Those Who Can, Do. Those Who Can’t, Please Refer!
THERE ARE TWO SIDES to every story, two peas in a pod, and it still takes two to tango. So with the word two in mind, our office has two philosophies when it comes to endodontics. First, we have always thought that one of the best ways to help our referrers is to teach them to do endodontic treatment as we do it. Obviously, by now you have all heard the benefits of our main technique—using SafeSiders® instrumentation and EZ-Fill® obturation—over and over again! Thus again I will stress that since the bar for endodontic results has been raised in past years by the results of greater tapered instrumentation and subsequent obturation, it is absolutely necessary for you to assimilate that standard in your endodontic technique. So, of course, why not learn a system that gets you to that end point in a stress-free easy way with low risk? Not to mention, of course, that this system is additionally somewhat inexpensive compared with the other systems out there. It’s a no-brainer!
Now to our philosophy number two: to teach you when to refer. Providing the best care possible for the patient is intimately tied to doing good acceptable endodontics. Thus case selection is paramount. This is where we as your specialist come into play. To be somewhat blunt, you should not let the economics of not referring a case obscure what is actually best for your patient and ultimately best for your practice. I have had the opportunity over the past years of doing professional review to defend colleagues of mine. In all cases there is one common line in the bill of particulars that plays the same tune: failure to refer to a specialist. Now of course there are plenty of clinical circumstances in which bad things happen to practitioners with good intentions. But when an endodontic case fails because a dentist missed a canal or because a calcification made a canal unobtainable and a specialist retreats successfully, failure to refer becomes a more pertinent issue and more difficult to defend. It goes back to that raised bar I talked about earlier. Your standard of care has to be the same as that of the specialist you might eventually refer to. Please understand that I am clearly not telling my loyal readers to refer every case to your friendly neighborhood endodontist, although that would a home run, but use your best judgment. What’s best for your patient is best for your practice.
Now for something somewhat interesting! I present to you tooth number 13. Endodontics was done in 2006, and six years later, in 2012, presto chango, an asymptomatic radiolucency presented itself on routine radiographic exam (Figure 1). It was a nice root canal with a good-looking result. Tooth number 13 typically has one large central canal, and on an angled radiograph that seemed to be the case with this tooth. Good dentist, good root canal filled to the apex, yet a nice-sized PAR. Why the failure, and what’s the appropriate treatment? Retreat or apicoectomy was the conundrum. After the discussion with the patient, we decided to retreat, considering that I could always perform an apicoectomy if the retreatment did not work. All risks of both alternatives were discussed as well as the option of extraction. I re-opened the case and removed the old filling material. I took a check film, confirmed my measurement with an apex locator, and verified a centrally located canal (Figure 2). I instrumented fully, using SafeSiders instrumentation to a # 40 to the apex and a .08 taper. I grabbed the scope after copious irrigation with EDTA, and much to my surprise there was a spot on the palatal aspect of the “centrally located canal” that my explorer caught. With a # 10 file I was able to negotiate a separate palatal canal with an independent apical opening (Figure 3). Thus I had found a perfect reason for the failure of a perfectly good-looking endodontic case. Without having a scope and using it, one might have simply retreated the original canal and hoped for the best. The canal was ultimately obturated using EZ-Fill single-cone technique (Figure 4).
So, in closing, my friends, it all comes down to the fact that it’s our business and, of course, our pleasure to help you guys in any way we can. When it comes to cases that might exceed one’s clinical experience, a referral can only benefit all involved. If the case is not treatable endodontically, let your specialist be the bad guy who pulls the trigger and announces the bad news. The success of the treatment is ultimately your success. Hope your summer is fantastic. Catch you in the fall!
July - September 2012