We want to help your practice thrive. Knowing that satisfied patients are the key to your continued success, we want to help you create situations where your patients are most likely to be happy with you as their dentist. Often when patients need endodontic treatment they are fearful and in pain. This can significantly decrease their pain threshold and make it more likely they will have an unpleasant treatment experience. When patients are referred to our office, the overwhelming majority report being pleasantly surprised and satisfied with their treatment experience. For those few patients who may not be satisfied, your referral to our office often preserves their good feelings toward you since an unpleasant experience did not occur in your office. Keeping your patients satisfied is extremely likely when you make the choice to refer. Please see Referring Patients to Treasure Valley Endodontics if you would like to refer your patient for endodontic treatment.
There will likely be times when you would prefer to perform endodontic treatment yourself. While each dentist’s level of comfort and skill with endodontic treatment varies, there are a few situations that are very likely to be extremely challenging for any practitioner and where a referral to an endodontist will likely benefit you and your patient. Recognizing the following situations early and referring to an endodontist before errors are created will likely provide the best result and greatest satisfaction to you and your patient.
- First and foremost, if you treat any maxillary molar and do not find and completely instrument at least four root canal systems, refer the patient to an endodontist. In most cases, the MB2 canal cannot be adequately negotiated, cleaned, and shaped until you have removed several millimeters of dentin, usually to a level apical to the pulpal floor. Without additional specialty training, an operating microscope, additional instrumentation, and extensive experience in managing this area, the risk of inadequately instrumenting or creating a perforation is great. When treating maxillary molars, experienced endodontists usually spend at least 30 minutes just to create the endodontic access and initially negotiate all root canal systems. Although treating the MB, DB, and P canals may resolve immediate pain and infection for patients, leaving the MB2 (or any other canal) untreated often results in lack of healing months or years later. Make your patient’s health and healing your highest priority and refer to an endodontist if you cannot adequately instrument at least four canal systems in upper molars.
- Calcifications: When evaluating radiographs, note the size of the pulp chamber and root canal systems. Constricted pulp spaces indicate tertiary dentin has been formed thereby reducing the size of the root canal systems. The risk of perforation and separated instruments increases with decreasing root canal size. Be very cautious, use high magnification, and instrument only what you can see while using light brush-like strokes of the bur to remove small amounts of dentin at a time.
- Uncovering the entire pulpal floor: Particularly in multi-rooted teeth, the pulpal floor often becomes covered with tertiary dentin that traps remnants of pulp tissue. When a tooth becomes necrotic, these areas are very difficult to identify (no bleeding tissue can be seen so you must distinguish between tertiary and normal physiologic dentin which can be very difficult, even with an operating microscope), but leaving them untreated provides a nutrient source for bacteria and increases the risk that long-term healing will not occur. Tertiary dentin over pulpal floors often covers additional canals and/or grooves between canals where bacteria flourish. When treating multi-rooted teeth, if you cannot completely uncover the pulpal floor (this has a grey-brown color), refer to an endodontist. Be extremely cautious to remove tertiary dentin rather than physiologic dentin to avoid creating a perforation.
- Significant root curvatures: Instrument separation and other complications become more common as root curvatures increase. Consider referring in these situations. Suggestions for instrumenting curves: coronally flare to the level of the curvature, use small hand files to create a glide path, use rotary files of a small taper (.04 usually, .06 at the most) and consider using files will small changes in tip size (e.g., ProFile Series 29).
- Blocked canals: The easiest was to manage a blocked canal is to never create one! Learn to refer difficult cases long before you create a ledge. The result is so much better for your patient in terms of time required for treatment and the healing result. In situations where canals are blocked by instrumentation errors, fractured instruments, or restorative posts, refer to an endodontist. To prevent formation of blocked canals, constantly maintain a sea of irrigant in the pulp chamber. Coronally flare each canal and create a glide path with small hand files before using any rotary instrument. Never push rotary or hand files. If a file will not go to the length you desire, it is probably catching on a calcification or sharp bend in the canal. Bend the tip of your hand file then gently work it in a twiddling (watch-winding) motion with occasional slight up-down motion until the file becomes loose in the canal before using the next larger size. Use hand files up to at least a size 25 before introducing a rotary file.
- Apical surgery: When healing does not occur following adequate root canal treatment and retreatment is not advisable, refer to an endodontist for apical surgery. Traditional techniques for apical surgery are successful only about 60% of the time whereas microsurgical techniques are successful more than 90% of the time. Given this drastic difference in success rates, apical surgery that is not performed using microsurgical techniques does not meet the standard of care.
Additional helpful information relating to many of these topics is covered in the CE Seminar entitled Optimizing Endodontic Treatment Outcomes.
