In my 12 years in dentistry, I have been on both sides of the specialist/referral relationship. For the past eight years as an endodontist, I have given many lectures on this relationship to my specialist colleagues. After having the pleasure of presenting this year at the American Association of Endodontists, it became even more obvious ... all of our lives would be easier if we communicated openly and honestly with each other. For this to come to fruition, we need to follow three simple rules:.
Rule 1:Don’t make it hurt.
Perform an endodontic diagnosis before all restorative procedures. This will save all our backsides when the patient comes back a few weeks later and says, “Doc, it didn’t hurt until you worked on it!” If we assume that the average practice has 1,000 patients, each with 20 teeth, that’s an astounding total of 20,000 teeth. If we misdiagnose just 1%, that equates to 200 teeth! Therefore, when a patient is referred to the specialist’s office before the crown preparation for a root canal, it’s easier to explain the need for treatment rather than one month after permanent crown cementation.
Rule 2:Don’t perf!
There are those days and patients where the only place to perform emergency root canal therapy is in your office. Performing the perfect molar pulpotomy can be a great service to the patient and allow for subsequent referral or return for finish. If done poorly, it can be a great disservice to the patient, a poor practice builder, and a source of tension with the specialist. Use these two instruments to remove the coronal pulp tissue, keep you out of trouble, and make everyone happy (Figs. 1 and 2).
Use the Endo Access bur at a predetermined length (marked with a Sharpie® permanent marker) so not to perforate the furcation (Fig. 3).
Once accessed, switch to the Endo-Z to safely and efficiently unroof the entire chamber contents and create straight-line access. At this point in the procedure, medicate with calcium hydroxide (CaOH) and send the patients on their way. If referral is your intended next step, do not instrument the canals with stainless steel hand instruments.
Rule 3:Don’t break that instrument!
There are those instances where you want to complete the moderately complex case. One of the more embarrassing experiences for the general practitioner and frustrating for the endodontist is the separated instrument and ledged canal. We’ve all had it happen, but being careful and conservative in your approach will minimize the risk. You can avoid some of the heartburn by using PathFiles (DENTSPLY Tulsa) to create your glidepath (Fig. 4).
Instead of using a series of stainless steel instruments to get to working length, use these nickel titanium rotary glidepath files. They will allow you to get to working length safer and faster. Since these files pre-enlarge the canals, your final shaping instruments are now safer since they glide to working length without canal constriction and aberrations.
By making a thorough and proper diagnosis, avoiding perforations, and minimizing ledging and separated instruments, it will make everyone’s life easier — the patient’s, yours, and your specialist colleague's. We are all in this world of dentistry together to make the patient’s experience better for generations to come ... SO, LET’S WORK TOGETHER.
Diwakar Kinra, DDS, MS, received his dental degree from the University of Michigan, School of Dentistry and his master’s degree in endodontics at the University of Detroit-Mercy, School of Dentistry. He began his solo private practice limited to endodontics in Flint, Mich, in 2004. Dr. Kinra is an adjunct professor of graduate endodontics and graduate periodontics at the University of Detroit-Mercy, School of Dentistry, as well as an adjunct professor of graduate endodontics at the University of Southern California. He is a member of the AAE, MAE, ADA, MDA, and GDDS dental societies. He recently was inducted into the International College of Dentists, serves as the committee chair for the ADA: Committee on the New Dentist, and has been chosen to serve on the ADA Institute of Leadership and Diversity. Dr. Kinra is a long-time national and international speaker on clinical endodontics and practice management. To learn more about Dr. Kinra’s hands-on courses, click here.