The one single thing: Unconditional focus

June 1, 2007
More than any other, what is the one single thing that drives a great endodontic result? While I am an advocate of bonded obturation with RealSeal after K3 rotary nickel titanium instrumentation (SybronEndo, Orange, Calif.

by Richard Mounce, DDS

More than any other, what is the one single thing that drives a great endodontic result? While I am an advocate of bonded obturation with RealSeal after K3 rotary nickel titanium instrumentation (SybronEndo, Orange, Calif.) more than the brand of root canal files or obturation material used, great results can be driven by an unconditional focus at all stages of treatment. Such focus implies preoperative preparation for every stage of the procedure - from informed consent and treatment planning to coronal restoration. Such focus inspires confidence in patients who know they will be well cared for, so they are less anxious about treatment. Let me discuss several of the steps to bring this unconditional focus into endodontic procedures.

First, communication between a patient and doctor should be optimal. Informed patients tend to be relaxed. Relaxed patients are easier to work with, and generally allow the doctor to achieve excellent technical results. Within reason, the patient should have no surprises before, during, or after treatment. Having a patient say after a root canal that he or she did not understand why the treatment was started, or what was done, is a significant breakdown in communication. Predictable outcomes and few surprises can go far toward building trust and long-term relationships. A patient-education system like CAESY (CAESY Education Systems, Vancouver, Wash.) is an excellent tool to aid in this process.

Focus implies that every step in a procedure is completed to the highest standard before advancing to the next step. Mentally, the entire procedure is rehearsed before starting. Steps are never skipped. Clinically, this is represented by a doctor who waits a sufficient amount of time for anesthesia to take full effect and tests its depth before starting. The emphasis always should be about the quality of a patient’s experience, not about the clock.

Profitability by saving time should never be the deciding factor in why or how treatment is conducted. A rubber dam that fits well is a vital precursor to command at the operative site. Having a surgical operating microscope for visualization will only enhance this command.

Root canal treatment is dynamic. Despite planning, the expected result from treatment can change in an instant. For example, bleeding might start unexpectedly from a canal even though the doctor is confident that the apical foramen has not been violated.

If one does violate the apical foramen iatrogenically, recognizing that it has happened and knowing what to do is essential. An unconditional focus allows a clinician to understand what is happening, and to choose the correct course of action.

An incorrect strategy when an issue arises can be the harbinger of a perforation, a separated file, or other iatrogenic outcome. This outcome is almost always preventable. For example, pushing on an RNT file in a blocked canal (irrespective of the source of the blockage) can lead to separation in a matter of seconds. Recognizing that the canal is blocked, patiently attempting to use hand files to pass the obstruction first, then making clinical decisions based on this outcome is recommended as opposed to forcing an instrument apically to exacerbate the problem.

While profit should never dictate treatment, profitable results are created by a synergy of excellent clinical technique blended with efficiency. The more efficiently treatment is conducted, the greater the chance there will be no breaks in a clinician’s focus during treatment. Leaving in the middle of a root canal to perform a hygiene exam is a significant block to the flow of treatment and focus.

In addition, such activity wastes anesthetic window time for patients and leaves them under the rubber dam longer than necessary. I cannot fully focus on more than one endodontic procedure at a time. It is hard for me to envision how some clinicians can treat multiple patients simultaneously, yet give each patient their best.

Finally, an unconditional focus during treatment can go far toward answering a patient’s primary questions: 1) Is this going to hurt? 2) How long is this going to take? 3) How much is this going to cost?

Unconditional focus provides answers:1) The treatment won’t hurt because all reasonable precautions to prevent pain have been made. 2) The patient will not be in the chair any longer than absolutely necessary. 3) In gaining consent, all fees and insurance-related questions were answered before access was attempted.

Each of these are strategies to create lasting relationships with patients.

As always, I welcome your feedback.

Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash. 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 [email protected].

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