Richard Mounce, DDS
At least every six months, a woman will tell me that she would rather have a baby than a root canal. Telling a patient they need a root canal can be stressful for both patient and doctor. The public, despite the explosive advances that have occurred in endodontics, has a very negative perception of the procedure. This perception may cause dentists to hesitate recommending treatment or delay referral in the vain hope that the problem will spontaneously resolve. The patient may also not be ready to accept the financial implications presented by this often unexpected expense. Perception and reality diverge on endodontics as the clinical reality has never been more painless, relatively pleasant, or effective.
What then to do? Being certain of the diagnosis by accurately interpreting the patient's signs and symptoms goes a long way toward making it easier when telling patients they need treatment. A diagnosis of irreversible pulpitis is characterized by spontaneous odontogenic pain, nocturnal pain, lingering pain to hot or cold, pain to hot relieved by cold, and a tooth sensitive to percussion and chewing in the presence of these other signs. Radiographs may show a widened periodontal ligament, but not always. The patient's history is key; the radiograph in such cases often will not yet show pathology. To delay treatment because of a lack of radiographic findings in the presence of such symptoms simply puts the patient through unnecessary pain. Placing a crown on a tooth with any of the above symptoms only further damages the pulp and accentuates the problem. If a tooth has a lesion apically or laterally (symptomatic or asymptomatic), the tooth should be tested with cold to verify a lack of pulp vitality, and, if it is nonvital, the tooth should be treated immediately. Neglecting treatment or waiting for symptoms is ill advised, as such a scenario can lead to significant discomfort, swelling, difficult anesthesia, inconvenience, and the need for possible surgical drainage under sedation.
If the diagnosis is not clear or if it is unsure that the patient has an endodontic problem, treatment can be either delayed or the case referred to a specialist. As an endodontist, there are still two to three cases a year where I seek a second opinion. Waiting for symptoms to localize in a diagnostic dilemma is also a powerful tool for making the correct diagnosis.
Conversely, ignoring clear indications for treatment (as those above) only leads to unhappy patients and poor outcomes. Patients lose confidence in their doctors when their pain goes untreated. Hoping that a tooth with definite signs and symptoms of pulp disease won't flare up, or crowning such a tooth is wishful thinking of the highest order.
If you recommend endodontic treatment, and the patient refuses, my bias is to excuse the patient from your practice (how to do this discreetly is a whole column unto itself). Dentistry can be difficult enough without the added stress of working with uncooperative patients. Never talk a patient into a root canal they don't want. My mentor, endodontic residency chairman Dr. F. James Marshall from Oregon Health Sciences University, taught, "the patient must care more about the tooth than you do." This is sage advice. Such an environment promotes trust between patient and doctor and makes the news that a root canal is needed more productive and palatable.
Dr. Richard Mounce is in private endodontic practice in Portland, Ore. He lectures worldwide and has published numerous articles in the Journal of Endodontics. Dr. Mounce also writes "Endo Made Easy," a bimonthly tips feature for Dentistry magazine, and a quarterly column for Endodontic Practice in the UK. Contact Dr. Mounce via email at [email protected]. Visit his Web site at www.mounceendo.com.
