Charlie Nicholas considers how to decide whether to treat or refer.
It is fair to suggest that from a GDP’s point of view, endodontic treatment is rarely a favourite and is something some want to avoid altogether. Having gone from a GDP who dreaded performing root canal treatment to a happy referral endodontist, I have run the gamut.
So, what changed my mind? It was the result of gaining a better understanding that there is more to endodontics than we are taught at undergraduate level; that prudent case selection is key to help build confidence and skill, as is having the right tools for the job and that all-important ‘c’ word – communication.
Communication and cost
At the heart of every successful treatment is effective communication – you do not need me to tell you that. Yet there is something about endodontics that makes it all seem slightly trickier.
It is tempting to be swayed by your patients’ preferences, which will often be to have you perform any treatment for three main reasons:
1. They trust you
2. You are cheaper than a specialist
3. They do not want to go to another practice or see someone else with whom they are not familiar
These are issues that can easily influence us, and if you feel up to the job, then great. If not, there is some talking that needs to be done, so that your patient knows exactly the situation you both find yourselves in. You must make sure that the patient’s expectations align exactly with your own.
Assessing the case together
In many ways, it is not for the dentist to make the ultimate decision about whether they or a specialist treats the patient. Rather, it is the job of the dentist to present all the options and let the patient make the choice.
That said, there is still clearly a need to assess the case, so that an informed decision can be reached in partnership. Proper treatment planning comes with proper diagnosis.
There is a lot of skill involved in every diagnosis we make. We can all read that classic endodontics bible, Pathways of the Pulp, which offers great insight into theoretical treatment. However, in the real world where we have to deal with patients and their feelings, it’s a totally different story. What patients say is important, but it is far from everything we need to know.
Some indications are clear – you might see obvious lesions if you take X-rays. However, then there are nuances to diagnosis – and therefore treatment planning – such as whether the tooth is restorable, or a patient might be on a medication that affects the choices we make, such as bisphosphonates.
How a dentist moves forward from each patient’s diagnosis will depend upon their confidence, experience, and expertise. This needs to be explained to each patient in terms they can understand, because every one of them will have different expectations. I have had patients who think a 10 per cent chance of success is great, and others who think a 90 per cent success rate is not good enough.
Again, communication and expectation are key to deciding about whether to refer.
Getting equipped
A lot of the pressure dentists face when it comes to endodontics can be eliminated if quality instruments with an easy to follow, sensible protocol are used. If they do what they say on the tin, and they produce consistent results, then that builds confidence.
Having to apply rubber dam, administer local anaesthetic, gain the best view of the treatment area, and use magnification can be a daunting process. Individually they might not worry a dentist, but together they can cause anxiety. However, if you create a consistent protocol and workflow that you can rely upon, it makes a huge difference to confidence levels.
In addition, not everybody wants access to lots of different file systems; it is perfectly reasonable simply to want one file that is pre-sterilised, user-friendly, easy to handle, flexible, wear-resistant, and able to create the appropriate shape to the working length.
If we take the VaryFlex reciprocating file (VFR) as an example, one file does it all. They come pre-sterilised in a blister pack, have incredible flexibility due to the heat-treated nickel titanium alloy, and a 11mm shank, which is shorter than usual, making working with them very comfortable and easy.
If things go wrong
Sometimes, even with the best will in the world, things go wrong during endodontic treatment. Here, rule number one is do not panic!
The great thing about endodontics is you can stop it at any time. If you have been sitting there for two hours looking for a mesial canal in a lower molar and you just cannot find it, there is nothing wrong with sealing everything up and saying, “Let’s see how things go. This is a real challenge.” So, down tools, seal it up, send them away, get them back in a week’s time when you have a completely fresh brain and fresh eyes.
If something does go wrong, for instance you think you have perforated a tooth or you have fractured an instrument, the most important thing is to explain to the patient what has happened. Breaking an instrument or perforating a tooth is not negligent in its own right. It can be, but, even if you have gone through the correct processes, it happens.
You may be able to correct the situation yourself but, if not, a professional relationship with a specialist endodontist is key at this juncture, as you can call them up and get guidance as to what to do next. If the advice is that the patient now needs to see the specialist, that is not the end of the world. In my experience, in fact, it often makes the patient feel very special.
Once more, and I cannot emphasise this enough, effective communication will see you through any circumstance. Be honest, be open and be clear, and you and your patients will be fine.