by Richard Mounce, DDS
There is an emphasis on speed and profitability in the discussion of how dentistry and endodontics should be delivered in North America as evidenced by the content of many magazines and CE courses. While profitability is important, it should be derived from excellent treatment that enhances health, and never solely from speed or financial motives.
Clinicians call me with cases in which they are clearly uncomfortable. But the clinician does not want to refer the patient because of the prospect of lost production. Usually these calls start with the clinician saying, “I’ve broken a file” or “I’ve perforated the root,” and “I need to know how to manage this.” While many issues could be discussed on this subject, a recent phone conversation I had is worth sharing.
A doctor called to tell me about a patient for whom sodium hypochlorite had been extruded into the maxillary sinus several days earlier. The treating doctor wanted to manage the problem “in house” and not refer the patient. The patient was described as being “in agony.”
There were additional complicating factors (the restorability of the tooth and management of the ensuing endodontic procedure), which also were at issue. I suggested, at a bare minimum, that I provide a consultation. This would allow me to evaluate the patient. The doctor flatly refused. Unfortunately, conversations such as these are not isolated instances.
Recently, a colleague related a similar situation to me. In this instance, a doctor had started the wrong tooth in the lower anterior. Then, during a second visit, the doctor tried to correct the problem by starting two additional adjacent teeth. Perforation ensued in two of the three access cavities. Making matters worse, at the second visit, a significant sodium hypochlorite extrusion followed through the perforations.
In either of the situations that I have mentioned, was the patient’s best interest ever at the center of the treatment?
Clinicians can have honest disagreements about clinical matters (the best materials and methods, etc.) and often do. I believe this debate is constructive and instructive for all involved. This notwithstanding, I often see events such as: crown lengthening not being performed in the interest of getting the crown placed; delayed root canals in the hope that a tooth will “settle down in time” (and doesn’t); and teeth that should be extracted but the doctor instead insists on endodontics.
Over the long term, many of these cases fail, and the net result is an unhappy patient. Often, patients in these cases ask me if I will recommend a new dentist. When the doctor-patient relationship breaks down, it ensures an unprofitable result. But more importantly, the patient will fear and mistrust future clinicians. A wall of apprehension and mistrust awaits the patient’s next dentist.
There are many great ways to create efficiency. Strategies include 1) refer often and early, 2) get a surgical operating microscope, 3) learn to visualize the risks and various treatment procedures required before starting, and 4) practice extracting teeth with your chosen system until it becomes second nature.
Practice extensively with with your assistant on extracted teeth. Do this so that reactions during treatment are reflexive rather than reactive. For example, significant efficiency can be achieved, in coronal access alone, if the dental team practices the order in which orifice openers are used. I use K3 Shapers (SybronEndo, Orange, Calif.), which come in three taper sizes - .12, .10, and .08. An assistant who anticipates which Shaper to use with a given orifice size (and has it ready) under the microscope can help the process become more efficient.
Practicing tactile control and using an adequate rotational speed to enlarge effectively an orifice in the presence of a viscous EDTA gel - like File-EZE (Ultradent, South Jordan, Utah) - provides excellent orifice management and facilitates ideal irrigation and apical canal instrumentation. The converse is true. In my opinion, this focus is always in the patient’s best interest, and only can make the procedure more efficient and - ultimately - profitable.
In summary, financial success comes as the result of a series of excellent long-term results that restore function and esthetics in a manner that honors the patient. There is no other path.As always, I welcome your comments and feedback.
Dr. Mounce has no commercial interest in any of the products mentioned in this article.
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].