We have had the privilege over the past 10 years to write more than 100 articles
on different aspects of endodontics. Topics have ranged from the latest techniques
and technology, to debunking some of the myths surrounding endodontics.
However, we have never specifically written about the special relationship that
exists between the general dentist and the endodontic specialist. Consequently, we
believe the time has come to evaluate this relationship and we would like to discuss
it from a few different perspectives.
The first perspective, and perhaps the most significant one, is the need for the
general dentist to work within a comfort zone. This is a zone that obviously varies
from one clinician to another. However, it makes little sense to attempt a root canal
in cases that are beyond your skill and experience level. Don't try to be a hero.
These cases will ramp up your anxiety level, generally require extended time and
energy and often prove to be non-profitable. In the long run the majority of these
difficult cases wind up being referred anyway, so be honest with yourself and do
what is in the patient's best interest from the outset.
Previously, we have recommended the AAE Case Difficulty Assessment Form
(www.aae.org) and it is a good place to start. The Assessment Form ranks the various
cases in terms of difficulty and will give you a heads-up for specific cases. Some
of the warning signs noted are calcified and ledged canals, severe curvatures and
retreatment cases. These are all good cases to refer but there are additional cases
(not addressed in the form) that might be troublesome and, in fact, are not related
to the specific anatomy of a tooth.
The first of these are elderly patients (or medically compromised individuals)
who cannot sit in one position for any significant period of time. These cases
require speed in addition to skill, and we believe they are best served through the
Another group that frequently merits referral is difficult patients. The old bromide
that says, "bad things happen to bad patients" is too often true. As endodontists,
we frequently see floor perforations that have occurred as the result of a
dentist trying to get into the pulp chamber (of an endodontic tooth) on a difficult
patient. Furthermore, difficult patients are many times best treated in one appointment,
which helps to minimize the experience for both the patient and the doctor.
Another patient group that warrants consideration for referral is anxious or
phobic patients, where one can appreciate that the treatment itself might very well
be comprised because of the level of anxiety of the patient. Root canal treatment can be difficult under the best of circumstances, so to compound the technical
challenges with emotional ones makes no sense. Identifying your own comfort
zone is equally important in making the decision to refer. The best time to refer a
difficult case is before you start it. This is why it is so important to get an angled
X-ray (or image) of the tooth before you begin the case. Take your cone head and
move it about 15 degrees to the mesial. Moving the cone head in such a manner
will allow you to separate the roots of the tooth in question. Additionally, a good
angled X-ray will help identify the periodontal ligaments that surround the multiple
roots. It will also help identify bifurcations and apical delta formations. In particular,
this is a great way to identify deep furcations in mandibular premolars. A
deeply bifurcated premolar is perhaps the most difficult endodontic case and it is
one usually best referred to a specialist.
Another example where a referral to a specialist is indicated but might not be so
obvious is the difficult diagnosis case. The most difficult part of endodontics is not
a curved canal. It is diagnosis. Furthermore, it is not the typical run-of-the-mill
cases. When a patient presents in pain and the diagnosis is not apparent, rather than
have the patient return to your office multiple times, refer them to your endodontist.
It is very important that you have a working relationship with your specialist
that includes his or her willingness to see your emergencies immediately. This does
not mean the next day or the next week. We have no tolerance for endodontists who
will not see emergencies in a timely manner… and nor should you.
There is a wonderful old axiom in endodontics that states, "When you are lost,
stop and take an X-ray." This can be extrapolated to a new axiom that states, "If
you cannot reproduce the chief complaint, stop and refer it to a specialist." This
will make your life a whole lot easier and your patient will appreciate it.
Another aspect of the general dentist-endodontist relationship and one that
receives little attention is the ability to perform appropriate emergency treatment.
Once you have proper anesthesia, you can handle emergencies. Seeing emergency
patients and treating them in the proper manner can be a huge help in establishing
your practice and enhancing your relationship with your specialist. The key is to
deliver the appropriate treatment for vital and non-vital teeth. Consequently, the
first thing you need to determine with your patient is whether you are dealing with
a vital or non-vital tooth. As a general rule, vital teeth can be handled with a pulpotomy
while non-vital teeth require a pulpectomy. Let's take a closer look.
Vital teeth: In these cases a pulpotomy will work, although in molars we also
recommend removing the inflamed tissue from the largest canal (such as the palatal
or distal) in conjunction with the pulpotomy. Do not put files down into each of
the canals, unless you plan on removing all the tissue. If you put a file into an
inflamed canal you have just committed yourself to a pulpectomy.
Non-vital teeth: If the tooth is necrotic, you really need to do a pulpectomy. A
great benefit of rotary instrumentation is that a pulpectomy can be accomplished
quickly and efficiently. You need to remove as much of this necrotic material as
possible at this initial visit. However, even a partial pulpectomy accomplished with
one or two rotary instruments will often suffice. Following the pulpectomy, we recommend
filling the canal with calcium hydroxide, a cotton pellet and an appropriate
temporary dressing. Also, do not forget to adjust the tooth.
The final perspective is communication with your endodontist. This is important
for both parties. The specialty of endodontics is referral-based and the
endodontist should be willing to reach out to his or her referring doctors. The doctor
should be approachable and willing to share his or her experience. Your endodontic specialist should be an education resource to you, his or her referring
doctor. While it might seem obvious, the lack of communication between general
dentist and specialist can often have unforeseen consequences.
For the general practitioner, part of creating a good relationship with the specialist
is not to just send them cases when something goes wrong, such as perforations
or broken instruments. It really does help to refer these difficult cases before
you start definitive treatment. It is also wise to be honest. As we like to say, "Don't
deceive your attorney and don't try to deceive your specialist." If you break an
instrument or think you might have ledged a canal, inform them in advance. It
makes it easier for endodontists if they know what's going on when they initiate
treatment and they are going to discover the truth during the course of treatment
anyway. Being up front and honest accomplishes a better relationship between
both parties based on trust. The establishment of trust is the foundation on which
all referrals are based.
The relationship between the general practitioner and the endodontist is
indeed special and to summarize this, we asked Dr. Jerry Cymerman, an endodontist
with more than 25 years of experience, to comment:
The general practitioner and the endodontist must realize that they are on the
same team. The endodontist really must be seen as an educational resource, not just
as a clinician, and it can be very constructive if the specialist can help the general dentist
do the straight-forward cases in the best manner possible. I also believe that the
endodontist needs to be on the same frequency as his referring doctor, when it comes
to restorative needs. In fact, I have a referring doctor who wants me to do all the necessary
things required, so that when the case is returned to him, it is (in his words)
'ready to go.' I cannot recommend strongly enough that
the general dentist needs to communicate their restorative
needs to the specialist, before the root canal is initiated.
As has been previously stated, endodontic diagnosis can
be a real challenge for even the most experienced dentists.
I also recommend the AAE Case Difficulty Assessment
Form as a guide in case selection for the general dentist.
This form, as well as other information on endodontics, is
available on the American Association of Endodontists
Web site (www.aae.org). When the case is beyond the scope
of general practitioners, the endodontist has the experience
and technology to provide exceptional treatment. We use
cone beam computer tomography in our office to aid in
diagnosis and treatment. This technology is extremely useful
in the diagnosis of lesions not apparent on two-dimensional
radiographs, in evaluating traumatic injuries, root
resorption, root fractures, previously treated cases and
patients scheduled for periapical surgery. Our goal is to
preserve the natural dentition and to assist the general dentist
in treatment planning.
The general dentist-endodontist relationship is a
relationship based completely on trust and the knowledge
that the ultimate goal is the same for each party – superb treatment of the patient.
|Dr. Dennis Brave is a diplomate of the American Board of
Endodontics, and a member of the College of Diplomates. Dr.
Brave received his DDS degree from the Baltimore College of
Dental Surgery, University of Maryland and his certificate in
endodontics from the University of Pennsylvania. He is an
Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas
Odontologic Honor Society Member. In endodontic practice for more than 25
years, he has lectured extensively throughout the world and holds multiple
patents, including the VisiFrame. Formerly an associate clinical professor at the
University of Pennsylvania, Dr. Brave currently holds a staff position at The
Johns Hopkins Hospital. Along with having authored numerous articles on
endodontics, Dr. Brave is a co-founder of Real World Endo.
Dr. Kenneth Koch received both his DMD and certificate in endodontics from
the University of Pennsylvania School of Dental Medicine. He is the founder and
past director of the new program in postdoctoral endodontics at the Harvard
School of Dental Medicine. Prior to his endodontic career, Dr. Koch spent 10
years in the Air Force and held, among various positions, that of Chief of
Prosthodontics at Osan AFB and Chief of Prosthodontics at McGuire AFB. In
addition to having maintained a private practice, limited to endodontics, Dr.
Koch has lectured extensively in both the United States and abroad. He is also
the author of numerous articles on endodontics. Dr. Koch is a co-founder of Real