Diagnosis
To conduct RCTs, we need a tooth to treat and a correct diagnosis. Failure to achieve a correct diagnosis can lead to patient and provider frustration, prolonged pain, repeat and unbilled appointments, refunds. and excessive and costly chair time. We get a proper diagnosis by taking a chief complaint, as much detail as possible from the patient about their medical history, and a thorough evaluation.
We have to “put on our detective hats” to make the diagnosis, but the diagnosis can be difficult. We need to determine whether the pain is odontogenic (related to the teeth) or non-odontogenic (not related to the teeth). We know that certain conditions such as trigeminal neuralgia, sinusitis, myofascial pain syndrome, temporomandibular joint (TMJ) disorders, and other conditions can mimic tooth pain, so we need to be strategic with our questions.
Be aware that if a patient is currently taking pain medication and/or antibiotics, their pain may be masked. If the test is inconclusive, reschedule the patient and advise them not to take these medications until their next appointment.
When diagnosing, ask the right questions and establish a baseline for the patient through thermal and apical examinations (percussion and palpation). I like to know if it’s pain caused by cold, heat, chewing or lying down, or if relieved by cool water. During the thermal test with cold and hot, set a baseline for the patient. Just because a tooth responds significantly to cold doesn’t mean it’s the cause of the pain. Likewise, just because a tooth doesn’t respond to cold doesn’t mean it’s the culprit.
Try several teeth in the area where the patient reports pain. Be aware that pain can radiate. In fact, we can see referred pain from the maxillary back teeth to the mandibular teeth and vice versa. Every patient is different, so what is normal for one may be different for another. A molar may respond differently than a bicuspid, so be open to testing other teeth in different quadrants to establish this baseline. Typically, we look for the outlier, the tooth that has a strong and prolonged response to the heat test. Do your best to find the extreme value, but if you are not sure, ask the patient to return for a recheck and compare the findings, or refer to a specialist.
Case selection
In the general dental environment, you want to be smart about the cases you’re dealing with. Be careful about when to see an endodontist or oral surgeon for an extraction. Choose cases that seem clear, especially as you hone your intramural skills. Cases that may result in a small gain and are best referred to an endodontist include:
- Calcified pulp chambers
- Calcified canals, curved (dilated) roots, and canals that tend to “disappear” apically on radiographs
- Cases with large lesions at the apex
- Cases with significant bone loss
- Teeth with crowns
- Upper first and second molars due to appearance of MB2 (fourth canal) and difficulty locating these canals without a microscope
- Teeth with deep incisors
- Teeth with vertical coronal bone defects noted on X-ray
Trying to deal with these cases can lead to running out of supplies quickly, prolonged sitting time, lost profit, patient frustration, and provider discouragement.
Preparation and organization
Get to know your patients. Do some of your patients take longer to anesthetize? Do some people have high anxiety? who may need sedation or sedation before the appointment? Prepare accordingly and make sure your schedule can accommodate their needs (ie limit side books). It may take some time to determine which instruments, equipment, materials and settings work best for you. But by taking the extra time before clinical care, you set yourself up for success. Having a dental assistant dedicated to your IV cases and developing a routine with that assistant will save you time and frustration. Maximize your process time by having your entire on-board arsenal properly configured and within reach. Inserting the discs the night before your treatment gets you off to the right start.
Adequate anesthesia
This can be one of the most critical steps in gaining patient trust, improving the patient experience and minimizing seat time. Inadequate anesthesia can lead to prolonged appointment times, return visits and unhappy patients. Know your anatomy, important landmarks for proper delivery, and lesser used techniques such as the Akinosi block for mandibular anesthesia and greater palatal foramen infiltration for palatal anesthesia of palatal roots of molars and incisors. Giving anesthesia slowly to minimize pain is a good way to get patients to praise you and spread the word about how kind you are.
Isolation and use of a rubber barrier
This is another critical step that can be overlooked. When performing RCT, the goal is to remove as much tissue and pathogens in the canal system as possible, as this leads to greater success. Failure to use a rubber dam or improper isolation allows salivary bacteria to contaminate the root canal system. This defeats the purpose of the RCT as infection will lead to treatment failure. This can lead to continued symptoms, more non-billable procedures and refunds to patients. Proper isolation will keep the cheek, tongue, and lips away from you, which allows for easy access and reduced clinical time.
Access and visibility
I have access to every tooth under a microscope—yes, even numbers 8 and 9! Seeing the internal anatomy of the pulp chamber, locating the canals and the internal view of the canals provides a great sense of comfort and minimizes the risk of perforation. It also takes very little time. A microscope is a smart investment, and sure, there’s a learning curve, but it’s worth the payoff.
Think about it: wouldn’t it be more timely and efficient to access and locate channels in a minute or two versus 10, 15 or 30 minutes? The microscope is a game changer in the endodontic world. I’d say the second best option for access and visibility is loupes and a projector. Although RCT involves a certain feel and touch, you have to see and locate the channels to deal with them. Also, consider a bite block for those patients who have difficulty opening. This also provides better access.
Endodontic treatment is a profitable service when performed in the right way at the right time. However, if appointments are long, repetitive, wasteful and unsuccessful, endo can negatively impact your business model and bottom line. Like any other skill, the key to successful RCT is practice, patience and training. Sometimes, we need to slow down and pay more attention to the phases of care that take place before the actual RCT process. Remember: “Get good before you get fast, because if you get fast before you get good, you’ll never be good.”
Editor’s Note: This article appeared in the April 2024 print edition Dental Economics magazine. Dentists in North America are eligible for a free print subscription. Register here.
Mark Doherty, DMD, is co-founder and CEO of D4 Practice Solutions, owner and CEO of Commonwealth Mobile Oral Health Services, and partner of Southcoast Endodontics. He is an associate clinical instructor for postgraduate endodontic residents at Boston University Henry M. Goldman School of Dental Medicine (BUGSDM). A sixth generation dentist, Dr. Doherty is a graduate of the University of Pennsylvania School of Dentistry. He completed his postdoctoral training at BUGSDM in endodontics and root canal therapy.
