Advances enhance treatment options
Albert (Ace) C. Goerig, DDS, MS
Recent advances in endodontic technology and treatment philosophy have enabled both the general dentist and endodontist to increase their quality and profitability in endodontic care. This article discusses those changes and reviews the key ingredients needed to make endodontics highly successful and profitable in your practice.
New technology
The single most important advancement in endodonics has been the new 360-degree, rotary-nickel titanium engine files. I have been using these files in my practice for the past five years and they have significantly improved the quality and efficiency of my endodontic procedures. The ability of these instruments to clean and shape difficult root canals systems in an extremely efficient way is unbelievable.
There are many rotary systems on the market. When selecting a rotary-engine file system, it should contain both 02 standard files and 03 to 06 tapered files. The 03 to 06 tapered files are not recommended around severe curves or while initially instrumenting the apical portion of calcified canals because they have a greater chance of breakage. They are best used to flare the middle and coronal third of the canal. The strength of the Endo Magic system I use is 02 taper 3115, #20 and #25 files. This file design is unique among all other engine files and allows practitioners to get around sharp and s-shaped curves enabling them to rapidly open calcified canals while maintaining canal position. This rotary system is made by TYCOM and distributed by Practical Endodontics (800 215-4245).
The MicroSeal system by TYCOM is one of the most efficient and fastest ways to obturate the root canal system. This is ideal for those who use lateral condensation or the warm gutta-percha technique. The inexpensive system incorporates an engine-driven compactor that effectively fills the canal space in three dimensions. The Obtura is another warm gutta-percha system that I use routinely in my obturation techniques.
Computer-generated radiography was made for endodontics. It allows the dentist to see the picture within seconds of exposure. If not all the canals can be seen, the cone head can quickly be modified and within seconds all canals and apices can be seen. Patients love the new technology and it becomes a great teaching tool when they can see the radiograph the size of a computer screen. In addition to these benefits, the exposure is one-tenth that of a normal radiograph. I use the Schick technology in my office and it allows me to complete one additional treatment per day with a lot less stress.
There are other new innovations that have added to the quality, speed and predictability of endodontic therapy. Some of these are the apex locators, endosonics, magnification (Design for Vision glasses), microscopes, nickel titanium files, lubricants (RC prep) and philosophy changes such as moving to more one-appointment endodontics.
Staff training
Endodontic packs should be developed that have all the needed sterilized instruments and files in one place. Staff members should be trained to work effectively with their dentist during endodontic procedures. After returning from a continuing education course, time should be set aside to make the changes learned from the program. One of the best two-day endodontic success and profitability courses available is given by Drs. Steve Buchanan and Cliff Ruddle [(800) 799-5701]. You will be able to see and try the new technology at their course. They also provide excellent hands-on workshops. The best two-day, hands-on workshop using the Endo Magic rotary system is given by Drs. Kit Weathers and Patrick Wahl [(800) 215-4245].
Anesthetic technique
One of the greatest stresses in endodontic therapy is to ensure profound anesthesia for patients with pain and/or swelling. If the patient still feels pain while attempting access after routine anesthetic has been given, I will immediately use the Stabident intraosseous local anesthesia system [(800) 233-2350]. This places local anesthetic at the apex of the tooth, and, within 20 seconds after injecting, I have profound anesthesia. It is profound, fast and predictable and can sometimes be used as the primary anesthesia. This is true in either the maxillary or mandibular arches. This has saved me as much as a half-hour waiting for profound anesthetic. Knowing I can always get the patient completely numb eliminates the majority of stress during endodontic treatment.
In the next few months, there will be a new one-step, intraosseous anesthesia device on the market. The Cyberjet looks like a slow-speed handpiece that penetrates bone and infuses the anesthetic. It will be disposable and will not have the problem of finding the penetration hole with the needle.
Proper case selection
Taking the time to evaluate each tooth for the degree of difficulty will improve your endodontic profitability. A publication recently sent out to all dentists by the American Association of Endodontists gives guidelines for assessing the difficulty of endodontic cases. Copies of this 1997 publication and assessment form can be obtained from AAE headquarters by calling (800) 872-3636. Patrick Wahl, a nationally known endodontist, suggests that certain teeth and conditions have a greater degree of difficulty and and an increased chance of complications. They include necrotic teeth, teeth that routinely have extra canals (mandibular anterior and maxillary molars), second molars, sharp curves, calcification, long roots, crowned teeth, swelling, retreatment, demanding patients, strategic abutment, malpositioned teeth, cases where profound anesthesia is difficult and cases that cannot be completed in one appointment.
Evaluate how long it takes you to do root canal treatment on teeth with the various risk factors described above. Have your assistant time your endodontic procedure with a stopwatch for one month and review the numbers to find out your true profitability. Learn from past experience and do the cases you love to do and only those that are profitable. Any case where you feel uncomfortable, stressed and/or unable to give a comparable quality of care as the specialist, then the patient should be referred. Remember that if something should go wrong and the case is litigated, you will be held to the same standard of care as an endodontist. Some teeth initially may look routine, but become more complicated when treatment begins. When this happens, cut your losses early and refer the patient out early. This always will be in the best interest of you and your patient. Patients can become easily disillusioned with the doctor if treatment doesn`t go as well as expected. The decision to refer should be made at diagnosis or at least before the patient`s confidence in the GP is lost.
You will find that many anterior, premolars and straightforward molars can produce profitability equal to crown-and-bridge procedures. You also will find that some teeth will not even pay your overhead and cost you more money than the fee you received. One practice-management consultant said: "If your overhead is $200 per hour and it takes you three hours to do a $550 root canal, it would be better to give the patient $50 and send him or her to an endodontist and spend the time doing other dentistry that is more profitable."
One-appointment endodontics
Determine how much time it will take you to complete each endodontic procedure. Schedule the amount of time needed to complete that case in one appointment. This forces you to be more efficient. Endodontic cases that are going to take multiple appointments are sometimes better referred out. Changing your mindset to realize that most routine cases can be completed in one appointment is essential.
I have yet to find a patient who would like to have his or her root canal spread over multiple appointments. This is especially true for patients who have to take off from work or who have traveled a distance to get to your office. You may be surprised, but most patients would like to spend less time in the dental chair. Some doctors are concerned about fee justification. But most patients probably would pay more if the treatment could be completed in one appointment.
Another concern is the greater chance of post-op flare-ups. In the past 20 years of doing single-visit treatment, I have found considerably less post-op problems with one appointment endodontics than in multi-appointments. Bacteria move from the periapical area into the canal space and become a constant source of periapical infection. When the canals are sealed off quickly, the bacteria have no place to hide and have to face the body`s defenses and antibiotic therapy. I feel the sooner the canals are sealed, the sooner the periapical infection will heal. Also, I have seen no difference in success rates between teeth completed in one appointment compared to multi-appointment endodontic treatment.
The savings in time to the dentist are enormous. Doing endodontic treatment with one appointment forces you to become more efficient. Many dentists who have changed to one-appointment treatments have found a 50 percent to 100 percent increase in net profit.
I treat all teeth in one appointment, except teeth where the canals cannot be dried for gutta percha placement. (In continuous weeping canals, I place calcium hydroxide and complete treatment at the next appointment.) Other exceptions include cases with large facial swelling where drainage can be obtained through the tooth, as well as cases when there is not enough time to complete treatment.
Endodontic fees
Many dentists have focused on raising their restorative fees at the expense of the endodontic fees to get them approved at a higher level by the insurance companies. Re-evaluate your endodontic fee schedule and raise fees accordingly. Howard Farran points out that you will be held to the same standard as the specialist, so on those cases you do yourself, you should charge the same as a specialist.
Working relationship
It is essential to have someone you know and work well with to help you in your learning process and the treatment of more difficult (non-profitable) cases. For this relationship to be successful, it always must come from a win-win philosophy. I am very thankful for the patients who are referred to me.
It is very important to have good lines of communication between the GP and specialist. My goal as a specialist is to make the generalists` life a lot easier and help eliminate some of the stress in their practice. I am there to help the generalists become more successful. I am there as a friend and coach to help them improve the quality of their endodontic care. One of my important jobs is to enhance their image and the quality of their dentistry to their patients as well as reinforce present and future restorative needs. After treatment is completed, I strongly recommend the patient return to the GP for a crown, if needed. In many cases, we call the GP`s office to set up a restorative appointment for the patient.
Some GPs only send patients to specialists after cases have been badly compromised. This not only increases the malpractice risks to both dentists, but stresses the relationship between them as well.
There are numerous elements of success that affect the bottom line in endodontics. Embracing the new technology, changing your mindset to incorporate more one-appointment endodontics in your practice, knowing when to refer and developing a win-win relationship with your referring endodontist are the keys to significantly increasing your endodontic profitability.
Referring the endo patient
First, evaluate the patient`s personality and type of case so that you can make a specific referral. Most patients do not want to leave their GP`s office, so you must get the patient excited about going to the specialist.
As a GP, I would tell the patient: "The nerve in your tooth is infected and I would like to send you to a specialist for evaluation and treatment. Your tooth is much more complicated to treat than normal and it is going to require someone who does this day in and day out. I have done a lot of root canals in my time and have learned that in many cases like yours, it is better to have a specialist render treatment. It goes more smoothly, generally with fewer appointments, and you will get a great consistent result."
I would then ask the patient if he or she prefers a particular specialist.
If not, I would say, "There are several excellent specialists in town, and I would like you to see Dr. G. He is very gentle, caring and he will possibly do everything in one appointment. I will have Debbie at the front office call over and make you an appointment."
It is always better to make a definitive referral. I would not recommend that the GP present a list of endodontists in the area and ask the patient to pick one. Your patients trust you and always want your best recommendation. A specific referral reinforces the necessity of the procedure.
