Knowing When to Send a Case to the Endodontist

It seems counterintuitive that endodontists–or any specialist–would want to turn business away. However, there are cases that could have been handled in the general dentist’s office, saving the patient the time, trouble, and the unnecessary pain of seeing someone else.

Don’t Pass the Buck

Often, patients that wind up in the endodontist’s chair find themselves there because a case’s treatment went sideways.

“A lot of times, we find ourselves having to properly diagnose pulpal health,” Nicholas Pappas, DDS, MSD, an endodontist from The Woodlands, Texas says. “We’ll get a lot of cases that follow the cementation of a crown, and the patient was in pain before the crown prep. The tooth may not have been properly diagnosed prior to the crown being fabricated. When they see me, they’ve been in pain for 2 or 3 weeks because they’ve been going through the process of getting a crown when they should have had a root canal before any of that. Sometimes it’s actually a case where the nerve is completely dead. It’s necrotic and they’re getting a crown before a root canal is done. Any time a final restoration is being planned, it is imperative that pulpal health is confirmed with proper sensibility testing.”

Beyond one’s skill or capacity, Ryan M. Walsh, DDS, MS, Diplomate, American Board of Endodontics, and endodontist at Advanced Endodontics of Texas, observes that there is one case that should never be passed off–dodging a tough diagnosis.

“There is really 1 circumstance of a case that I don’t think should be referred to the endodontist,” Dr Walsh says. “And that’s one in which there is gross decay to a point where it’s clearly a non-restorable tooth, but the dentist doesn’t want to tell the patient to extract it, and then it gets referred to me. In other words, it is a case where it’s clearly non-restorable due to caries, but the general dentist doesn’t want to be the bad guy, so he makes the endodontist deliver the bad news.”

But it isn’t simply a case of professional courtesy; it’s for the patient’s benefit.

“Those are the cases that I think shouldn’t be referred, because you’re not serving the patient well,” Dr Walsh says. “The patient is out time and effort, having to come see me just because a dentist didn’t want to tell him to get it extracted.

Competence Versus Confidence

Often, those cases wind up at the endodontist because treatment didn’t go as planned. As a result, treatment had to be escalated.

“I don’t know if it’s necessarily my place to judge the confidence or the competence of a general dentist who’s referring a case,” Dr Pappas says. “The reason I say that is we get anterior cases, and some are very straightforward. But if the general dentist hasn’t done endo in 20 years, that slam dunk of a case may scare them. For me, it’s going to take only a few minutes to properly diagnose and to treat. On the other hand, if someone asked me to prepare a veneer case, I don’t know where I would even start.”

If the referring dentist is out of their depth, those cases can become the endodontist’s challenge.

“Some of the cases that are sent from general dentists who are confident, but not necessarily competent, can be scary referrals,” Dr Pappas says. “Because they’re sending over cases that maybe they shouldn’t have started, based on their skillset.”

“I definitely think that there are times where maybe somebody is more confident and their confidence outweighs their competence,” Dr Walsh adds. “If you’re unsure about the diagnosis, the anatomy, or any other complicating factor, it’s worth evaluating further, either with additional imaging or by referring to a specialist. Just because you can’t treat a tooth or just because a general dentist can’t effectively diagnose or treat a tooth doesn’t mean they’re a bad dentist. It just means that maybe there’s a challenging tooth or a challenging patient that’s preventing them from achieving easy success.”

After-Action Report

Once the endodontist treats the patient, the time is right to circle back and check in with the referring dentist.

“General dentists don’t like for a specialist to lecture them or tell them that they’re doing something wrong, and rightfully so,” Dr Pappas says. “That’s not a conversation that I would want as well. What I try to do is to provide as much detail about how I perform a case. When I send my report back to a general dentist, I show several screenshots of my CBCT, I describe the procedure in terms of the materials that I’m using, and try to explain the level of detail that I’m using to approach the case. I’ve had a couple general dentists call and say, ‘Hey, I was reading your notes. I’m just curious. I do some anterior endo, what do you mean by bioceramic endodontic sealer?’ And then I’ll explain why I’m using a specific sealer versus a different material that they’re using and try to be as collaborative as possible.”

The referring dentist is important to consult, but the patient must also be included in the conversation.

“I think that conversation starts with the patient, or it starts with my interaction with the patient because I never want the patient to lose confidence in their general dentist,” Dr Walsh says. “Just because a general dentist couldn’t complete a case or had a hiccup during the middle, doesn’t mean they lack competence; it just means that there was a challenging case. So that interaction usually starts with me building the general dentist up to the patient to make sure that that relationship both between the patient and the general dentist and between me and the general dentist stays really strong. And then if there is an issue to talk to the general dentist about, I want to be there as a resource for them.”

Of course, talking to the referring dentist requires a certain level of tact and diplomacy. That conversation might also be intimidating if the referring dentist is a very experienced practitioner.

“I’m 2 years out of residency, and I’m also in a practice that has been in the community for over 20 years,” Dr Pappas says. “So being the new guy on the block can be a little bit more difficult when having a conversation with an older general dentist. But again, I think if you approach any of those situations with no judgment and if the general dentist is looking for information or if they’re looking for some advice, valuable information can be shared in both directions.”

Tact may seem especially necessary when consulting with established dentists, but it works the other way, too–it may also be essential for new practitioners.

“It’s just a little different approach, because a brand-new dentist doesn’t fully know their limits yet,” Dr Walsh observes. “Sometimes those conversations are harder to have with new dentists, because they think they haven’t really had the real-world experience to hone a specific skill set. As opposed to a seasoned dentist, they’re usually aware of what they could or couldn’t find or where they got off track. So, I think it’s almost easier to have it with a seasoned dentist, because we’ve been down this road before. To have that casual conversation is easier with the seasoned professional.”

Never a Bad Case

Endodontists are vital in diagnosing tough cases, and while those cases should, ideally, have been handled by the general dentist, the entire care team has a vested interest in a positive outcome for the patient.

“Endodontists are expert diagnosticians,” Casey Turner, DDS, MS says. Dr Turner is endodontist at Advanced Endodontics of Texas. “There’s never a bad case to send because we diagnose everything from hypersensitivity all the way to trigeminal neuralgia. We don’t necessarily treat all of these cases, but at least we can help effectively diagnose an odontogenic problem or a non-odontogenic problem, and then provide that patient with the next to best step, whether it’s endodontic treatment or whether it’s referral to another specialist. Other than clearly non-restorable teeth, all teeth are worth evaluating meeting.”

“In my group practice, we all agree that we would much rather see a case, even if it’s clearly non-restorable, than have that dentist not refer the next one like that,” Dr Walsh adds. “Because each case is unique and sometimes there are things that we can do to save the tooth or there are other options or alternatives rather than rushing to extract. I never think there’s a bad case to refer to an endodontist. I think we’re excellent diagnosticians and we can help route the patient to the next step, if we can’t save the tooth predictably.”

As specialists, endodontists not only serve the patient’s treatment needs, but they also have an opportunity to provide an educational resource for the general dentist.

“If I’m a general dentist and I’m looking at an article like this, the question I would want to know is how can I get my endodontist to explain how to do simple procedures in a way that I can implement into my practice?” Dr Pappas says. “I think general dentists are sometimes afraid of that, because they think that endodontists are wanting to do all these cases and say, ‘I’m not going to tell you my secrets.’ I’d be much happier if my community is getting endodontic treatment done properly the first time.”

While not every case, needs to be referred to an endodontist, if the general dentist fears that the case may be out of his or her depth, it’s better to refer the patient to an endodontist sooner rather than later.