For more on this topic, go to www.dentaleconomics.com and search using the following key words: preventing endodontic failure, Steve Jobs, Apple, Dr. Richard Mounce, The Endo File.
My letter to Steve Jobs …
I love my Apple computers; I've bought many Macs and iPods over the years. About two months ago, I bought an iPhone 3GS, and about one week ago it stopped charging. When I took it to the Apple store I was told that I had gotten water in it, that it was out of warranty, and that I needed to pay $199 to get another one.
I am frustrated because the first phone was paid for, and I agreed to a two–year contract, but with no other option, I had to pay another $199 to get a new phone. The irony is that I have no recollection of getting my 3GS wet in any way, and I admit I am now gun–shy and trying to make sure this won't happen again. I just want you to know that this taints an otherwise great relationship between Apple and me as a consumer.
Thanks for listening, Rich.
The letter is self–explanatory. After I sent it, I had a cognition. What do we tell patients when their endodontic treatment fails shortly after it is completed? What good options can we then give our patients? Could the majority of clinical failures be prevented? Can we take steps that will minimize such failures? Do we not leave some patients with my iPhone experience?
Much endodontic failure is preventable. It's not endodontics that fails us. We fail endodontics. In an endodontic context, how often have we seen poor treatment fail followed by a re–treatment, surgery, and ultimately an extraction?
This cycle is largely preventable with proper planning and treatment of the highest standard. Meeting the patient's expectations is critical. Before starting, the patient should always know what the probabilities of success are, as well as all available options. Had I known my iPhone was not covered for water damage, and that its replacement would be $199 two months after buying the phone and a two–year service contract, I might have taken a different direction.
Included here are a number of steps that can be taken to improve outcomes and patient expectations:
1 The value of a comprehensive evaluation of the patient and tooth prior to treatment cannot be overstated. Most of the clinical issues and challenges that bedevil treatment are foreseeable. For example, simply extracting teeth that are not restorable is an excellent first step in performing endodontic treatment in cases that can provide predictable success.
2 Has the tooth had previous root canal therapy? Is there evidence of coronal leakage, a previous iatrogenic event, or clinical or radiographic failure? Recognizing each of the issues can direct the clinician quickly to the optimal treatment solution. For example, performing apical surgery on a tooth with a previous root canal that has coronal leakage is contraindicated, and re–treatment is optimal.
3 If the tooth needs re–treatment or surgery, will the re–treatment or surgery make the tooth highly susceptible to future iatrogenic events, vertical fracture, or long–term failure?
4 Does the case need referral? If the clinician does not have the will, skills, time, equipment, experience, or passion to do the case well, it should be referred. Starting a case with the belief that it can be referred later, if needed, is rarely a positive development for the tooth, patient, doctor, or relationship between the doctor and patient.
5 Clinicians must know the strengths and limitations of their equipment and systems. There are few comprehensive systems that can address all clinical indications. While there are many ways to perform endodontic treatment in a clinically acceptable manner, I use the Twisted File* and bonded obturation in the form of RealSeal* in master cones and bonded obturator form (RealSeal One Bonded Obturators). Babies crawl before they walk, walk before they run, etc. Clinicians can do the same. Practice in extracted teeth can go far toward understanding the capabilities of any given system. I have chosen the Twisted File and RealSeal because these materials are predictable, clinically proven, and cost effective.
6 The vital importance of coronal seal cannot be overstressed. A lack of coronal seal is a prima facie reason for treatment failure. Immediate placement of a coronal seal is correlated with clinical success.
7 The procedure, alternatives, and risks must be addressed, and all patient questions must be answered. A well–informed patient is invaluable to avoid creating unmet expectations. Our patients are just as likely to make different choices if they know all the ramifications of the treatment choices presented to them.
I welcome your feedback.
*SybronEndo, Orange, Calif.
Dr. Mounce is the author of the nonfiction book, “Dead Stuck,” “one man's stories of adventure, parenting, and marriage told without heaping platitudes of political correctness” from Pacific Sky Publishing at DeadStuck.com. Lecturing globally and widely published, he is in private practice in endodontics in Vancouver, Wash.