The key is proper diagnosis and case selection. Only treat what you can treat well.
It was after dental school when I didn’t have to study for those tests that my real learning began. The more lectures I took, the more I realized that there was still a lot more that dental school did not teach me ... or I am just not smart enough to remember. I have mentored young dentists and reviewed cases for the Georgia Board of Dentistry. The one commonality these cases share has more to do with patient management than with the actual clinical dentistry. The questions that come from these young dentists and the reasons why some of our colleagues get into trouble have to do with the missing link that dental school seldom provided. Here, I will try to answer some of these questions and provide pearls or links that will enhance your clinical practice. Five-star customer service in a Christ-centered environment is the hallmark of our practice.
1. What is the most common preventable endodontic postoperative discomfort?
Pearl →The most common postop discomfort that is easily preventable is high occlusion. After the root canal treatment is completed and a temporary is in place, take a second to check the occlusion. This is more critical if the diagnosis is acute apical periodontitis. If I know the tooth needs a crown, I go ahead and reduce the occlusion. This takes the load off the inflamed periodontal attachment. An excellent preemptive pain management strategy is to reduce the occlusion and give the patient an NSAID like 600 mg of ibuprofen prior to leaving the office.
2. How do you handle a patient who needs endodontic treatment after restorative treatment?
Pearl →Any restorative dentist can attest to this scenario: The patient’s tooth was asymptomatic but needed restorative treatment ranging from a simple one-surface restoration to a crown preparation. Then, the next day, the patient calls the office in severe pain, needing a root canal. This very common occurrence can ruin your relationship with your patient. The patient is angry at you, because you are the cause of the problem since the tooth was asymptomatic. This is when the depth of your emotional bank account with the patient comes into play. Your patient will easily forgive you if the trust factor is high. You can prevent the problem in the first place if you ...
- take a periapical radiograph to check for periradicular lesion or pulpal proximity.
- pulp-test the tooth prior to a crown prep.
- inform the patient if there is a chance that he or she might need root canal therapy due to the proximity of the decay to the pulp.
- know that if the tooth has a crack, the odds of root canal therapy are high.
- consider prophylactic endodontics if the restoration is extensive or requires substantial dentin removal.
I have a standard script when I see my patients: “Your tooth had a problem even though it might not have been painful. I did all I could to take care of the problem. The treatment did not cause this problem; it only made a problem that already existed become evident.”
3. Who is your ideal referring dentist?
Pearl →Believe it or not, my ideal referring dentist is not necessarily the one who sends me the most or the easiest cases. Most specialists classify their referrals into an A, B, C system. An “A” referral is one with whom I have a relationship. These doctors view us as an extension of their practices; I don’t just hear from them when they have a crisis. They realize that we need each other; they are not helping me as much as I am helping them. Life is all about relationships - vertical and horizontal. You have relationships with your staff, relationships with your patients, and relationships with the specialists. There are plenty of root canals to be done, and most endodontists will help you do what you do well. I strongly encourage the general dentist to cultivate a relationship with specialists. They are the ones who bail you out when you run into difficulties like perforation and a separated instrument. You need a “go to” person in times of need.
4. How do you handle a patient with a treatment complication that is the referring dentist’s fault?
Pearl →This is when the relationship with your endodontist comes into play. If you do root canals, you will run into problems like perforation, calcified canals, separated instruments, and other procedural misadventures. Correcting these problems can sometimes be stressful and time-consuming. An “A” referral will call to inform me of the problems and even offer to pay the extra charges incurred in correcting the problem. My recommendations are:
- Stop immediately when you encounter the problem.
- Get on the phone, make the referral personally, and speak to the endodontist about the problem.
- Cut your losses and consider not charging the patient for the visit.
- Tactfully inform the patient about what happened and explain the course of action: “Ms. Jones, in the course of doing your root canal, we ran into some complications that I am not equipped to handle. I have talked with Dr. Brown who is a specialist and has some of the latest technology, like a microscope, to take care of your tooth.”
5. What single area can significantly improve a practice’s bottom line?<
Pearl →As stated earlier, life centers around relationships - how you get along with your colleagues, family, patients, and employees who do not work for you. The saying, “Patients do not care how much you know until they know how much you care” has become a cliché. If success to the realtor boils down to “location, location, location,” then to the dentist success is relationship, relationship, relationship. The most successful dentists I work with are those who invariably have a healthy relationship with their patients and colleagues, and even send gifts to their Patterson sales reps. They call their referred patients to make sure they are doing OK even though they did not perform the treatment. These patients will not dream of going anywhere else; they will refer their friends and family. The other extreme is patients who come in wanting us to do all their treatment and ask us to refer them to another dentist, or even filtering what their dentist tells them through us. Value your relationships and your bottom line will swell.
6. What are the preventable causes of endodontic failures?
Pearl →Coronal leakage is one of the leading causes of endodontic failures. Make sure the patient understands that treatment success is contingent on having the tooth properly restored. Research shows a root canal system becomes reinfected within 30 days if not properly restored.
Another common cause of endodontic failures is posts. Some dentists think that posts will strengthen the tooth. This is far from the truth. The American Endodontic Association recommends using posts only when necessary to retain a core buildup. With the proliferation of new, enhanced bonding agents, the need for posts is becoming less.
7. What are your feelings toward one appointment vs. multi-appointment endodontics?
Pearl →I am not too aggressive and lean more toward multi-visits, depending on the preoperative status of the tooth and the presence of an endodontic lesion. Here’s a rule of thumb: Vital cases are an excellent indication for a single visit, whereas nonvital cases with periradicular lesions and retreatment cases are not ideal for single visits. The financial benefit should not override our judgment.
8. Do you feel threatened about dental implants?
Pearl →I love dental implants. They have indeed increased my success rate. Will dental implants replace root canals? Not in this lifetime. Root canals and dental implants both have their places, and they complement each other. To push root canals where dental implants will be better is malpractice just as pushing dental implants where endodontic therapy will work is also malpractice. The restorative dentist needs to present all treatment options and then recommend what is best for the patient.
9. How do you handle a failed root canal that you treated?
Pearl →A speaker at a seminar said, “The only successful root canal is six feet below.” I thought that was heresy. But the longer I practice, the more true this statement becomes. The best-looking root canal with the entire canal instrument obturated to length still fails ... and you see a patient from Korea with a crown stuffed with cotton pellet that has been successful for more than 20 years. Endodontic therapy can be a significant investment for some patients. If the patient loses the tooth within a year due to no fault of his own, I simply refund part of what he paid to help defray the cost of replacing the tooth. For the general dentist, you will sleep well if you cut your losses, refund the patient’s money, and refer him or her to an endodontist.
10. What are your views on the technological explosion in endodontics?
Pearl →I love the new technology like my microscope, ultrasonic handpiece apex locator, and digital radiographs. All of these have made endodontic therapy a lot easier and more fun, but they do not replace science and proper diagnosis. I see a lot of procedural misadventure because dentists are not assessing the complexity of the case to meet their expertise and giving improper diagnoses. Endodontics can be fun if you pick and choose your cases carefully.
Endodontic therapy is a game that you either hate or love. Like any game, it has rules which - when violated - can lead to failure and distress. As a general dentist, if you play the endodontic game, it is best to play to the same standard as the endodontist. The key is proper diagnosis and case selection. Only treat what you can treat well.
Dr. Emmanuel Ngoh maintains a private practice, Augusta Endodontic Center, and serves as an assistant clinical professor in the Department of Endodontics at the Medical College of Georgia. Dr. Ngoh is also author of the book, “Principles of Success.” He serves as endodontic consultant with the Georgia Board of Dentistry. Dr. Ngoh can be reached by phone at (706) 869-9117, by e-mail at firstname.lastname@example.org, or visit his Web site at www. augustaendo.com.