All are realities and all may be inevitabilities to everyone! What is difficult to ignore and difficult to escape is the current global economic environment. Newspapers, magazines, television and Internet news sources at this time are filled with little else than the financial downturn. In endodontics, we are not isolated from its effect. Endodontists are experiencing a diminished number of referrals especially in large metro areas. Fewer patients believe they can spend disposable income on root canal treatment opting instead for extraction in the short term. In addition, lost insurance benefits reduce the number of patients available to the general practitioner. As a result, especially from the second influence, the experience of many endodontists, at this time, is that cases that would have been referred in the past are being used to fill the schedule of the general practitioners.
As endodontists, we accept and embrace the reality that the vast majority of root canal treatment across the globe is done by general practitioners. We have lectured extensively over the past several years in over 50 countries teaching general practitioners how to perform first time orthograde root canal treatment. Teaching endodontics, to raise all skill levels is something we believe in. Through continuing education, if a clinician learns what the state of the art is, they certainly can appreciate those cases that are outside their skill level. If they are ethical and have the patient’s best interests at heart, they will refer these patients and cases to get them the best care possible, even when they insist on having the treatment done by their family dentist. The treating endodontist will in turn ensure the best endodontic outcome possible by advising the patients to return back for definitive restoration and full coverage as soon as possible. It’s a win-win for all involved!
When cases that should be referred are kept “in house” though, there is a far greater risk of an iatrogenic event. If an iatrogenic event were to occur, many cases which could have been safely and effectively treated the first time, are extracted or at severe risk of being lost in the long term because it is often not possible to subsequently retreat them back to the highest standard even if the correct concepts and techniques are later applied. For example, if a lower molar is treated with too much taper in the mesial root through excessive dentin removal, even if a perforation does not occur, it is possible that the tooth is subsequently at risk for vertical fracture over the long term. If the case were to fail and need retreatment, no amount of care and diligence can replace the lost dentin caused by the initial overzealous shaping.
There is only one best chance to create an excellent result in an endodontic treatment and that is the first time that tooth is entered. Once the natural landmarks are altered in the cleansing, shaping and obturation of the canal space, the possibilities in endodontic retreatment become more limited depending on the nature of the initial root canal treatment provided. After failure, even if the tooth can be saved, retreatment rarely leaves the tooth in better condition than that which would be found if it had only been treated once. In any event, if the case fails, it imposes a cost in time, money and discomfort onto the patient that would otherwise likely may not have been necessary.
The single biggest reason that we see patients leave their general dentists is a lack of referral when it is indicated. In other words, if a tooth should have been referred and was not, when the patient finds out that their root canal has failed, and in the worst case scenario finds out that they have an iatrogenic event present and did not know, they are rarely pleased. Trust is lost between the clinician and patient and that is a trust that is difficult, if ever, to be rebuilt. In the long term, a productive relationship is a lasting one where ultimately, the patient has the general practitioner perform the indicated work within their skill set over the long haul and has comprehensive care as a cornerstone. Viewing any case as a short-term production fix to fill a hole in the schedule where there may be a better treatment alternative is ultimately never successful. If a case is not treatment planned with longevity in mind, the possibilities and probabilities for both a successful result at all levels are most certainly diminished.
How then could a clinician improve their technique to treat more cases and not refer arbitrarily? It is not realistic to refer all cases that might be at the edge of a clinician’s skill level. Several easily adapted strategies are possible. Integration of new technology should not be intimidating or particularly daunting but can be planned and integrated with intention over time. For example if the clinician wishes to integrate the nickel titanium rotary files into their every day armamentarium, they can hone their skills with attendance at any number of hands on courses as a starting place. Practice on extracted teeth is another excellent way to develop fluency in dealing with a new instrumentation system or technology. Watching an endodontist will allow the clinician to pick up a host of tips, tricks and strategies in a clinically relevant manner. In any event, the astute clinician can find any one of a number of outlets for learning that can responsibly teach them how to utilize new concepts and integrate this technology. Coincident to this learning is an affirmation of the vital importance of lighting and magnification to the treatment process, in the form of a surgical operating microscope (SOM). The improved tactile and diagnostic control possible with the SOM cannot be overstated relative to the naked eye. It is a precursor to treating all of the aforementioned cases at the highest possible standard.
Finally, it bears asking, what makes a great referral? First off, there is the obvious information such as tooth number, whether the referring doctor wants a post space and/or build up. What is especially important is information that might inform the specialist as to any unusual findings that may affect treatment. For example, does the patient have pain and/or swelling? Has any medication been prescribed? Had endodontic treatment been initiated? Has a procedural accident occurred such as perforation or separated instrument? It is easy to envision a referral made without enough information but difficult to envision a referral made with too much!!
Despite the downturn, our ultimate duty is treat our patients, as if they were our family members and refer the cases that are outside our comfort zones and skill levels. Enhancing these comfort zones and skill levels through continuing education is one of the spices of dentistry and sweetest means of making our careers as fulfilled and enjoyable as possible. Profitability in such a crucible can only be one step behind.
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It is easy to envision a referral made without enough information but difficult to envision a referral made with too much!!
