Th 264445


Oct. 1, 2007
Go ahead. Grab the ball. It's time to live your QB dreams.
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Go ahead. Grab the ball. It’s time to live your QB dreams.

by Matthew Brock, DDS, MSD

Patients’ loyalty and the trust they have in a clinician for providing the best care possible are hallmarks for an ideal practice. The best care possible requires a team approach. Creating a highly skilled and knowledgeable team allows a dentist to focus on what he or she does best, which is to listen, diagnose, and treat each patient with the quality care he or she deserves. An often forgotten, yet integral member of the dental team is the specialist to whom you refer.

As with any specialist, referring to an endodontist can be a reflection of you and your office. One might think of a general practitioner as the quarterback of the team, picking and choosing the plays that will most effectively meet a patient’s needs. When an endodontist smoothly and efficiently assists in restoring a patient’s dentition while carrying out a general practitioner’s game plan, everyone wins.

Several important considerations may enter into a GP’s decision-making process in determining the best treatment plan for a patient. The American Association of Endodontists has created a case difficulty assessment form that helps a GP work through this decision process. Considerations include:

  • Inclination or Rotation of the Tooth. Extreme inclination or rotation of the tooth in the arch is one variable that signifies a difficult case.
  • Curvature of the Canal and Root. Moderate or significant curvature of the canal and root increases the difficulty of treatment and is an indication that referral is warranted.
  • Radiographic Appearance of the Canals. A pulp stone can almost obliterate the pulp chamber space, making access to the pulp chamber and canals very difficult and putting a tooth in the high-difficulty category.
  • Presence of a Crown or Post. Radiopacity in the periradicular bone makes length determination more difficult, while the presence of crowns makes access more challenging.

AAE case difficulty assessment sheets

A GP might be exceptionally competent in treating difficult endodontic cases and might refer only for convenience. Whatever the reasons for referring, the process requires additional considerations in building an effective practice team.

Important variables are involved. Is the endodontist readily available? Does he or she use an operating microscope to find four- and five-rooted canal systems? Is he or she technologically oriented? Does he or she work with the insurance or payment plans that you do? Does he or she help you do a better job for your patients? Does he or she treat your patients with the utmost respect, as you do? Does he or she promote your treatment plan? Is he or she on board with your treatment philosophy? Is communication easy? Does he or she refer your patients back to you in a timely fashion? Does he or she deliver consistent quality care?

Assuming quality care and respect are givens for the endodontist, a general dentist must evaluate three especially prevalent considerations: Is the endodontist readily available? Does he or she keep abreast of advancements? And does he or she communicate the status of treatment?


Once the decision is made to refer, you or your office staff should be able to make a phone call and have the patient seen without delay. Immediate availability results in a synergistic relationship for everyone involved.

  1. It allows the referring dentist to maintain the scheduled day with minimal disruption.
  2. Any discomfort of the patient is immediately addressed.
  3. Potential problems of delay are aborted.
  4. The patient’s recognition of efficient teamwork builds one’s practice.


Consistent, quality patient care is paramount for a successful relationship. One way to assure quality is through the use of advancing technology. Developments such as digital radiographs reduce radiation exposure and optimize a diagnosis through various image enhancements. Digital radiographs are more efficient because images may be viewed in approximately five to eight seconds as opposed to the time required for a chemical processor.

One of the most impressive applications of digital X-rays displayed on a monitor, however, is patient education. We have all heard “a picture is worth a thousand words.” This is the case with digital X-rays. When you explain to a patient that the dark spot at the end of the root is an infection they can actually see, that becomes a powerful image. I have actually had a disgruntled patient leave an endodontist who was trying to explain to the patient what he wanted to do by holding a conventional film up to the ceiling light and asking, “Now do you see this?” I guess that is why I saw the patient later that day.

The surgical operating microscope is another asset that helps patients make informed decisions about treatment. It allows endodontists to see more tooth and canal system anatomy, and it also allows the capture and documentation of what has been seen and what is actually conveyed to the patient, as well as the referring dentist. A patient rarely forgets seeing a picture of his or her own tooth while discussing the benefits and limitations to illustrate the case.

Experience teaches us that a thoroughly informed patient who has participated in treatment decisions would be highly unlikely to become problematic, even if the treatment fails. One example might be a cracked tooth, one of the most difficult cases frequently encountered. A picture on the monitor illustrates where the crack is, its prognosis, and factors determining treatment. Captured images illustrating particular circumstances can be shared with the patient as well as with the referring dentist.


A solid synergistic relationship is good communication between the patient, GP, and endodontist. When you have good communication within a team, errors are reduced and efficiency is enhanced. Images in a report may convey much information, such as portraying an uninstrumented fifth canal that was the problem with the initial treatment, or the location and extent of a crack. Reports can also help communicate to the restorative dentist that a treatment plan was discussed and accepted by the patient at the time of endodontic therapy. Providing a proposed treatment plan to an endodontist can be of great benefit in reinforcing the importance of treatment to a patient. For instance, images of old, cracked, or leaking restorations may be used to illustrate to a patient the urgency of moving forward with the proposed treatment.

Web sites, another developing technology, are rapidly becoming the most relied upon source of basic information for patients about a practice: location, office hours, treatment description, expectations, and even scheduling appointments. It provides a dentist a more effective means for monitoring treatment that can be shared with a referring dentist and patient. This helps inform both about prognoses so that they can make informed decisions about future treatments.

One way for a busy GP to stay busy is to effectively and efficiently develop a vision for what he or she does best and enjoys most. A referral to an endodontist should make the practice easier and more streamlined with pleasure and excellence being the consequence. We all have particular procedures that we enjoy more than others. One should have the flexibility to choose what makes one the most efficient in day-to-day routines. In some practices, endodontics might not be as beneficial to the GP as preparing a three-unit bridge, so he or she refers to an endodontist.

Added into the formula for referring is the expectation that the endodontist has the experience and technological equipment for optimal results. Microscopes, digital radiographs, apex locators, and nickel-titanium rotary instruments that might be common in an endodontic practice are not so common in a general practice. A GP should expect an endodontist to provide the same high quality of care that he or she provides patients in a timely fashion.

Our goal as endodontists is to be readily available to referrers and patients so that we might streamline the process and refer asymptomatic and satisfied patients back to GPs as soon as possible so that they may effortlessly and seamlessly progress with their treatment plans.

According to a recent AAE survey, 80 percent of all root canals were performed by GPs. This same survey, however, stated that 97 percent of all GPs had referred to an endodontist within the past year. Synergistic relationships should be a goal for GPs and endodontists. Consideration should be given in selecting the endodontist that can achieve practice goals and deliver the best possible care for your patients.

In conclusion, the referral process can be a synergistic relationship in which everyone wins. Keep in mind the availability of the endodontist, his or her knowledge of technological advancements for better patient care, and ease of communication. An endodontist who can help you provide better quality patient care and promote your treatment plan can be a true asset in patient retention and treatment acceptance.

Dr. Brock is a graduate of the University of Tennessee College of Dentistry and received his Certificate of Advanced Graduate Studies and Master of Science in Dentistry at Boston University School of Dental Medicine. He is a member of the American Dental Association, a Specialist Member of the American Association of Endodontists, and a member of the Tennessee Dental Association, Chattanooga Dental Society, Tennessee Association of Endodontists, and Georgia Association of Endodontists. E-mail him at [email protected].

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