March 1, 2008
Even though many general dentists do not routinely perform root canals, there are some who offer endodontic treatment ...

by Roger P. Levin, DDS

Even though many general dentists do not routinely perform root canals, there are some who offer endodontic treatment or who are considering adding endodontic services in the near future. Expanding the service mix usually presents both clinical and management challenges. Obviously from a clinical standpoint, the dentist and staff must receive the appropriate training and education to successfully complete the planned procedures.

From a management standpoint, incorporating endodontic procedures into the general practice can present significant challenges, especially in these areas:

• Scheduling
• Case presentation
• Referring doctor communication

#### Scheduling

The starting point for increasing endodontic productivity begins with an analysis of endodontic production —

• What percentage of total current production is endodontic procedures?
• What percentage of root canals is true emergencies?
• How many are scheduled in advance?

Without this information, it is very difficult to design a scheduling system that will work for your practice.

Once you have analyzed the total number of all emergencies against the number of root canals performed each year, you can start designing a better schedule. For example, suppose a practice performs 120 emergency root canals per year. That same practice has on average two emergencies per day during 180 practice days that year for a total of 360 emergencies, with root canals (120) accounting for 33 percent of all emergencies. This information can then be used to build a mathematically designed schedule to ensure that the 120 root canals are performed in the most efficient manner possible. If the practice leaves no time in the schedule for emergencies (including root canals), then the office is welcoming chaos and inefficiency with open arms.

To clarify this scenario, imagine a day with no emergency time and the practice is swamped. We know from the above example that the office is likely to receive an average of two emergency calls a day, with one of every three emergencies a root canal. If the practice has a completely full schedule, then the emergency patient will be brought in to receive some level of diagnosis.

If it is indeed a root canal, then the practice has three choices:

1. Perform a diagnosis and then reappoint the patient depending on his or her level of pain
2. Begin endodontic treatment and complete the root canal another day
3. Perform a complete root canal from start to finish

Clearly, the most efficient method is to perform a complete root canal so the patient won’t have to come back. One-appointment endodontics has become very common and has created a much higher level of efficiency in endodontics. If the practice has no emergency time available, then there will be either upheaval throughout the day causing tremendous stress for the doctor and team, or the patient will have to be reappointed, which creates a higher level of inefficiency and increased overhead.

When you also consider that root canals can vary in terms of complexity and that diagnoses are not always immediately 100 percent clear, you can see how endodontics can create high levels of inefficiency if the right systems are not in place.

Not all root canals are emergencies, however. For example, radiographs will reveal that some current patients need root canals. Levin Group recommends that these root canals be scheduled using Power Cell Scheduling™— a system that ensures time is built into the schedule for these procedures. By establishing the number or prescheduled root canals each year, the schedule attains greater predictability and efficiency. Patients can be seen quickly and conveniently while the practice remains productive without upheaval and stress.

#### Case acceptance

From a patient perspective, endodontics is very different than most other dental services. There are many dental services that require a great deal of education, motivation, and influence for patients to accept treatment. These include comprehensive dentistry, multi-tooth dentistry, implant dentistry, cosmetic dentistry, etc. Endodontics is a field in which treatment is often readily accepted.

Case acceptance for root canals is extremely high. In fact, we have observed it as high as 99 percent in some offices. Faced with the potential loss of a tooth, most patients readily agree to undergo root canal treatment. This creates an opportunity to streamline the normal case presentation process and increase overall practice efficiency.

Levin Group has observed that it is not necessary to spend the typical amount of time in case presentation for root canals. While case presentation involves numerous steps for cosmetic dentistry (and other services), the same is not true for a root canal. Most patients will accept the treatment as long as they understand that it will likely be successful, save the tooth, and relieve pain.

Keep in mind this technique is contingent on the doctor confirming that a root canal is necessary. If 95 percent of all root canals can be accurately observed by a well-trained assistant, then she or he can provide education about root canal therapy. This will save enormous amounts of time for both the patient and doctor regarding treatment.

The main point is that root canals should be presented quickly and easily. Levin Group also recommends providing patients with a brochure so they receive an overview of root canal treatment, including benefits. This additional information reinforces patients’ decisions to accept treatment.

#### Referring doctor communication

Levin Group has noted that the majority of general dental practices refer to endodontists throughout the year. Maintaining a high level of communication with an endodontist is critical to an effective working relationship.

The first step is to determine which cases should be referred. Even a practice that likes to perform root canals should consider referring to an endodontist when a particular procedure will disrupt the schedule. While some dentists think they should retain the root canal simply to generate production, a disrupted schedule will wreak havoc on the team and practice over the long term. In many cases, referring the root canal is more efficient for that day and more profitable on an annual basis.

Many root canals are more complicated than they initially present. Every dentist has started a root canal and, at some point, wished that he or she had never touched that tooth — it seems to go on forever, can require multiple appointments, and may never be fully treated, which leads to problems down the road. When these cases can be identified in advance, it is far more efficient and productive to refer them to an endodontist.

There are other reasons that dentists refer root canals, including decisions not to perform root canals, or only perform root canals on certain teeth, such as anteriors. Whatever the reasons, it is imperative that excellent communication occur between the general practice and endodontic practice.

Levin Group recommends giving all relevant information to the endodontic practice, including clinical diagnosis, radiographs, medical history, etc. It is also important to note whether this is an emergency or a condition that can be seen within the next day or week. This type of thorough communication strengthens the relationship between the general practice and endodontic practice, prevents system breakdowns in the endodontic practice, and facilitates optimal patient care.

#### A final word

Each dental service you provide has different parameters regarding clinical technique, practice management, and team productivity. Root canals differ from other services, and therefore require their own set of guidelines and protocols. Compared to most other services, root canals are often emergency procedures that can disrupt the schedule, leading to lower levels of productivity and customer service for other patients. By creating a schedule that accounts for endodontic emergencies, practices can better manage patient flow, reduce stress, and provide the highest quality of care.

Dental Economics® readers are entitled to receive a 50 percent courtesy on a Levin Group Practice Analysis, an in-office analysis and report of your unique situation conducted by a Levin Practice Development Specialist. To schedule the next available appointment, call (888) 973-0000 and mention Dental Economics® or e-mail [email protected] with “Dental Economics” in the subject line.

Roger P. Levin, DDS, is founder and CEO of Levin Group, a leading dental management consulting firm that is dedicated to improving the lives of dentists through a diverse portfolio of lifetime services and solutions. Since the company’s inception in 1985, Dr. Levin has worked to bring the business world to dentistry. Levin Group may be reached at (888) 973-0000, or at www.levingroup.com.

#### The endodontic referral process

The relationship between the endodontist and the referring doctor is critical to successful treatment outcomes. Practices should clarify how they would like referrals to be handled in the best interest of their patients. The more information exchanged, the easier the referral process will be.

One recommendation is for the endodontic practice and the general practice to meet quarterly to discuss how each office is handling referrals and whether any changes should be made. Traditionally, these meetings are initiated by the endodontist, but it is truly the responsibility of both parties.

In addition, immediate communication should take place in any scenario where the referral expectations may have to be altered or cannot be met. This approach allows both the restorative doctor and endodontist to determine the best course of treatment and case planning.

Endodontists should work closely with referring doctors in the areas of diagnosis, referrals, and complications. Once again, clear communication should take place as to which practice will handle the different aspects of endodontic diagnosis and treatment. If conflicts arise in the referral process, these should be discussed at the quarterly meeting.

As a final note, endodontists should work with referring doctors to teach endodontic diagnostic concepts to increase the percentage of referrals for patients who have teeth that need root canal therapy.

When expectations are clarified and regular communication takes place between the endodontist and referring doctor, the referral process is easier for everyone and the ultimate winner is the patient.

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