Oral Health Group

The tooth needs a root canal, should I treat this patient? PART III OF III

September 1, 2005
by Rich Mounce, DDS

This column will continue a discussion initiated in Part I (June ’05) and II (Aug. ’05) of this three part column, which addressed the factors that go into creating better communication and trust between doctors and patients with a simultaneous eye toward helping doctors avoid unnecessary patient management problems. Specific factors that can help identify problematic situations were detailed in part two. The discussion is finalized here in part three.

Does the patient communicate in a manner that it is clear that they understand what you are saying and are assimilating the information being given? Does the patient interrupt you when you are speaking?


The worst of all worlds is for the clinician to assume that the patient understands what they are being told and the patient does not. For example, it is imperative that the patient understands that they will need to get a crown build up and a subsequent crown after the root canal. If the patient doesn’t clearly understand this, they might let the tooth go unsealed after endodontic treatment. Such a tooth will be subject to coronal microleakage that causes the endodontics to fail. In this scenario, now the patient is in the unenviable position of having to either have the tooth removed or retreated, again at significant cost. Unless specifically instructed by the referring doctor to not place a build up I generally place a bonded core material such as Core Paste (DenMat, Santa Maria, CA, USA) most often without a post. Bonded obturation techniques such as Resilon and RealSeal (Resilon Research, Madison, CT, USA and SybronEndo, Orange, CA, USA) offer some resistance to coronal microleakage but ideally are complimented with a bonded core build up.

Has the patient put limitations on the procedure that limit your ability to achieve the best possible long-term result?

It is not unknown to have a patient come in with a completely unrealistic notion of how long a procedure should take or what the procedure should involve. For example, if the patient refuses to have x-rays, use the rubber dam, sit back in the chair far enough, open wide enough, wants a 4 canal molar done in 30 minutes, etc., a significant impediment to clinical excellence has been created. To treat such a patient is akin to boxing with one hand behind your back, simply don’t do it. It is important for the clinician to have all the variables aligned to allow them a platform with which to achieve their best work for the patient. Refer such a patient or have them find someone they can work with via the local dental society. Life is too short to work with such patients, especially when their cooperation is physically, mentally and emotionally possible and they have no challenge that would limit them. Cooperation is most often a choice, work with patients who chose to help you do your best work for them.

Have you taken the time and effort to get to know the patient?

Again, while this might be slightly outside the regular scope of the column, when treatment is performed with profit and speed as the predominant guiding values, it is very challenging if not impossible for trust to be established with many patients. Such an environment would include clinicians treating multiple patients at one time (having more than one patient under the rubber dam at one time, etc). Each of us would have to honestly ask ourselves whether we would like to sit and wait under a rubber dam for another clinician who we know is in the next operatory working on another patient. The golden rule, “Do unto others…..” applies.

In conclusion, establishing trust and determining which patients can and should be treated based on the ability of the clinician to establish rapport is essential to the long-term success of any given procedure. 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.

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