June 1, 2005
by Rich Mounce, DDS
Did you ever start an endodontic procedure and later wish you hadn’t? If you are like most clinicians, the answer is yes. The source of this answer is either a clinical challenge or patient management issue that arose unexpectedly after starting. The prospect of having a root canal can provoke anxiety in some patients, despite modern techniques for pain control, new materials and optimal treatment strategies. For a clinician to perform at the highest level, especially in a focused endodontic procedure, trust and excellent communication must exist between doctor and patient throughout the process. I am biased to the degree that I believe that many endodontic results are determined before they are ever started.
It is very difficult to get an excellent clinical result for a patient (no matter how well thought out the clinical endodontic treatment preoperatively) when the patient is not comfortable and/or does not possess trust and confidence in the clinician. Pre-operative clinical planning, case evaluation, risk assessment, an honest assessment of ones clinical skills as well as equipment and materials are all essential elements in creating an excellent clinical result. Knowing which patients to treat (assuming that the clinical evaluation above has been done well) and which to either refer or to recommend extraction for in lieu of a root canal are just as essential. Making this latter judgment is often partly a function of the level of trust and communication that exists and sometimes amounts to nothing more than a feeling inside the clinician that some unspoken issue may arise which later will prove problematic, clinical or otherwise. With exceptions, sometimes the most profitable and well-performed endodontic procedure is the one that is referred and/or the one that is not performed. Simply put, because we can do a root canal does not mean that we always should. As an aside, while it is beyond the scope of this column, I would suggest that we as clinicians are not meant to be all things to all people and there are both teeth and patients we are not meant to treat.
What if, for example, the clinician were using a new rotary nickel titanium file system and a file were to separate in a patient with whom adequate rapport and trust were not established? Dealing with the fall out in such a clinical event can be very difficult. This underscores the importance to two separate threads (one clinical and the second patient management) that converge in such a scenario. As clinicians, we should be intimately familiar with our materials and methods and deliver the care in a personal manner, ideally on a patient who values us, and vice versa. As an aside, to help prevent this unfortunate scenario, in my empirical opinion, the K3 rotary system by SybronEndo, Orange, CA, is the most fracture resistant and efficient brand available. The file merits investigation to help prevent the clinical side of the aforementioned scenario.
Without trust and communication between patient and doctor to create this environment, especially given many peoples level of anxiety towards endodontics and dentistry in general, attaining an excellent result may be problematic if not very challenging. The practical question then becomes if the tooth needs a root canal, is this a patient I should treat? How can I establish the trust and rapport needed with these patients? Is there someone else who might be better able to meet these patients’ needs? The cost of treating patients in an environment that lacks trust and excellent communication is high. Licensing board complaints, a lack of profitability and a less than satisfactory outcome for both parties can be the outcome.
In an attempt to help clinicians to deal with these situations, several ideas and strategies, which follow in the next two columns, will be presented. I welcome your questions and feedback.
Dr. Mounce is in private endodontic practice in Portland, OR and is the endodontic contributing consultant for Oral Health.