When you make the decision to refer a case for Endodontic treatment, you are making the referral because you believe it is in the best interest of the patient. Whether you refer all of your endodontic cases, select cases, or only very difficult cases, these tips will apply to you. The key is good communication. Yes, it is a cliché, but it really is very important.
I know you are a busy clinician. You may not have time to write a comprehensive case report. But just circling a tooth on a referral pad or sending one periapical film is simply not good enough. You need to make the Endodontist part of your treatment team. Writing an Rx for "an endo" - ie/ dispense 1 endodontic treatment on #16 (just like a pharmacist dispenses medications) is unfair to your Endodontist and to the patient. There is a lot more involved. With this in mind, this month's EndoFax will examine ways to assist you in optimizing the Endodontist-Referral relationship.
1. Use the space provided on the referral pad or online referral form. Be as complete as possible with any pre-treatment notations. This includes things like: Difficult to anesthetize, apprehensive, gagger, TMJ or medical problems, medications. Are they a bruxer? etc. If you are too busy to do this yourself, have your assistant make the notations on the referral pad for you. The more information, the better. It takes just a few moments but it makes a huge difference in preparing for examination and treatment.
2. Take a second periapical radiograph at a slightly different angle and include it with your referral. Always take a bitewing film to examine crowns. Caries under crown margins are often only visible in bite wing films.
3. Provide a minimal restorative history of the area - Which teeth were worked on in the past 6 months? Was there a M-D crack originally? Give the endodontist an idea of what is under the restoration - deep base, near exposure? Is that amalgam or prefab/cast post in the canal space? Indicate what type of cement was used for the posts.
4. Triage the patient. Place the treatment in perspective with the patient's overall needs. The patient may have an endodontic problem but is this really a priority in this patient's mouth? Other problems such as chronic generalized periodontitis, major occlusal problems that prevent adequate hygiene, grossly poor oral home care and a history of unrestored endodontically treated teeth all suggest a poor long term prognosis. Do we really wish to expend major funds treating one tooth while the rest of the mouth goes untreated? If you are not sure, consider performing emergency treatment until a comprehensive treatment plan can be made.
5. Indicate exactly what you have planned for the post-endodontic restoration and always discuss this with the patient before the referral. Patients get upset when they are referred for treatment without having been told that cuspal coverage is required for posterior teeth. In some cases longer-term temporization may be necessary after the endo is completed. e.g./ patients wish to wait for the next calendar year for a crown. It is essential that this be known before treatment starts so that arrangements can be made for you to protect with tooth with a core or band.
6. Financial or insurance considerations mean that preauthorizations may be necessary. (This is especially important with retreatment.) Please provide this information to the Endodontist prior to patient arrival. It is easily done by phone call, fax or E-mail.
7. Periodontal considerations. Does the tooth need crown lengthening due to fracture or deep decay? Does it have a potential periodontal, muco-gingival or furcal involvement? One advantage of my office is that a Periodontist is just two floors away and is available for immediate consultation at the endo exam appointment. We can even make arrangements for coordinated endo/perio treatment on the same day. This means more convenient treatment for patients and faster healing time.
8. Always discuss possible treatment alternatives with the patient before referral. For example, in cases where radiographs indicate retreatment is needed, disassembly of the case (removal of the post and core crown) will often be required before conservative retreatment can be performed. Otherwise, surgery will be necessary. Patients need to know the possible financial consequences of this before they are referred. This includes extraction and prosthetic replacement.
9. Sometimes the tooth is not salvageable. If you prefer that an Oral surgeon perform your extractions for you, or a Periodontist place an implant, please indicate your clinician of choice. My office will be pleased to contact you if this is necessary and keep this information on file for future reference.
10. Get a can of Endo Ice and use it to test all suspected necrotic teeth. Establishing the vitality of the tooth is central to diagnosis and referral. There is nothing more frustrating for the Endodontist and the patient than to make a vital diagnosis of a suspected necrotic tooth less than 10 seconds after the patient sits in the chair. Patients often get angry that the test was not performed by the referral and even more frustrated when they are informed that they now must reschedule with a Periodontist because the problem is periodontal, not endodontic. There is no reason why any clinician should not have cold tests in their office. If you don't have a can of Endo Ice, get one. Its cheap, it works reliably and it's also great for checking for adequate anesthesia of a tooth when performing routine restorative dentistry.
The Referral of Last Resort - Bail me out !!
Even the most cautious clinician can be faced with problems such as broken instruments, perforations and blow-ups. It is important that the referring clinician be totally honest with the Endodontist and the patient at all times. (Endodontists hate surprises!) This also means informing patients of any problems encountered during treatment. It is not only important for the referral; it is essential to cover your legal requirement for informed consent. Remember, unlike the General Practitioner, the referral specialist has two clients to keep happy - both you and the patient. It is sometimes a tricky balancing act, especially when things have not gone as planned. The endodontist must not only salvage the case at this point, his job is also to help protect the reputation of the referral. We do this by explaining the problem to the patient in a manner that places the referring dentist in the best possible light and then reassuring the patient that the appropriate referral was made.
Single Appointment Diagnosis/Treatment cases
During the past 15-20 years, Endodontic treatment has moved away from a multiple appointment protocol to single appointment treatment in many cases. I believe almost all teeth can be treated in a single appointment (if given sufficient time). This includes vital and necrotic teeth. Many of my referrals have taken advantage of this. Rural patients who often must travel several hours by car to see me especially appreciate it. However, in order to schedule such appointments, we must be sure that Endodontic treatment is needed. A well-angled pre-operative periapical radiograph must be received before treatment is scheduled. The tooth must also be restorable and periodontally sound. All the above listed factors must be taken into account and restoration of the tooth must have been discussed before treatment is performed. If you are not sure, send the film and report. Then discuss the case with the Endodontist on the telephone before scheduling the appointment.
The Best Patient is the Fully Informed Patient
It is time for your office to connect to the Internet. In the September MDA Bulletin, The Registrar wrote that many patients were phoning the MDA offices for information they were unable to obtain from the treating dental office. The callers indicated that dentists were often "too busy" to answer questions about treatment and options!! This is unacceptable in our profession. One of the best ways to educate patients is to provide a web site that describes you, your office, policies and treatment. It doesn't have to be fancy or expensive. But it does mean that your office must be "wired" and able to accept E-mail. (I am amazed at how many patients have access to the internet as opposed to how few dentists do!!) Most of us have a cable TV connection to our offices. For a small additional monthly cost, an invisible high speed telephone DSL line or cable modem or can be installed that blows away your dial up modem and does not tie up a phone line. Once this happens, a whole new world of possibilities (besides E-claims) will open to you. E-mail patient appointment confirmations and recalls, referrals by the internet, digitized images and films, the possibilities are endless. If you are not availing yourself of the technology to improve communication with you patients and referrals, then you are not providing the best service to your patient.