Getting to the root cause of diagnosis

24 October 2023

Alyn Morgan considers the problem of determining case complexity and its impact on treatment planning.

Back in June, Kevin O’Connor, the White House physician, got a call telling him President Joe Biden was suffering from dental pain. Following X-rays, an initial root canal procedure was carried out (lower right premolar, tooth 29). The pain continued, and the procedure was completed in the White House the following day by the presidential dental team from Walter Reed National Military Medical Centre. The 80-year-old was not put under anaesthesia.

While the leader of a country should perhaps be made of stern stuff, many patients have preconceptions when it comes to root canal treatment despite not accurately understanding what the procedure is.

As you are aware, there are many contraindications to endodontic treatment, which include erosion of the root apex, loss of alveolar bone and lateral perforation. But another key factor is the patient’s anxiety level.

Worries about pain levels are common, though the treatment is often no more unpleasant than having a filling. However, the Adult Dental Health Survey 2009 suggests that around 51 per cent report low levels of anxiety, 36 per cent more moderate levels and 12 per cent report trait anxiety at a level that could be considered ‘phobic’.

There are recommended models of care for when you are confronted with a highly anxious patient, which tend to include the use of conscious sedation. This is a technique where the use of a drug or drugs produces a state of depression of the central nervous system, enabling treatment to be carried out, but during which verbal contact is maintained.

The Modified Dental Anxiety Scale provides a quick, reliable and robust measure to assess dental anxiety in adults. The five-point scale has specific items relating to different aspects of dental treatment (such as X-rays, use of the drill and so on). Patients scoring between five and 10 are mild; those scoring 10-18 are regarded as moderate, and scores of >19 are considered to be severely anxious.

NHS England emphasises that it is important to remember that some patients require a combination of management techniques or, perhaps, different techniques for different dental treatments.

Cognitive behavioural therapy (CBT) is a short-term talking therapy that can help manage fears by changing thoughts and behaviours. Psychologists working with dental patients at King’s College London have developed the UK’s first dedicated CBT service for individuals with dental phobia. Nine-tenths (93 per cent) of dental phobic patients who completed the course then went on to have dental treatment without the need for sedation.

Just as patients have to be assessed, so does the treatment plan. In all likelihood, Joe Biden’s case was probably straightforward, but not all are. Discussions with colleagues can help, but members of the British Endodontic Society (BES) also benefit from the advent of its Case Assessment Tool.

The BES EndoApp is a web-based case difficulty assessment tool designed to help assess the risks and intricacies of a case that requires non-surgical endodontic treatment. The algorithm takes into account various tooth and patient factors relevant to the complexity of a case. A score is generated which suggests the most appropriate management route. The clinician can then decide as to whether to treat the case or refer onwards.

Easy to use, the assessment begins with the clinician identifying the tooth requiring treatment and number of canals expected to be present. The dentist then estimates the curvature of the root by clicking on a selection of diagrams (from mild <15o to exceptional >60o). Clinicians then estimate the length of the tooth (the longest root, based on radiographic assessment) from <25mm to >31mm.

The clinician continues to input a series of details and measurements about the case, including any particular tooth factors (such as dental trauma or developmental abnormalities) or if there are any patient factors, such as health or anxiety issues, to consider.

A complexity score and expected difficulty are generated, together with a suggestion as to who the case would be best managed by (for example a specialist endodontist if the complexity score is 36 and the level of difficulty is estimated to be very high).

Developed from the original version of EndoApp, it is compatible with both desktop and mobile devices. With root canal treatment boasting a high success rate – in around nine out of 10 cases a tooth can survive for up to 10 years afterwards – ways to increase that success rate even further can only be welcomed.

References available on request.