by Dr. Richard Mounce
Are excellence, speed, and profitability in endodontics mutually exclusive? In one word, no. But blending all three qualities into daily endodontic practice can be very difficult. We can be fast without much quality. We might perform treatment that deserves to be displayed in an art museum without profitability. We might make a large profit from cases done quickly and yet experience many failed teeth attached to unhappy patients. The re-treatment, surgery, loss of trust, refunded fees, litigation, state board complaints, etc., that can flow from such a string of bad results is the antithesis of profitability. This article will seek to define the terms above (excellence, speed, and profitability) as they relate to endodontics. It will also make specific suggestions to achieve a blending of these three goals.
First of all, how does profitability benefit the patient? If doctors are not profitable, they cannot provide the service, cannot invest in their endodontic skills and equipment, and cannot afford to donate work to needy patients and charitable causes. Profitability is not a dirty word, but simply a fact of life. It's the manner in which this profitability is obtained that is at issue. Would you want your mother treated in an office with outmoded equipment and techniques and a less than ideally trained doctor? All of our patients are someone's family member, and patients desire and deserve our best at all times. Profitability, if used correctly, can provide a place from which excellence can flourish. Advanced training and materials can be expensive. But their cost is minimal when compared to the alternative. Predictably successful clinical procedures, satisfied and well-cared for patients, and a sense of pride and confidence on the part of the dentist is simply priceless.
Is speed in endodontics important? My belief is both yes and no. There is wisdom in the motto "Do it right the first time" because we always seem to have time to do it a second time! Giving enough time to do one's best initially, while sometimes inconvenient in the context of running a busy practice, gives the tooth, the patient, and the doctor the best chance of success. Some teeth can be done quickly; many cannot. Knowing which cases can be treated rapidly and those which will require more time and advanced skills is an art, not a science. Such wisdom is borne of experience and mistakes. Some teeth that look straightforward become anything but, given a procedural misadventure and perhaps a challenging patient. That said, many of the articles, videos, and courses on endodontics address only how to go faster without a comprehensive discussion of the inherent difficulty a case presents. In my opinion, these materials, which address endodontics strictly as a manipulation of tooth structure, provide a message that is misplaced, misleading and possibly harmful. One of the significant differences between endodontics and such "manipulation" is that the endodontic procedure ideally evolves as the treatment unfolds. Many are the teeth that hold a surprise or twist that may not have been anticipated, even in the very best hands. A "cookbook" approach to endodontics that does not treat each tooth as unique and that is performed with speed and profit as the dominating factor may be bound for failure, as neither the tooth nor the patient has read the "cookbook." Endodontics can imitate flying. At times, it can seem as though things are progressing normally, then all of a sudden the instruments go out. The endodontic equivalent to this might be in a lower molar, near the end of instrumentation, when, suddenly and without warning, the chamber rapidly fills up with blood, where everything was smooth to that point. This and other such potential misadventures are not in the cookbook! The cookbook technique may have been ill suited to this particular tooth and could have been the source of the misadventure. Severely calcified teeth and extremely curved roots are prime examples of teeth that require improvisation; generally, they cannot be treated rapidly and to a high standard of excellence with speed alone as the predominant philosophical force behind the hand of the operator.
Efficiency is actually much more valuable than speed. I value efficiency in the pursuit of excellence as opposed to speed; the distinction is critical. Speed might imply that steps are being ignored. In endodontics, the most overlooked factor to attain speed is a lack of proper irrigation of the canal system. Rotary files have significantly reduced treatment times for endodontic procedures, but removal of the bulk of the pulp with these files is only half the story if a proper irrigant is not in place for the correct length of time and irrigation technique is less than ideal. A case performed with minimal or poor irrigation might look radiographically stellar but actually is anything but when examined microscopically. Leaving irrigants in the canal system long enough (a function of speed/time) mixed with performing the irrigation properly (a function of efficiency) is an ideal combination.
In addition, knowing the biologic goal of root canal treatment is truly at the heart of this discussion. The goal of endodontic treatment is the three-dimensional cleansing, shaping, and obturation of the root canal system from the canal orifice to the minor constriction of the apical foramen. In other words, endodontics should duplicate the net effect of removing the entire tooth. If the tooth is extracted, the patient heals. If root canal treatment removes all the pulp, and the canal system is obturated, the patient will heal. Realizing this goal is key. If speed can be obtained in the pursuit of this goal and done efficiently without iatrogenic misadventure, then treatment will be successful. Realizing this fact may slow some practitioners down as they determine that their present techniques may be leaving pulp (filing arbitrarily short of the radiographic terminus of the root and filling with a cold lateral technique that does not obturate all the anatomy within the canal system), creating a higher chance of failure. Conversely, this realization may speed others since they can more clearly focus on what it is within the tooth that they are actually trying to achieve. Muddying the waters somewhat is the clinical fact that less-than-desirable endodontic treatment can sometimes succeed. How often have all of us seen roots filled five or more mm short, the tooth radiographically within normal limits, and the patient asymptomatic? It happens. This can give a false sense of security. Empirically, such treatment can work, as can paste root canal fillings and a myriad of different materials and techniques. However, success is most consistently obtained by ideal treatment as described above. In summary, if one is working toward this goal in endodontics, all speed and efficiency possible directed toward achieving excellence is warranted and desirable. To attempt or achieve anything less in the interest of speed holds a less-than-0ideal prognosis for the patient and will ultimately diminish the dentist's personal satisfaction.
Endodontics is a very detail-oriented discipline. Often, the difference between excellence and something far less hinges on the slightest detail and nuance that may not be readily apparent. For example, in an abrupt apical curvature, maintaining apical patency can often take as much time as doing the rest of the entire case when done properly. Seeing such a curvature on a radiograph, appreciating its complexity, and owning the result takes time. The difficulty is that the patient won't know if a ledge is created or if the canal is filled ideally but the doctor will (or should). Excellence in the author's mind is the doctor that sees the ledge coming before it happens and manages the challenge adroitly. Conversely, telling the patient — whose tooth will not settle down after treatment — that the root must be fractured or that their bone didn't respond to the root canal, results from a less-than-comprehensive evaluation and management of the clinical situation. Taking the time to give the patient the best result possible simply cannot be rushed. The doctor's personal integrity is on the line every time this bridge is crossed. The choice is to do it right the first time or do it fast with an often less-than-optimal result. Charging a fee that represents a fair compensation for practicing at this level is important, and explaining to patients why their cases are challenging beyond the average is imperative. In the patients mind, a root canal is a root canal, while the reality is that it should be anything but. Performing at the highest level in these cases and earning the fee provides the greatest satisfaction to all involved and virtually ensures profitability, excellence, and the most efficient result.
What is "excellence" in endodontics? Aside from the usual definitions of success (asymptomatic on long-term recall, functional, radiographically within normal limits, ideally cleansed and shaped and obturated), I believe there is a further meaning to the word "excellence" as it relates to endodontics. Excellence might also encompass important issues such as
• Did the patient have a good experience overall?
• Did the patient feel cared for?
• Was the root canal a rodeo or was it calm and placid?
• Was the experience a good one for the doctor or a cardiac stress test? Did the treatment further excite the dentist about endodontics or was it a difficult event masked by a calm demeanor?
Many other questions could be asked, but the entire event called a "root canal" has meanings and significance well beyond where the gutta percha was parked for both doctor and patient. For the patient, the experience hopefully means relief from pain without inflicting additional discomfort. If the patient's perception of the experience is generally positive, they will further trust their doctor, fear treatment less, and will seek more treatment in the future. If we visualize the experience from the patient's perspective and provide the best experience possible, we will create high demand for our services. Profitability will follow and excellence can flourish like seeds thrown on fertile ground. The doctor's treatment experience cuts to the heart of his or her professional satisfaction and confidence. A string of good results begets more good results; excellence can follow and become a habit. Such an event might be termed mastery.
Seven specific strategies (outlined below) can help make these goals a tangible reality. In real estate, location is everything. In endodontics, the equivalent is to practice with a desire for improvement. There is no substitute for experience and the wisdom gained through success, and, more importantly, failure. People of conscience will learn more from their failures than their successes. Failure and misadventure experienced once, can, if learned from, improve results later. Failures have certainly had this effect on the author. Learning from experience and failure, and adopting the specific steps outlined below, can go a long way toward bringing excellence, speed, and profitability together.
In addition, reading the Journal of Endodontics (for the science) and other publications is really the best way to obtain the background for providing excellent care. Real learning comes with clinical use and repetitive practice. RxRoots.com, the endodontic educational Web site (as well as all the major endodontic suppliers' sites) can also be great resources for both learning and sharing information. Practicing on extracted teeth and plastic blocks is the next best thing to performing the actual procedures and can provide valuable experience. Better to separate rotary files in an extracted tooth than in your most challenging patient. For example, such practice will give strong tactile clues to the amount of pressure that can be applied to an endodontic file before separation. Learning the trade is always preferable to learning the tricks.
• Know which cases to start and which to refer. Sometimes the best case ever done is the one sent to your endodontist. If you have an uncomfortable "feeling" about a case, don't do it, no matter how much you may need the production. As a specialist, cases that were started and then referred mid-treatment are the most difficult. Patients are seldom happy and teeth rarely better from the experience. "I can always refer it later if I get into trouble" is a recipe for diminished profitability and dissatisfaction for all involved.
• Organize equipment and supplies as much as possible. Keeping all needed endodontic supplies in the same place, organized ergonomically, is desirable at all times. Using only one room for endodontic therapy might be one way to achieve this. Alternatively, a rolling cart that contains all needed material could be moved between rooms. Hunting through boxes for needed supplies spread about the office only creates delay and confusion.
Similarly, practice "dry runs" with your assistant frequently. Verbally walk through each step of the procedure so that the assistant knows why things are being done as they are. Patients can tell if you and your assistant are functioning like a symphony, or if they have walked into a restaurant where plates are crashing on the floor and tables are dirty, etc. Give them the Michelin four-star experience instead of the greasy spoon.
• Get profound anesthesia and test it before you start. Nothing kills a great endodontic procedure like a patient who is not numb.
• Do your treatment in one visit if possible. There are certain situations where this is not clinically indicated, but most cases can be done in one visit with good long-term success. One-visit treatment is contraindicated where there is purulence draining from the tooth, swelling, the apex cannot be dried, complex retreatment (where disassembly alone might take a full visit), or any case where, due to location, access difficulty, calcified canals, etc., an additional visit will be required to achieve the best result possible.
Set aside enough time for the procedure so that the patient has your full attention. Moving between chairs to see multiple patients is ill advised. Endodontics is a highly focused, labor intensive mental exercise. Full focus on the canal, the tactile feedback from the canal during the procedure, and then properly interpreting that feedback is essential. Extemporaneous music, conversation, and background noise make it more difficult for the operator to focus, which delays the result unnecessarily. One might think of these procedures as a concert. When the curtain goes up, the concert starts (the procedure begins) and there is no second chance to get it right.
• Know your instrumentation and obturation system and its limitations. I am a strong advocate of the K3 rotary nickel titanium file system (SybronEndo, Orange, Calif.). All the rotary file systems available have some merit, much like all cars can take you from one place to another. But would you take the family on a cross-country vacation in a Ferrari (you could, but would you want to)? That said, some file systems cut efficiently but are very fracture-prone; others are fracture-resistant but cut poorly; and others might be marginal in both regards. The K3, in my hands, has the greatest applicability in the widest number of clinical cases.
In my opinion, it is the most fracture-resistant file system available and easily tracks a canal in which a proper glide path (a canal which has been instrumented to true working length to a 15K file first) has first been created.
The excellent performance of the K3 combined with its fracture resistance should increase profitability, as fewer separations means fewer cases referred mid- treatment and more patient and doctor satisfaction. The .04 and .06 tapered files (above tip size 30) are very robust and there is little risk of fracture if used properly and if they show no signs of stretching and fatigue.
• A host of efficiencies can be gained in the endodontic process by:
• Having a hygienist give anesthetic if it is legal in your state.
• Having staff explain what a root canal is or having the patient watch a video or read a brochure preoperatively to describe what will occur as well as to walk the patient though the postoperative experience.
• Buying a surgical operating microscope; you won't know what you're missing until you see it up close!
• Cold-testing every tooth on the initial examination (you might be surprised at the number of irreversibly inflamed and necrotic pulps that are asymptomatic).
• Taking multiple-angled periapical radiographs prior to extensive restorative treatment. It's always a bit embarrassing when the patient has a new crown on a symptomatic tooth with a large periapical lesion.
• Know your endodontist; don't just phone him or her on a Friday at 4 pm because you are in deep water. Take your specialist out to lunch and learn from his or her experiences. The diversity of opinion within the endodontic community is great. There is little that is agreed upon, and even gurus within the specialty disagree radically on a number of very basic issues. The disagreement over where to terminate root canal fillings is an example of such a clinical controversy. Much can be learned from these debates.
I believe that excellence, speed, and profitability can be attained and blended within your practice, but only with a conscious effort borne of experience mixed with a desire to learn, change, and improve. Best of luck as you embark on this journey.
Dr. Mounce has no commercial interest of any kind in any product recommendations made in this article.