May 1, 2005
by Steven J. Cohen D.D.S., Cert. Endo., Gary D. Glassman, DDS, FRCD(C)
At a recent endodontic study club meeting, we had the opportunity to discuss what endodontists often chat about. Included in the discussion were levels of busyness, new techniques and technologies being used, and the different types of procedures that we are seeing in our day-to-day practices. Before long, it became obvious that the pattern of cases looked incredibly similar and strangely unsettling. The next week’s schedules at these two different offices in completely separate areas of the city were almost identical. Three broken instrument cases, two perforations, four “blocked canals–couldn’t get any further”, and six retreatments resulting from previous failing treatments performed within the past year. How did it get this way? Judging from other conversations at our specialty meetings with our endodontic colleagues all of us have been experiencing the same profile of cases being referred to our offices.
Clinicians are feeling pressured to start endodontic cases in situations where the odds may be stacked against them to reach success. Canals appearing calcified on radiographs, severe root curvatures, difficult canal anatomy, and failing ancient silver point treatments seem to be on the menu of items that are selected for “Well, we’ll give it a try, I don’t know if I can do it, but….let’s see!”
There is often pressure from the patient’s themselves, in that they want all the work done with their family dentist and not have to travel to a specialist’s office. Of course, that is all forgotten, when the case ends in a complaint to the regulatory College.
Procedural accidents such as perforations, ledges and broken files will occur. Ouch! There, we said it, files can break–stainless steel files as well as rotary files! Here’s a little secret. They can break in our hands too. But yes, there are ways to minimize these unfortunate procedural misadventures. Separating an endodontic file is one of the worst endodontic nightmares that can occur. The clinician starts to sweat. The stomach starts to ache, and nights become sleepless. But have no fear: these procedural accidents can be prevented. Remedies, however, are available but may be complicated and technically difficult.
Properly taught continuing education programmes by skilled and experienced clinicians need to be attended in order to master the techniques adequately to provide our patients with predictable success. Judging from the snail mailings and e-mailings arriving on a daily basis, there are an abundant amount of accredited programmes to choose from.
Once learned, one must have patience in order to master conventional techniques successfully and predictably. Repetition is the mother of skill. With practice comes confidence. With confidence come efficiency, efficacy and ultimately predictability.
In 1995, we went to San Diego for micro-endodontic training using the surgical operating microscope. Ten years and six microscopes later, we find very little that phases us in what we see on the pre-operative radiographs during consultations. But what is still amazing is how the cases are referred. The response to a procedural mishap is a real study in human nature, for both the patient and the referring clinician. We are here to help. We are here to help the patient and here to help our referring dentists. All specialists are here to help!
The majority of dentists are extremely competent, conscientious, document carefully, honest with their patients, honest with their referring endodontist and appreciate their individual practice limitations. They are often surprised what a “practice builder” it is when the appropriate referral is made and all information is revealed honestly to the patient. Why not spread the responsibility to the endodontist and other specialists involved in the particular case to maximize predictability?
There are a few clinicians who experience procedural mishaps that can be divided into different categories. There is the “jumper”, the clinician who is so upset; it sounds like he/she is out on the window ledge of his/her office tower, ready to take that problem solving leap. There is the “hibernating bear”, who is annoyed at having to be woken up to deal with the problem. There is the “hide’ n’seeker”, who doesn’t even acknowledge that an instrument has separated, does not inform the patient, and sends a blank referral form with the tooth number circled and a preoperative radiograph BEFORE access is prepared and BEFORE the instrument had separated. And then of course, there is the snarling patient who presents to our office waving the insurance benefits handbook in one hand, and his/her attorney’s business card in the other.
Like everything else in dentistry, it’s all about control and case selection. Control of the operatory, control of anaesthesia, control of salivary contamination, control of the access cavity, and control of the 9mm. of space; the average canal length from orifice to apical terminus. Case selection includes treating those cases that are within your own realm and own scope of treatment. This will vary among all practitioners. If you feel you don’t have control of the above factors and the case seems to be beyond your limitations, then please consider referral. It will save you and your patient future grief and psychological torment.
So, as caring endodontic specialists, we protect our referring dentists and want to provide the patients with the best treatment possible and have them sent back immediately to their referring dentist for a post endodontic restoration.
So we talk the jumper down off the ledge, we give the angry bear something to eat and some time to wake up, and we drag the hide’n’seeker from his/her hiding spot.
We find out the pulpal status of the case before it was started (vital or necrotic – has a bearing on success!), when the perforation occurred (timing is important!) and if and what dressing was placed. The canal the problem occurred in is identified, how clean it was before the incident occurred, what size and what system the broken instrument came from, and what has the patient been told by the referring dentist.
The snarling patient is then de-fanged and de-clawed; the mishap is explained to them along with the technical difficulty of the corrective procedure, the prognosis, the cost and the treatment alternatives are all discussed. While some endodontists feel threatened by implants, this alternative should be embraced. It’s a get out of jail free card, when recommended in the right situations. Here’s a second little secret. Implants fail too… ouch (but this is a whole other discussion)!
The objective is to neutralize all the external factors and bring everything down to ground zero. Because when you get right down to it…its all about determination, the tooth, and three hours under a microscope. As endodontists, we want the patient in our corner. We want the referring dentist to succeed. We want the patient to want us to succeed.
Some days, it’s like being a junkyard dog…slowly picking and scratching away, not giving up until we get that piece of instrument out, negotiate that nasty curve, seal that unfortunate perforation or unblock that dentin laden apex to ensure clinical success and predictability and allow our patients the opportunity to retain what nature has created.
So, stop kicking that junkyard dog. He will either get meaner, gnaw through the chain link fence, or grab on and not let go. But with some patience and some time, we can tame that wild dog and walk away unscathed, without even a scratch!
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