Better to be a prophet than make excuses

I am proud to be an endodontist, but I don’t like to announce it socially.

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I am proudto be an endodontist, but I don’t like to announce it socially. “Oh, you are an endodontist” is often closely followed by “ouch” and a change in subject, or a long monologue about how the last doctor made this person’s root canal a misery. Changing this stereotype is possible.

One remedy is to eliminate preventable challenges and mistakes. Errors in diagnosis and treatment planning can cause immense pain and suffering, and as a result, turn a relatively calm patient into a phobic and anxious one. For example, if a patient has signs and symptoms of irreversible pulpitis (spontaneous localized pain, nocturnal localized pain, lingering sensitivity to hot and cold or sharp predictable pain to hot or cold, pain chewing along with the other symptoms, etc.) the person needs a root canal.

Crowning the tooth, then placing a filling or sedative dressing, and hoping that the pain will go away is unproductive. This will only delay the inevitable. Some believe if such symptoms subside that the pulp heals spontaneously. It does not.

The cumulative trauma of the decay, cracks, fillings, preparations, impressions, etc., in the presence of these symptoms is the harbinger of a necrotic pulp. The necrotic pulp might remain quiet. Eventually, though, the odds are overwhelming that it will arise with pain and - ultimately - swelling.

Every day I treat patients who had extensive dentistry performed and who needed root canal treatment prior to the restoration. After days or weeks of pain, the patient is finally referred. It is an unfortunate and preventable fact that a large number of new crowns and bridges are fractured or damaged and have to be repaired (or replaced) after endodontic access. I know that if I were a patient who invested in a new porcelain crown and shortly thereafter had to have it drilled and later filled, I would be very frustrated. I believe this is a daily occurrence in most endodontic offices.

One strategy to prevent this from happening is to assess properly the pulp prior to any coronal filling. Such evaluation would include cold testing (EPT and hot as needed), percussion, palpation, mobility, probings, as well as two radiographs from different angles. These tests can build a case about the health of the pulp, and alert the clinician that a tooth should have a root canal before restoration. I think it is better to be a prophet than to make excuses.

If the tooth needs endodontic therapy prior to the coronal restoration, it is highly advisable to do this prior to crown placement. This process should be followed by endodontics instead of the other way around. To place the crown when the pulp is clearly not healthy or is necrotic is, at best, living in a land called hope and, at worst, negligent.

Recently, I had a patient who had clear signs and symptoms of irreversible pulpitis for approximately two weeks before the doctor performed a “pulpotomy.” Upon examination, the mesial root of tooth No. 18 had a separated file beyond a significant curvature. The patient had not been informed of the separation. In this case, more than just a pulpotomy was performed. While a comprehensive discussion of this case isn’t possible here, treatment was delayed unnecessarily and the patient suffered considerable pain, lost trust, and had a preventable, compromised final outcome.

Proper case assessment, early intervention when symptoms are clear, and direct and effective communication can help to avoid the morbidity and loss of trust that occur when needed endodontic treatment is delayed. Just as importantly, following these principles can lead to a change in the prevailing stereotype. I welcome your questions and feedback. 0609de060

Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Portland, Ore. Among other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau, Korror, Palau (Micronesia). He can be reached at Lineker@aol.com.

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