After reading this chapter, the student should be able to:
Evaluate the multiple factors that determine case difficulty and potential need for referral.
Identify the indications for referral to an endodontic specialist.
Explain the major differences in predoctoral training in endodontics and advanced specialty training in endodontics.
Describe differences in quantity and type of endodontic treatment performed by general dentists and endodontists in the United States.
Describe the optimal methods of communication between the general dentist and the endodontist.
Define the standards of care for endodontic treatment.
Identify the important elements of record keeping with respect to endodontic treatment.
Dentistry is one of the most trusted professions in the United States, routinely ranked among the top five in surveys that ask the public to rate the honesty and ethical standards of people in different fields. This high level of trust has been earned by generations of dentists who have consciously chosen to act in their patients’ best interests. Perhaps nowhere else in the practice of endodontics is the responsibility to act in the patient’s best interests more relevant than initial evaluation of case complexity and deciding whether to treat or refer to a specialist. The American Dental Association (ADA) Code of Ethics addresses the duty to refer, when indicated, by stating: “ The dentist’s primary obligations include keeping knowledge and skills current, knowing one’s own limitations and when to refer to a specialist or other professional…” .
Although the definition of standard of care still varies somewhat by location, most states have moved away from a local, experience-based standard of care to acceptance of a national, evidence-based standard of care. The standard of care for endodontic therapy is the same for specialists and general dentists; therefore, if case difficulty assessment determines that the procedure is beyond the level of skill and experience of the general dentist, referral to an endodontic specialist is indicated. This chapter provides an overview of specialty training requirements, standard of care, communication between general dentists and specialists, and a more detailed review of evaluation of case complexity. The American Association of Endodontists (AAE) Endodontic Case Difficulty Assessment Form ( Fig. 6.1 ) will be presented with guidance for clinical use.
Advanced Dental Education Programs in Endodontics
Endodontics is one of the nine specialties recognized by the ADA. Specialty recognition is currently in a state of flux in the United States. To reduce potential bias and conflict of interest in the recognition process, the ADA recently supported the formation of an independent specialty recognition body, the National Commission on Recognition of Dental Specialties. Another independent specialty recognition board, the American Board of Dental Specialties, was also recently formed and recognizes four dental specialties that are not currently recognized by the ADA. Ultimately, it is under the purview of each individual state to determine which dental specialties to recognize.
Specialty recognition is separate from the actual accreditation of an advanced dental education training program. Advanced dental education programs in endodontics are accredited by the Commission on Dental Accreditation (CODA) and have specific and rigorous clinical, didactic, research, and teaching requirements. Programs are between 2 and 3 years in length, with a minimum of 24 months. Completion of a CODA-approved program in endodontics is required to announce specialty status in endodontics.
Communication Between Endodontists and General Dentists
According to the most recent ADA summary of dental services, in 2005 to 2006, there were 22.3 million endodontic procedures carried out, with general dentists performing 68.2% and endodontists accounting for 25.4% (the remainder carried out by other specialists). These trends are little changed from the ADA 1999 study, which reported 75.2% and 20.3%, respectively. Most endodontic procedures are performed by general dentists, and for optimal patient care it is important to have a good communication between the generalist and specialist. This partnership is essential in helping patients save their teeth.
Communication between general dentists and specialists takes place in the context of the referral of urgent or complex cases, discussion of an optimal treatment plan for a patient, and/or discussion of the latest evidence for a particular procedure or material used in endodontic treatment. Many endodontists also endeavor to speak at local study clubs or regional meetings to promote information on the latest technologies and practices in the field. Most interactions occur by printed forms or letters that are given to the patient (for subsequent delivery) or sent by mail. Phone communication is a common and secure means to efficiently exchange ideas and information about the patient. Electronic forms of communication have become very common. However, many popular methods of electronic communication, such as e-mail, text messages, and online portals, are not inherently secure. Some e-mail programs permit encryption, which must be used for communication related to patients. Some practice management software programs offer online sites where information can be uploaded and viewed in a secure manner. According to the Health Insurance Portability and Accountability Act (HIPAA), there are 19 information items that constitute protected health information (PHI), which can be used to potentially identify a patient. These include the name, birth date, contact information, and health record number, among other items, and they must be kept secure to comply with the law.
What is Expected of a General Practitioner
Woodmansey and colleagues found through an online survey of 40 predoctoral program directors at U.S. and Canadian dental schools that the average predoctoral student completed an average of 5.9 root canal procedures on live patients, and only 36% of the directors felt that their graduates were competent to perform molar root canals in private practice. By contrast most postgraduate endodontic programs in the United States run about 2 to 3 years. Gulabivala and coworkers (2010) wrote a position paper published by the European Society of Endodontology stating that the minimal clinical requirement should be at 60% of the time, with a minimal number of 180 clinical cases completed.
Burry (2016) looked at a very large database from insurance companies for up to 10 years for treatment completed by endodontists and general dentists, and the data indicated that there is no statistically significant difference in success and failure for incisors, canines, and premolars at 10 years. For molar teeth, however, the results were statistically significant at 10 years, with better outcomes for teeth in treatments performed by endodontists. This data is borne out in private practice as well, with studies showing that molars are the teeth most commonly referred to the endodontist.
Clearly this is a challenging gap and therein exists a potential opportunity for better relationships between the specialist and general dentist.
Abbott and colleagues surveyed general dentists to assess their perceptions and understand the factors associated with referrals to endodontists. A total of 983 general dentists responded; 93% agreed that “endodontists are my partners for delivering quality dental care.” In that study, the highest percentage of general dentists (96%) rated communications in the form of timely follow-up reports and images as the best ways to build relationships/partnerships, followed by referring the patient back for restorative treatment (94%) and patient scheduling accommodation (92%). Conversely only 38% mentioned that signs of appreciation, such as gifts, was an effective way to build a lasting relationship. This study reconfirms the importance of communications.
Explicit written instructions, pertinent findings, treatment history, and appropriate radiographs (original or duplicate) are mailed or sent via secure e-mail or website link to the endodontist. (Asking the patient to hand-carry these materials is discouraged.) These instructions should include how the tooth fits into the overall treatment plan, including the anticipated restoration.
What is Expected of an Endodontist
Lin and colleagues looked at the relationship between the endodontists and their referrals. They looked at many different factors related to the economics of endodontics and referral base. A total of 875 endodontists responded to the survey. In terms of marketing, the majority of participants reported providing gifts (77.8%), personally visiting GP offices (76.0%), having websites (66.8%), and organizing social activities (51.9%). Some participated in local study clubs (39.7%) or had their business in the Yellow Pages (29.9%) or on Facebook (19.4%). Seven percent of participants reported having mobile app presences. Also, of interest here was the fact that the most commonly referred tooth type was maxillary molar (60.2%), followed by mandibular molar (38.8%). Almost 10% of the referral cases were referred after a procedural mishap. Almost 50% of the endodontists had performed some form of regenerative procedure.
Specialists serve both the patient and referring dentist, and their responsibilities are to both. They should deliver appropriate treatment and communicate with the practitioner and the patient. When treatment is complete, the referring dentist should receive written confirmation from the endodontist that includes a radiograph of the obturation. A note is included about how the tooth was treated, anticipated recalls, the prognosis (both short term and long term), and unusual findings or circumstances. A suggestion regarding the definitive restoration is appropriate. Before and during treatment, the endodontist explains to the patient all the important aspects of the procedure and the anticipated outcome. After completion of treatment, the patient is informed of the prognosis, appropriate follow-up care, and any possible additional procedures in the future, as well as the need to return to the referring dentist for definitive restoration and continued care.
Based on these findings, two main points become clear. First, there is a disparity in predoctoral dental education, and second, the general dentist has great confidence and belief in the partnership with the endodontist. As the pendulum shifts back to the maintenance of a healthy dentition related to our increased awareness of peri-implantitis, the generalist and specialist have a great opportunity to work together for the benefit of our patients.
Many endodontists are educators at heart, having taught in the undergraduate endodontic clinics, and are passionate about their craft. One of the best ways to nurture this relationship is through education and continuing education (CE) courses to develop the deep relationships that would strengthen and solidify these bridges and ultimately lead to a better patient experience. Fig. 6.2 shows the outline of a CE program that has worked well for one of the authors. There are many other topics, such as dental trauma, regenerative procedures, and cone beam computed tomography (CBCT), that are common areas of interest and will help with the synergistic relationship that will ultimately lead to better patient outcomes.
Standard of Care and Endodontic Case Documentation
Based on reports by the AAE, approximately 75% of nonsurgical root canal procedures are performed by general dentists, and 25% are performed by endodontists (endodontists perform 62% of molar root canals and the majority of retreatment root canal and endodontic microsurgery procedures). Although case selection plays a significant role in these percentages, it is important to recognize that there is one uniform standard of care for providing endodontic treatment regardless of whether the procedures are performed by general dentists or endodontists. Case selection is made based on proper diagnosis, factors that affect long-term prognosis, and complexity of the case being considered. Each practitioner should be fully aware of his or her technical skills and levels of knowledge to determine which cases to treat and which to refer. The AAE has developed a Case Difficulty Assessment Form (see Fig. 6.1 ) that can be used to assist dentists in assessing the level of difficulty when treatment planning a tooth for endodontic procedures.
Once the decision is made to plan an endodontic procedure treatment of a tooth, the procedural steps and quality of services provided must adhere to the same standards, regardless of who provides the treatment. These steps include obtaining informed consent based on assessment of patient history, chief complaint, clinical and radiographic examination, diagnosis of pulpal and periapical status, and clear presentation of the treatment plan, which includes prognosis as well as risks, benefits, and alternatives. Accurate record keeping is paramount in documenting that the patient has been advised of his or her condition and understands the treatment recommended, including associated risks and costs. Accurate record keeping is also important to memorialize the examination procedures that were used, as well as specific materials employed during treatment. When performing the procedures, if a general dentist encounters challenges that could jeopardize the outcome or create procedural accidents, a consultation with a specialist is advisable.
Proper diagnosis and pretreatment assessment of long-term prognosis depend on accurate and complete gathering of relevant information. Diligent review of the patient’s medical history and chief complaint provide an initial impression that can serve as guidance for next steps required to confirm a diagnosis. Even the best treatment based on the wrong diagnosis will predispose the clinician and patient to frustration and an unfavorable treatment outcome. In fact, no treatment is better than rendering the wrong treatment, regardless of how inclined the clinician is to perform services to help a patient in need. The next steps include employment of proper diagnostic tests and obtaining diagnostic radiographs.
The clinical tests currently available simply evaluate the response of an individual to a given stimulus. Thus control teeth are necessary to understand a normal response for the individual patient. For instance, some patients may have extreme sensitivity to cold with all dentition. Evaluation of a single tooth may yield a false impression of an elevated response indicating pulpitis. On the other hand, some individuals do not exhibit a response to stimulus from any teeth. In this case lack of response to a stimulus in the suspected tooth alone may falsely indicate pulpal necrosis. Inclusion of control teeth will help establish normal responses to pulp testing in unaffected teeth before testing the suspected tooth.
A complete radiographic evaluation requires multiple angulations when using intraoral radiographic images to 3-dimensionally visualize a single tooth with multiple roots, presence of severe dilacerations, or multiple canals in a single root. Further, more information can be gathered from multiple views. The radiographic image must capture the whole root and periapical structures, including the entire extent of an apical lesion when present. If apices are not clearly visible, additional images are required. All images obtained must be kept in the records regardless of quality because each angle can provide potentially beneficial information and because records must show all radiographs obtained. Bitewing radiographs allow visualization of bone levels in relation to existing restorations or caries, as well as visualization of the depth of the pulp chamber. When challenges are encountered visualizing pathologic findings (e.g., incipient periapical lesions), to diagnose fractures or to determine proximity of certain anatomic structures, CBCT scans may be indicated. Again, accurate documentation and recording of the preoperative test results are required for future reference.
The ultimate long-term prognosis of a tooth may be determined by other factors, such as periodontal status and restorability of the tooth in question. Measurement of periodontal attachment loss is critical in determining the correct diagnosis, which will ultimately dictate whether a tooth is likely to respond to endodontic treatment. Restorability may often require removal of existing restorations and caries to assess fully the remaining sound tooth structure. Patients must be informed of these considerations before initiation of treatment. Completion of endodontic treatment on an unrestorable tooth is as unethical as extraction of a sound tooth.
Once a definitive diagnosis is made and the patient has consented to begin treatment, endodontic procedures performed must adhere to the accepted standard of care. These steps include the following:
Proper and profound anesthesia. Although this topic is covered in detail in Chapter 8 , it is important to point out that most patients who express anxiety with regard to root canal therapy (RCT) have concerns about pain during the procedure. Profound anesthesia will provide a more pleasant experience for patient and clinician and will allow greater attention to performing the procedure properly.
Adequate rubber dam isolation. The primary goals of nonsurgical root canal treatment are to remove microbial contamination and to provide an adequate seal to prevent reinfection of the root canal system. To adhere to strict aseptic protocols, proper rubber dam isolation is necessary to prevent salivary contamination of the field of operation and to prevent aspiration of instruments, irrigants, or other materials. In short, tooth isolation using a rubber dam is standard of care and mandatory.
Proper biomechanical débridement. Biomechanical débridement relies on the use of endodontic files to remove debris and to enlarge the canal space, allowing penetration of irrigating solution. Although canal enlargement should be adequate to allow passive insertion of a small-gauge needle, care must be taken not to overinstrument the canals at the expense of dentinal walls (no less than 1 mm). Proper working length determination early in the procedure is essential to minimize occurrences of overextension of material or creation of procedural mishaps, such as ledge formation or strip perforations.
Use of approved materials. Mechanical instrumentation alone does not allow for optimum disinfection of the root canal system, and irrigation solutions with antimicrobial activity are required during canal débridement. Although sodium hypochlorite in various concentrations remains the most popular root canal irrigant, many new irrigation solutions have entered the market with various properties, including antimicrobial activity and/or smear layer removal activity. Because many of these irrigants can cause some degree of irritation to the periapical tissues, care must be taken to avoid inadvertent extrusion of the solution beyond the root apex, which may occur by locking the needle in the canal space.
Most obturation systems include a solid core used in conjunction with a sealer. Proper canal instrumentation and competency in techniques employed for placement of these materials is essential to prevent overextension of the materials beyond the root apex. Although relatively biocompatible, most root canal filling materials can cause irritation because the immune system in the periapical tissues may recognize these materials as foreign. Paste fillers generally are not recommended because they are more difficult to control during obturation. Further, paste fillers containing paraformaldehyde must be completely avoided.
Adequate final restoration. After completion of endodontic treatment, proper coronal restoration is critical to prevent reinfection of the root canal system and protect the tooth. Studies have shown that properly instrumented and filled root canals can become rapidly contaminated if not properly restored and exposure of gutta percha and sealer to saliva can cause rapid penetration of bacteria. Provisional restorations placed after the completion of endodontic procedures serve as a temporary seal and must be planned for replacement with a permanent restoration, preferably within 30 days. Exposure of provisional access restorations to saliva can cause recontamination of the root canal system within 30 days.
Proper postoperative care and instructions. Postoperative instructions should be provided before and after treatment to help patients know what to expect in the ensuing days. These instructions should be provided in written form because patients often forget verbal information. Additionally, adequate perioperative medications should be provided as needed. More specific information regarding medications will be provided in Chapter 9 .