When to Call for Help with Your Endodontic Cases

Confidence is key when providing dental care to your patients. You need to have the knowledge to effectively diagnose and treat a variety of indications. You need to instill trust in your patients. You need to avoid second guessing yourself in the middle of procedures.

But when does confidence become overconfidence? It is important for dentists to remember that sometimes a case is just too specialized to handle in house. And knowing when to forgo the hubris and call in the experts is a critical skill.

“Case selection is immensely important with respect to endodontic care,” says Rebekah Lucier-Pryles, DMD, an endodontist in White River Junction, Vermont and cofounder of Pulp Nonfiction Endodontics. “Knowledge about the procedure, and one’s own limitations with respect to endodontic care, can facilitate good outcomes for patients and clinicians alike.”

Richard Mounce, DDS, an endodontist practicing in Pacific City, Oregon, agrees.

“General practitioners (GPs) should refer whatever is beyond their skill and equipment level and only do what is in the patient’s best interest,” says Dr Mounce, “If you wouldn't treat your mother or your spouse, you shouldn't treat the patient.”

Case assessment

But how exactly can GPs assess whether the procedure is in their wheelhouse or not? Luckily, when it comes to evaluating case difficulty, GPs do not have to go it alone. The American Association of Endodontists (AAE) have resources for practitioners who are concerned about the potential challenges of a case.

“The AAE has an immensely helpful (and free!) screening tool on their website to help clinicians assess case difficulty,” Dr Pryles says. “This tool can help general practitioners consider the factors related to care and whether they feel care can be confidently provided in their offices.”

The AAE’s Endodontic Case Difficulty Assessment Form helps clinicians make case selection more consistent, efficient and better documented. The form outlines levels of difficulty, potential risk factors that could potentially complicate treatment and negatively affect treatment outcome, and other considerations to help clinicians provide quality care.

On the form, clinicians can assess how tough a case will be by answering questions about a set of criteria. Then, cases can easily be broken down and classified into minimal, moderate, or high difficulty, depending on the criteria selected in categories such as medical history, canal and root morphology, gag reflex, endodontic treatment history, or emergency status. For instance, clinicians can rate their patient’s reaction to anesthesia (with no history of anesthesia problems presenting minimal difficulty, and difficulty achieving anesthesia classified as high difficulty.)

A case that falls under minimal difficulty is a preoperative condition that will require routine complexity. These uncomplicated procedures can be successfully performed by a practitioner with limited experience. In contrast, a case classified as high difficulty would present complicated factors that would make achieving a predictable outcome challenging for even an experienced practitioner. In these cases, it’s time for GPs to turn the case over to the endodontic experts.

“If there is any doubt as to these assets (skill, equipment, time) going into the case, the case should be referred,” Dr Mounce says. “I’m a frequent expert witness [in court cases] and my desk is littered with cases where someone did not take the time to competently assess the clinical situation, carried out a flawed procedure, and ultimately had a claim made against them.”

Skill building

For general practitioners looking to increase their skills to be equipped to tackle moderate or higher-difficulty level cases, there are opportunities for education. Dr Mounce has several recommendations for clinicians looking to expand their expertise:

• Take every endo course you can; ignore the product claims and listen for the clinical pearls and principles.
• Get to know your endodontist and go watch them work. Observe their setups; there’s no reason to reinvent the wheel, so see how their operatories are laid out, how they set up and perform procedures, and observe their file sponges. Listen to how they talk to patients about complex issues, and learn to what patient concerns and reactions to expect. Pay attention to the wording the endodontists use to explain procedures while avoiding frightening their patients.
• Understand the procedures and how to explain them to patients. Make sure the patient understands what you will be doing—and why—in every case. Getting informed consent is a must for each and every procedure—but impossible to do if the patient isn’t actually informed.

In order to keep your patients informed, GPs need to have a deep understanding of the procedure and protocol, as well as the ability to perform accurate and methodical diagnosis. Identifying the problem (and the correct tooth!) is the first step towards treatment. Using a system of easily repeatable diagnostic tests can help a GP hone in on and identify diseased teeth that may not be obvious at first glance.

After you’ve done your homework, it is critical to make sure you have the right tools for the job. Purchasing the proper accessories, such as a surgical microscope, electronic apex locator, loupes, or cone-beam computed topography (CBCT) system and learning how to use effectively use them can streamline diagnosis and make procedures more accurate. Being able to magnify your field, or enhance or enlarge an image or X-ray can make identifying the trouble area much easier.

“Get these tools and learn to use them correctly,” Dr Mounce says. “It will change your life.”

Once you’ve got the tools, make sure you know where to find them and that they are easily accessible. This makes them easy to pull out in a pinch. But before you can implement these tools in the chair, you’ll need to practice. Extensive practice prepares GPs for standard cases, allowing you to create strong fundamental skills that you can build on to eventually take on more difficult cases. Additionally, building up a good understanding of tooth preparation, endo prep, and isolation will increase the success rate of cases.

“Practice extensively with your chosen system in extracted teeth,” Dr Mounce says. “Such practice includes learning to gain patency with hand files, and learning how much stress it takes to break NiTi files on the benchtop. Practice making cone fit with gutta percha.”

But even with practice and education, there are cases that should not be handled in house.And recognizing those can make all the difference to treatment success.

“Remember to slow down,” Dr Mounce says. “Sometimes the best case you ever did is the one you referred."