by Diwakar Kinra, DDS, MS
In my 12 years in dentistry, I've been on both sides of the specialist/referral relationship. For the past eight years as an endodontist, I have given many lectures on this relationship to my specialist colleagues. After having the pleasure of presenting this year at the American Association of Endodontists, it became even more obvious -- all our lives would be easier if we communicated openly and honestly with one another. For this to happen, we need to follow three simple rules:
Rule 1: Don't make it hurt
Perform an endodontic diagnosis before all restorative procedures. This will save all our backsides when the patient comes back a few weeks later and says, "Doc, it didn't hurt until you worked on it!" If we assume that the average practice has 1,000 patients, each with 20 teeth, that's an astounding total of 20,000 teeth. If we misdiagnose just 1%, that equates to 200 teeth! Therefore, when a patient is referred to the specialist's office before the crown preparation for a root canal, it's easier to explain the need for treatment rather than one month after permanent crown cementation.
Rule 2: Don't perf!
There are those days and patients where the only place to perform emergency root canal therapy is in your office. Performing the perfect molar pulpotomy can be a great service to patients and allow for subsequent referral or return for completion. If done poorly, it can be a great disservice to patients, a poor practice builder, and create tension with the specialist. Use these two instruments to remove the coronal pulp tissue, keep you out of trouble, and make everyone happy (Figs. 1 and 2).
Use the Endo Access bur at a predetermined length (marked with a Sharpie® permanent marker) so as not to perforate the furcation (Fig. 3).
Once accessed, switch to the Endo-Z to safely and efficiently unroof the entire chamber contents and create straight-line access. At this point in the procedure, medicate with calcium hydroxide (CaOH) and send patients on their way. If referral is your intended next step, do not instrument the canals with stainless steel hand instruments.
Rule 3: Don't break that instrument!
There are those instances where you want to complete the moderately complex case. One of the more embarrassing experiences for the general practitioner and frustrating for the endodontist is the separated instrument and ledged canal. We've all had it happen, but being careful and conservative in your approach will minimize the risk. You can avoid some of the heartburn by using PathFiles (DENTSPLY Tulsa) to create your glidepath (Fig. 4).
Instead of using a series of stainless steel instruments to get to working length, use these nickel titanium rotary glidepath files. They will allow you to get to working length safer and faster. Since the files pre-enlarge the canals, your final shaping instruments will be safer since they glide to working length without canal constriction and aberrations.
By making a thorough and proper diagnosis, avoiding perforations, and minimizing ledging and separated instruments, everyone's lives will be easier-- the patient's, yours, and your specialist colleague's. We are all in dentistry together to make the patient's experience better for generations to come … so, LET'S WORK TOGETHER.
If you want to learn more about ensuring endodontic success in all step-- from diagnosis to obturation--please contact me or consider attending one of my one- or two-day hands-on courses.
Diwakar Kinra, DDS, MS, received his dental degree in 1999 from the University of Michigan, and his master's degree in endodontics from the University of Detroit-Mercy in 2004. He began his solo private practice limited to endodontics in Flint, Mich. He has lectured domestically and internationally on practice management and endodontics since 2007. For more information, contact Dr. Kinra at [email protected].
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