What price for excellent treatment?

A friend recently asked me an interesting question about his upcoming root canal.

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by Richard Mounce, DDS

A friend recently asked me an interesting question about his upcoming root canal. To me his question really was: What creates value for our patients and what can we do to immediately improve the value we provide? In essence, what immediate steps can we take to lessen the gap between where we might be now and where we want to be in an endodontic context?

His question was: "I have a root canal scheduled for tomorrow on tooth No. 31 that has bothered me for months. Doctor assumes it's dead and will try to save a PFM crown. I was quoted $900, which sounds high to me. Does that sound reasonable to you? I'm afraid that if the crown can't be saved I'm looking at another $1,000. Thank you for your help."

The value of an excellent root canal that preserves a tooth is hard to measure in dollars and cents. If the treatment is carried out to the highest possible level, it has immense value to the patient — in my belief far beyond the treatment fee. If the tooth is lost, what is the cost of replacement? What amount of money can compensate the loss of function and pain, and the value of lost work time to replace the tooth? Will the replacement be as satisfactory as the natural tooth?

I told the patient that this fee was more than reasonable, with the caveat that the treatment was carried out to the highest standard. Creating value has two components — getting the technical treatment right, and delivering care in an environment of trust and good rapport.

Trust and rapport occurs through:

  1. Obtaining the patient's consent for all treatment. Make sure the patient fully understands the ramifications of the treatment, i.e., that they will need a build up, crown, and possibly periodontal surgery to make the tooth restorable.
  2. Listening to and answering all the patient's questions before treatment. Having a root canal obviously provokes anxiety in patients. What is simple to us may be overwhelming to them.
  3. Dealing with patient fears and expectations before treatment is started.
  4. Always treating the patient like a valued family member.
  5. Making sure that the patient is numb before starting the procedure.
  6. Considering referral if you are not the best person to care for the patient on a given day with your time, skills, equipment, and desire to create an excellent result.

Creating trust and rapport takes time and resources. This time and effort has a tangible value. There are no shortcuts to accomplish this. Some people have challenging needs.

In my opinion, earning the fee means anticipating what can go wrong and where the technical risk is, deciding on a plan to avoid the risk of perforation, separated file, etc., and maximizing the outcome through the right materials, methods, and techniques for the given clinical case.

While one size does not fit all, the chosen materials, methods, and techniques for me include:

  1. Crown down technique under a rubber dam. Never skip steps because one excellent portion of treatment sets the stage for the next.
  2. Valuing apical patency at all times. Never let the minor constriction of the apical foramen be blocked with debris if it can be avoided, and it can nearly always be avoided.
  3. There is no substitute for the surgical operating microscope (SOM) (Global Surgical, St. Louis, Mo.). Working without it is literally working in a black hole by tactile feel only or settling for second best with loupes.
  4. Irrigation is copious and recapitulation is frequent. I heat my irrigants and ultrasonically activate them. Future columns will describe how this is done.
  5. The smear layer is removed (SmearClear) and the obturation is bonded (RealSeal) and delivered via the Elements Obturation unit (all SybronEndo, Orange, Calif.).
  6. The coronal seal is placed at the time of treatment. Either the orifices are covered with a flowable composite or the entire build-up is placed, but to leave the obturation covered only by a cotton pellet and temporary invites leakage. Ideally, the coronal build-up is placed at the time of treatment and done so under the SOM and rubber dam. I use PermaFlo delivered by the Skini syringe (Ultradent, South Jordan, Utah) for this purpose. As an aside, the Skini syringe and Navi Tip make a very precise method for the delivery of sealer into the canal.

Delivering a service with technical excellence and compassion can go far toward creating professional fulfillment. But more importantly, it can create a value for patients that enhances their health and well-being, and that is priceless.

I welcome your feedback.

Dr. Richard Mounce offers intensive, customized endodontic single-day training programs in his office for small groups of one to two doctors. For information, contact Dennis at (360) 891-9111 or e-mail RichardMounce@MounceEndo.com. Dr. Mounce lectures globally and is widely published. He is in private practice in Vancouver, Wash.

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