Creating a great endodontic result depends on three essential factors, all of which must be compatible:
❶ the doctor
❷ the patient
❸ the tooth
An uncooperative patient is challenging, even for a very skilled clinician. Similarly, a cooperative patient (with or without a difficult tooth) in the hands of a relatively inexperienced clinician is problematic. Ideally, prior to initiating any endodontic treatment, the clinician should assess his or her own skills and equipment, the patient’s level of cooperation, the tooth’s risk factors, and if there is enough time to achieve the best result possible.
Obviously, it is difficult to generalize about populations. Still, my bias is that a significant percentage of the American public is dentalphobic and can be a challenge in trying to obtain proper consent in order to perform to the highest level of endodontic treatment possible. Patients who do not listen, and squirm during treatment (among a host of other, often stress-related behaviors) create a hurdle over which the clinician must vault to perform his or her best work. It is hard to do great endodontics on a moving target! Suffice it to say that, if a patient will not cooperate substantially, it is better to refer the patient, consider appropriate sedation, or simply refuse to treat the person. Ultimately, the dentist is responsible for the clinical result, and the patient’s cooperation during the procedure becomes irrelevant to the final result. One of my mantras is that I want to work on happy patients with whom I have developed some semblance of trust and communication. This gives me the best chance to perform the work of which I am capable.
Even with the best communication between patient and clinician, a tooth must be carefully evaluated pre-operatively. How often has each of us started on a tooth and then wished we hadn’t? More often than we would like to admit, I’m sure. This sinking feeling often can be prevented by evaluating the tooth in every detail preoperatively. Recognizing risk factors first, then developing a plan for their management, is far preferable to creating a preventible iatrogenic event and realizing the danger when it is too late. Having to refer a patient after access in the presence of an iatrogenic event takes all the profit and, more importantly, satisfaction out of the procedure. This is true for both the doctor and patient. In addition, the tooth is rarely - if ever - better for the misadventure.
Finally, a clinician must make an honest assessment if he or she is the best person to perform the required therapy on a patient given the clinician’s skills, experience, and equipment. If there is someone better suited to provide the patient with an excellent result, the honorable thing to do (which is also in the patient’s best interest, “Do unto others ...”) is refer the patient to someone who can complete the treatment to the highest standard possible. As a full-time practicing endodontist, I believe general dentists should do as much endodontic treatment as they can within their respective comfort levels. This said, the vast majority of retreatment I perform is done on teeth that contain both major and often completely preventable problems had the initial clinician carefully assessed the tooth. It is essential for a clinician to know thoroughly his or her equipment and techniques. For example, if a clinician is going to work with a new material such as RealSeal (SybronEndo, Orange, Calif.), a bonded obturation product I use and advocate, I would strongly advise that the clinician read the relevant literature about the material, take a hands-on course, practice on extracted teeth, and - if possible - talk to other knowledgeable clinicians about the material. Using this or any endodontic product without study and practice is a recipe for misadventure.
Of the three - the clinician, the patient, and the tooth - we can only control one factor, ourselves as dentists. While this might seem daunting, our preparation and careful evaluation preoperatively of a given situation can, in large measure, go a long way to allowing us to achieve the best endodontic result possible.
Dr. Richard Mounce is in private endodontic practice in Portland, Ore. Dr. Mounce is the author of a comprehensive DVD on cleansing, shaping, and packing the root canal system for the general practitioner. The material also is available as audio CDs and a Web cast pay-per-view. He lectures worldwide and is a widely published author. For more information, contact Dr. Mounce via e-mail at comfort@MounceEndo.com. Visit his Web site at www.MounceEndo.com.