Ken Koch, DMD and Dennis Brave, DDS
The key to endodontic profitability lies in predictability. Consistency improves the quality of the procedures, making endodontics more enjoyable for the practitioner. Endodontic procedures that are predictable and enjoyable are profitable.
Multiple paths can lead to more predictable endodontics, such as a fully tapered .06 rotary preparation, but we would like to concentrate on two factors that frequently are overlooked: case selection and continuing-education courses. Proper case selection can help practitioners avoid those "nightmare" scenarios, while constructive continuing-education courses can take your predictability and enjoyment to new levels.
Avoiding an "endodontic nightmare" requires proper case selection. Practitioners must honestly determine whether they can properly treat certain cases. There's no shame in deciding that a case is beyond your expertise and then referring it to a specialist — in fact, it is smart dentistry!
Case selection isn't just about complex dental anatomy; medical history and patient management factor in as well. If the patient is anxious (and most are), take the time to fully explain the procedure before you begin.
Patients also are far more tolerant when they understand what you are trying to accomplish jointly. Let your patients know that they do have some control. For example, agree in advance that if a procedure becomes painful, they can raise their hand, and you will stop. Working with the patient allows treatment to progress much more smoothly.
The American Association of Endodontists has addressed the problem of case selection through the publication of a difficulty assessment form. Using a numbering system, this form can help determine the difficulty of a potential case. Some of the specific situations that this form addresses are: restricted pulpal space, aberrant root morphology, severely ledged canals, resorption defects, retreatment, and difficult parients. We recommend that every dentist who performs root canals obtain a copy and use it as a reference tool. You can obtain this document by contacting the AAE at (800) 872-3636, or at through their Web site at www.aae.org.
Nightmare cases are frustrating. The time they absorb usually erodes any profit. Let's examine some specific instances where a decision to treat a tooth could lead to a less than profitable result.
Calcified cases: The "graying" of America means we are treating more geriatric patients. Many of these teeth are heavily calcified and are very difficult to treat. If you can't see a canal on the X-ray, then consider referring the case. We call these "Associate's case" because somehow they are delegated to the new associate (who is, by the way, usually the least experienced in such matters.) From an economic standpoint, these cases are unprofitable, as they usually involve extra time and multiple visits. Also, be aware of calcified canals underneath pulp caps and paste fills.
Dilacerated or bifurcated roots: These are the most difficult cases to treat endodontically. Bifurcated lower bicuspids are particularly problematic. These cases are quite common with certain ethnic groups. A telltale sign of a bifurcated root is when you see the canal suddenly stop on the X-ray (canal break). Extra ligaments are another indicator. If you have a tooth with a deep bifurcation, do yourself a favor and send it out for treatment.
Retreatment: We believe general dentists can effectively retreat some cases; however, it is best to refer some of them. For example, paste cases can be especially difficult. Previous cases involving Russian paste are almost impossible to effectively retreat; they present difficulties for even the most experienced endodontists. Use some common sense before you tackle retreatment. Getting in over your head with some of these challenging cases is certainly not profitable.
Severely ledged canals: Ledges can be man-made (iatrogenic), but they also occur naturally. They are extremely difficult to treat even for endodontists and often require surgical intervention. Ask yourself: Do you feel lucky? Do you really want to treat this case? If you decide you are up to the challenge, be prepared for multiple visits that will likely impact profitability.
Resorption defects: Internal resorption cases are easier to treat than external resorption. Correct diagnosis is the key. However, many cases, particularly external resorption, will require multiple visits and even surgical repair. It therefore is best to refer these cases.
Difficult patients: Let's face it — some patients are high-maintenance by nature. The combination of a difficult endodontic case with a demanding and anxious patient can quickly deteriorate into a time-consuming nightmare. The adage, "Bad things often happen to bad patients" certainly still rings true today. Practitioners must determine whether the challenge and satisfaction of completing an endodontic case is worth the extra time spent in patient management.
The AAE has performed a real service for the general practitioner. If their difficulty assessment form is filled out for each case, it can offer a defense should the ultimate endodontic nightmare — litigation — occur. If an attorney asks why you felt capable of performing a particular case, you can rely on the case selection difficulty form to support your decision.
Continuing education for fun and profit
The wise use of continuing-education courses is another means to create predictability within your endodontic cases. Don't attend a CE course merely to punch in your CE credits — make them work for you! The key is deciding what course level fits your needs. Make the course profitable for you.
Dental schools and dental laboratories are the leading sponsors of accredited courses. Manufacturers also offer courses that promote their products and services. Additionally, there are individual courses that are sponsored by clinicians. How can you determine which course is best for you? You must first truthfully analyze your experience. Are you a wizened practice veteran, or are you a recent graduate? You must also decide how involved you want to be with endodontic cases. Are you interested only in treating anterior and premolar root canals, or are you ready for the big time?
We are strong proponents of CE courses that have a hands-on component. It's indisputable that before you apply any new technology clinically, you must learn the technique at a hands-on course. Some company courses meet this requirement but often promote only one product or point of view. Generally, they fall short of an in-depth educational experience. Single-day courses address the basics, but, in our opinion, multiple-day courses are vastly superior. The ultimate learning experience is an extended, institute-quality course that offers hands-on experience.
Institute-quality courses are designed for those clinicians serious enough to take endodontics to a higher level. A multiple-day course allows the participant the necessary time to truly learn how to perform a technique, not just purchase a product. For example, our three day "Institute Course" allows participants do nothing but learn access during the first hands-on session. Participants learn how to create proper straight-line access with the best burs, how to find canals with different probes, and how to apply piezo electric technology to enter calcified canals. No one places rotary files into canals on the first day. On the final day, when participants obturate and learn retreatment, our participants fill an average of 15 to 20 teeth, instead of three or four teeth that is customary at many courses. Why can they fill so many teeth? Because they learned proper straight-line access on the first day, they subsequently were able to instrument many teeth on the second day. Teeth that are properly instrumented are easy to fill. No obturation technique can make up for a blunder in canal preparation. It is all about being comprehensive and informed!
New products and techniques make this an exciting time for endodontics. However, the key to making endodontics profitable is predictability. Knowledge is the foundation of predictability and the correct continuing-education course will facilitate the acquisition of such knowledge. As usual, we will continue to suggest ways to make your endodontics better and will bring you, "Just the Facts, Nothing but the Facts."
