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The other night I had a delightful Thai dinner at Arawan in Vancouver, Wash., with my wife, Laura. The waitress was cheerful, helpful, and the food quite good. The service was unobtrusive and spot on for timeliness.
A half hour later I was in the electronics department of one of the local Fred Meyer stores. Angry, loud, and violent metal rock music that would have made fingernails on a blackboard sound sweet by comparison was playing in the background. After about 30 seconds of this auditory assault, I asked the clerk if he would change the music.
Incredulous, he said no, and proceeded to tell me (among a number of other things) that I needed to expand my musical horizons. In the process he also managed to tell me that he did not like country music, although I never said anything about country music. I can only assume that he thought I looked like a country music lover.
I voted with my dollars and left without buying anything. I told the manager and wrote an online e–mail to Fred Meyer. Maybe this kind of thing only happens in the Pacific Northwest of America, but I doubt it.
What's this got to do with endodontics? A great deal, actually. Which of these two experiences do we offer our patients before, during, and after a root canal? Is the service well thought out and rehearsed so as to flow effortlessly, or does it place our needs above that of our patients? I believe that a common denominator in endodontic success or failure is largely determined by the preoperative planning that occurs before the case is attempted.
Such preoperative planning goes a long way toward avoiding iatrogenic issues and maximizing excellent clinical outcomes. Alternatively, if the details of treatment are left to chance, the procedure can end up a long way from where it was intended to go.
Taking this analogy further, if the customer always comes first, the clerk would have cheerfully changed the music, no questions asked, or the music would have been programmed to something acceptable for all age groups, and at an appropriate volume.
What ingredients make up the preoperative treatment planning needed to foresee the aforementioned clinical iatrogenic issues and creation of a satisfactory clinical result? I list several here:
1 In consent, give the patient realistic expectations of success and failure. Refer often and early if the case requires skills, equipment, time, or care that you cannot provide, but a trusted specialist can.
2 Assess the case for its iatrogenic risk early, well before picking up a handpiece and making access. A simple case can be made extremely difficult and a difficult case impossible if it is not managed correctly from the start. For example, in the mesial root of a lower molar, the risk of strip perforation is high using large Gates Glidden drills to the point of first curvature, which is the harbinger of not only strip perforation but also vertical root fracture.
3 Determine the number of needed visits to complete treatment, expected master apical taper and diameter, as well as restorative treatment plan before making access. Keeping patients happy involves managing expectations. If treatment will require two visits, this should be communicated to the patient.
Similarly, the optimal master apical taper can easily be determined from a careful assessment of the initial radiographs. Knowing the flexibility and cutting ability of your rotary nickel titanium file system can also allow you to predictably shape the expected taper. For example, the Twisted File* can prepare a .08 taper to the apex of the mesial root of a lower molar predictably if it is used in a crown down manner with a gentle two to three second continuously and controlled motion, followed by irrigation and recapitulation.
4 Develop a case before starting treatment that answers these questions and confirms both the diagnosis, and that the offending tooth has been correctly identified. Is the offending tooth restorable? If not, can the tooth be made restorable? What is the long–term risk of vertical fracture? Do I have the magnification and lighting necessary to see the treatment as it unfolds, which can be provided by an instrument such as the surgical operating microscope (SOM) (Global Surgical, St. Louis, Mo.)?
Ultimately, whether providing Thai meals, retail electronics, or root canals, the patient comes first, and each of us, whether restaurant owner, electronics clerk, or dental professional, must decide whether we choose to honor the customer (patient) or watch the patient walk away.
I welcome your feedback.
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,” by Pacific Sky Publishing. To learn more, go to DeadStuck.com. Dr. Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash.
