diagnosis. 

  • Examining the gingiva. This may be where dental hygienists are the absolute best at endodontic diagnosis. Many endodontic infections drain through a tiny opening in the gingiva that is easily and often missed. Finding a tiny draining sinus tract then alerts the hygienist to take a periapical radiograph which often verifies a periapical abscess. Any small, raised area in the gingiva near the root apex can also point to an endodontic problem that calls for a periapical x-ray.
  • Examining the tooth. Examining each tooth for small cracks or defective restorations can lead to further testing for a tooth. A discolored front tooth is a strong sign of trauma, and the tooth likely needs root canal treatment.
  • Palpation test.

Gently press on the gingiva overlying the tooth’s roots, especially the area near the apex of the root. You are examining for any swelling area and testing for any tenderness that is often associated with an inflamed or infected dental pulp.

  • Bite test. 

If a patient reports a painful tooth, especially pain to biting, or you find a tooth with a crack, a bite test can be very revealing. Begin with a cotton roll and ask the patient to bite slowly and gently. An endodontically involved tooth can be extremely sensitive to a very light biting pressure.

  • Percussion test.

If you suspect an overly sensitive tooth, begin by lightly tapping the tooth with your finger. If the tooth is tender, you need not continue testing. Otherwise, use the handle end of a dental mirror and lightly tap on the tooth. It is important to perform this test on multiple teeth to ensure the suspect tooth is more tender than other teeth.

  • Cold test.

There are several ways to perform this test. A common method is using a dental spray made specifically for endodontic testing. Saturate a cotton pellet and lightly touch the tooth after instructing the patient to lift their hand as soon as there is any sensation. Never spray teeth directly. With time and practice, you can master this valuable diagnostic test.

Learning and taking part in endodontic diagnosis is not likely to become a requirement for a successful career in dental hygiene. However, endodontic diagnosis can add to your skill set and help you become an even more involved and valuable member of your dental care team.


Written By Dr. Steven Tuggle