Written by Arthur K. Wheathers, DDS Friday, 31 May 2002 19:00
An organized, systematic approach is important in all phases of dentistry, but it is especially important in endodontics. If endodontic treatment is organized, it can be easy, efficient, and enjoyable. But if it is disorganized, it becomes stressful, confusing, and chaotic.
The very best way to get organized in any field of dentistry is to create reproducible systems for every procedure you perform. However, creating systems is not always easy, so by way of example I would like to share my top ten systems for practical and efficient endodontics. Many of these systems may adapt well to your practice.
Incidentally, this is not meant to be a comprehensive article on endodontics, but merely an introduction to the concept of using systems to enhance all phases of a dental practice. If you pick up a few tips on efficient endodontics along the way, so much the better.
SYSTEM 1: A FLOWCHART FOR EFFICIENT DIAGNOSIS
In my EndoMagic! “Root Camp” seminars, I show a slide of Frankenstein hooked up to a complicated electronic device, and the caption says, “Doc, it really hurts when I place an electric pulp tester on tooth No. 13!” Obviously, no one ever comes to the office complaining of pain from home pulp testing, but the point I’m trying to make is that we should listen to our patients and try to duplicate their chief complaint. We want our patients to say, “Yes, that’s the pain I’ve been feeling.” I’m not suggesting you never use a pulp tester; I am suggesting that you use a systematic approach to determine when and if a given test is indicated.
The first step in creating a more efficient system for any procedure is to write down all of the steps you currently perform. Examine the list and determine which steps can be eliminated, and then decide if it would be more efficient to change the order of the remaining steps. Ultimately, you will use your final lists much as a pilot uses a “checklist” prior to every flight. In diagnosis, your checklist might take the form of a flowchart, which branches according to the patient’s answers.
The first test we routinely perform in my practice is a “hearing test.” That means we listen to our patients’ problems and make certain we hear what they are trying to tell us. As we listen, we mentally ask ourselves the following three questions:
(1) Is the problem caused by a tooth?
(2) Which is the offending tooth?
(3) What treatment is required?
To identify the specific tooth involved, try using the time-honored series of questions asked by every good newspaper reporter. These questions are who, what, where, when, how, and why.
•WHO knows the history of this tooth? The patient knows, so the first thing we must do is listen while she explains the problem. If the patient is a child, it might be the parent who knows the history of the toothache.
•WHAT makes the tooth hurt? Is the pain caused by heat, cold, biting, tapping, or changes in posture?
•WHERE is the pain coming from? Can you pinpoint a specific location? Which side hurts? Even when patients cannot identify a specific tooth, they can usually tell if it is an upper or lower tooth, or a front or back tooth.
•WHEN does it hurt? Ask the patient, “Does it wake you up at night?” Spontaneous pain that awakens the patient is almost always irreversible.
•HOW long does the pain last? A lingering pain virtually always indicates a need for endodontic therapy.
•WHY did you wait so long to come see me? (Just kidding on this one. You might be thinking it, but it’s probably not appropriate to verbalize that question.)
Anyway, you get the idea—customize your lists to obtain the information you are seeking.
SYSTEM 2: THE TELEPHONE INFORMATION FORM
|Figure 1. Telephone Information Form.||Figure 2. Patient Routing Slip (back of telephone form).|
One of the most important and most abused of all forms in the dental office is the lowly telephone message form. These little pink slips can be found scattered throughout the office on desks, tucked in charts, doubling as book marks, and hiding in drawers waiting to mature. The information contained on most of these forms is woefully inadequate at best, and downright cryptic at worst.
I hated those little pink phone messages until I saw a much improved version created by my business partner, Dr. Michael Goldstein. Mike combined a telephone information form and patient routing slip to create a very useful information management tool. The front of his pink 5” X 8” form is reproduced in Figure 1.
The “Telephone Information” side of this form is used to obtain critical information during the initial telephone call, while the “Patient Routing Slip,” printed on the back (Figure 2), helps track a new patient from the initial contact through the first few visits.
The Telephone Information Form provides a wealth of information:
(1) How long has the tooth been hurting? Is this a “pain emergency”? You might approach a 1-month-old toothache differently from one that began suddenly at 2:00 in the morning. If a patient has a “cosmetic emergency,” such as a chipped maxillary incisor, you will probably approach that problem differently if he’s been walking around for 6 weeks like that, or if he has taken the day off work so he can have it fixed before he is seen in public again.
(2) What have you been taking for the pain? How patients respond to this question tells us a great deal about the severity of the emergency, and their “dental IQ.”
(3) Always ask, “When was the last time you saw the doctor?” rather than “Have you ever been here before?”
(4) If you ask about insurance, make certain this is not the very first question on your form.
(5) Always let the patient know that he is being worked into your busy schedule.
(6) When you turn the form over and begin using the Patient Routing Slip, the initial telephone notes stay with the patient’s chart.
The Patient Routing Slip is a checklist of additional forms and information that the patient will receive. By dating and initialing each time one of the forms is processed, your “routing system” ensures nothing is overlooked. Some of the entries on this form include the following:
(1) New Patient Welcome. This refers to a handwritten note sent to all new patients (the new patient brochure and a copy of the doctor’s CV is included with this mailing).
(2) Health Questionnaire. This box is initialed as soon as the patient fills out this important form.
(3) Welcome note. A short, handwritten note telling the new patient how much we appreciate having him join our dental family.
(4) Thank You for Referral. A handwritten note on a preprinted card is sent immediately after the first visit. Two “patient referral cards” are enclosed with this mailing.
(5) Financial Philosophy. Tells patients what we expect from them and what they can expect from us, including their payment options. The “Appointment/Cancel Policy” is also presented at this time.
(6) Other items that may be included on this form are prevention/re-care information, children’s dental health book/article, a note when family members are appointed, additional referral invitation, and an insurance letter.
(7) There are also a few blank lines for additional entries as well as room for comments following each entry.
As you can see, the Patient Routing Slip is a very comprehensive form, and provides valuable, ongoing information.
SYSTEM 3: CREATING VISUAL LAYOUTS FOR TRAY SETUPS
Many offices have lists of instruments and supplies that should be included on every tray setup, but these lists are often confusing to new team members and ignored by “veteran” assistants. A much more efficient solution is to have photographs of ideal tray setups posted in the sterilization area.
|Figure 3. Example of a tray setup photograph. Staff members refer to photographs such as this as they prepare the instrument trays. If the tray looks exactly like the photo, they know nothing has been omitted.|
Many offices have digital cameras available to quickly create and update photos of tray setups, but if you don’t have a digital camera, a standard copy machine will do the job. Arrange instruments and supplies on the glass copy area, press the copy button, and in seconds you have a life-size rendition of the materials you want for each tray. The detail is not quite as good as a photograph, but instruments are easily recognizable; if you change layouts, these images can be updated in a couple of minutes. Figure 3 shows an example of a tray setup we use in my office.
SYSTEM 4: THE 80/20 REFERRAL RULE
Determining which teeth should be treated and which teeth should be referred can be one of the most difficult aspects of a general practice. The 80/20 rule says that 80% of all endodontic problem cases are caused by 20% of the patients needing treatment. Wouldn’t it be great if we had a system for accurately identifying problem cases before we commit to performing endodontic therapy? There is a system for identifying cases that should be referred to reduce stress and maximize profitability.
The first step is to keep a journal documenting cases that you wish you had never started. Every time you find yourself “in over your head” or regretting having started a particular case, document the conditions present, and you will soon see a pattern developing. This pattern will vary according to your current skill level and will be different for every practitioner. There are some cases, however, that every general practitioner should consider referring whenever possible.
Your list of cases to avoid might include (but not be limited to):
(1) Re-treatments. There is a reason these teeth failed, and the reason may not be obvious until you get in over your head. Additionally, re-treatments have a much lower success rate and higher possibility of creating unwanted stress.
(2) Extremely calcified canals. Why spend hours fighting your way down these teeth? Life is too short.
(3) Working through crowns. Poor access and limited visibility make these cases more difficult than need be. Whenever possible, remove the crown or refer the case.
(4) Severe swelling and patient management problems. This one is fairly obvious.
(5) Roots with multiple canals. If you cannot routinely locate all the canals in certain teeth (such as upper molars or lower bicuspids), refer them or practice with extracted teeth until you become proficient in their treatment.
Using the 80/20 system, you can document problem cases, observe patterns as they develop, and refer the troublesome 20% before committing to treatment.
SYSTEM 5: QUICK AND PAINLESS ANESTHESIA
Patients do not know how well you clean and shape their root canals or if your obturation material completely fills the canal system, but they do know if you hurt them. Routinely obtaining rapid, profound anesthesia, and not hurting the people who pay your bills, provides many advantages:
(1) Minimize treatment delays associated with re-injections.
(2) Remember the 12 P’s. Painless procedures produce positive patients with a propensity for paying promptly and promoting positive, premium practices.
(3) Patients who are not in pain are more cooperative and are less likely to break appointments or initiate lawsuits.
(4) Reduce stress associated with inadequate anesthesia—reduce stress to the doctor as well as the patient. A recent study1 found that 19% of all dentists consider “missed” anesthesia to be their major cause of stress, and 9% indicated they had become so stressed they had actually considered changing professions because of it. Sound familiar?
(5) Even when using block anesthesia, there is no need to wait for it to take effect. You can jump-start your blocks with a painless, instant intraosseous injection using a product such as the X-tip from X-tip Technologies.
So, how can we develop a system for delivering painless, predictable anesthesia? Most of us tend to use a “shotgun” approach to anesthesia, and we just keep adding anesthetic until hopefully the patient gets numb. Unfortunately, as we inject more and more anesthetic with epinephrine, we lower the pH in the area and reduce our chances for success. If we follow a checklist, we will select a different type of injection rather than continuing to repeat something that is not working. Here’s my checklist for obtaining profound local anesthesia:
(1) Use a topical. Although topical anesthetics do not always work as quickly as we might like (requires a minimum of 1 or 2 minutes according to Dr. Stanley Malamed2), they do provide an excellent form of distraction. I like to place the topical on the injection site and then wipe a little on the tip of the tongue as I’m withdrawing the applicator. The instant numbness of the tongue reassures patients that the topical is working and helps them relax.
(2) Initially inject with an anesthetic that does not contain epinephrine, such as 3% Cabocaine plain. This injection will be virtually painless because of the almost neutral pH of epinephrine-free anesthetics.
(3) Wait until the patient begins to feel the effects of the first injection (eg, lip numbness) before adding anesthetic containing epinephrine. (In short procedures, the second injection is usually not necessary.)
(4) If a block doesn’t work within 3 to 5 minutes, go straight to a system that is proven to work about 98% of the time: intraosseous anesthesia. Don’t just continue adding additional amounts of anesthetic containing epinephrine or you may wind up with an area that is increasingly acidic and impossible to numb.
(5) Even when using block anesthesia, there is no need to wait for it to take effect. You can jump-start your blocks with a painless, “instant” intraosseous injection.
SYSTEM 6: RAPID RUBBER DAM PLACEMENT
My rubber dam system utilizes the following simple steps for isolating any tooth in 10 seconds or less. It takes longer to explain than it does to implement:
(1) Have your assistant prepunch the rubber dam and preposition the clamp on the holder before seating the patient.
(2) Mark the tooth to be isolated. Many teeth look alike (Nos. 24 and 25 for example), and it can be very embarrassing to place the dam on the wrong tooth. The easiest way to mark a tooth is to begin access preparation prior to placing the dam.
(3) Slip the dam over the tooth and have your assistant hold one side while you hold the other side.
(4) Using your free hand, slip the clamp over the tooth, and enjoy a clean, saliva-free work area. A recent study3 showed that placing the rubber dam over the tooth prior to placing the clamp caused zero leakage, while placing the clamp first, followed by the dam, and finally attaching the frame, resulted in leakage virtually 100% of the time. A few tips:
•For endodontics, use the largest hole on the punch.
•Use the HandiDam or the InstaDam with the frame built in.
|Figure 4. HandiDam prepunched, with #211 clamp and spreader on top. To the right is the InstaDam, also prepunched.|
•Use one size clamp for all teeth. The No. 211 clamp will fit any tooth in the mouth (Figure 4).
SYSTEM 7: ACHIEVING IDEAL ACCESS
You might wonder how you can have a “system” for obtaining access. Aren’t we just drilling a hole into the pulp chamber so we can insert files into the canals? That’s basically true, but my organized, systematic approach to access includes tips such as the following:
(1) If the tooth has been restored with a crown, it’s best to remove the crown prior to access.
(2) Enter the pulp chamber using a No. 4 round bur.
(3) Use the safe-ended, Endo-Z bur (DENTSPLY Caulk) to refine the access preparation.
(4) On molars, always remove the MB cusp (the MB canal is directly under that cusp).
(5) Remove enough tooth structure so you can close one eye and see all of the canal openings without moving your head (or the mirror).
(6) Transilluminate the tooth, and the pulp chamber will glow, emphasizing canal openings.
(7) Use the Stewart probe to pick away at surface calcifications and make way for your first file.
(8) Bend the tip of a stainless steel, K-type hand-file at a 45° angle (as close to the tip as you can) to negotiate curved canals or bypass ledges.
SYSTEM 8: PREPARATION AND OBTURATION
My complete system for canal cleaning, shaping, and obturation is beyond the scope of this article, but here are a couple of systems that can be applied to almost any endodontic technique.
|Figure 5. The Edno Organizer Box from the EndoMagic! Company has five rows of holes, numbered 1 to 10. Each time a file is used in a canal, it is moved to the next row to the right. When the files make it to the last row, they are used one more time and then discarded. In the box on the right, the files in the last row will be discarded after the next use.|
Keep track of the number of times a file has been used with an “Endo Organizer Box.” The one I use is made by the EndoMagic! Company, but you can adapt many other storage canisters using this one as an example. The canister should have five or six columns containing enough holes for each file you routinely use. In my case, I use 10 files, so the rows are numbered 1 through 10, and each time I use a file in a canal I move it to the next row to the right. When the files reach the last row, they are discarded after the next use (Figure 5).
|Figure 6. The Thompson instrument canister, containing the Universal Placement Instrument, size 0 mirror, cotton pliers, Stewart Probe, and double-ended endo plugger. Two extra mirrors are shown in the right-hand storage compartment.|
The EndoMagic! Instrument Cassette (Thompson Instrument Company) includes a small, size 0 mirror (that doesn’t interfere with the rubber dam clamp or files entering the tooth), a Stewart Probe (for locating and entering calcified canals), a special double-ended plugger, cotton pliers, and specially designed combination temporary placement instrument and plugger. There is room in the hinged top case for additional instruments, and the contents may remain in the cassette for ultrasonic cleaning and sterilization (Figure 6).
SYSTEM 9: A SYSTEM FOR TREATING EMERGENCIES
Every office should have a system in place for treating emergency patients. My emergency tray setup is shown in Figure 3, under System 3: Creating Visual Layouts for Tray Setups. It’s very important to have everything you need at your fingertips as soon as you sit down.
Emergencies are not planned, of course, and usually occur when you do have very little time. Using the following system, I can usually get an emergency patient numb, do a “partial pulpectomy,” and temporize the tooth in less than 5 minutes.
(1) Numb the tooth with the X-tip and intraosseous anesthesia (1 minute).
(2) Enter the pulp chamber with a No. 4 round bur (30 seconds).
(3) Use the Endo-Z bur to quickly enlarge the access, exposing at least the largest canal, for example, the palatal of an upper or distal of a lower molar (90 seconds).
(4) Clean out as much of the largest canal as you can in 10 seconds or less using the No. 1 EndoMagic! file or a Gates-Glidden or Peeso bur, depending on your preference (30 to 40 seconds).
(5) Place a large cotton pellet in the pulp chamber and seal with your favorite temporary filling material.
If you have a little extra time, you can fine-tune the access using the safe-ended Endo-Z bur, and use the No. 1 EndoMagic! file in all of the canals for 10 seconds or less. The more pulpal contents you remove, the longer the patient will go without recurring pain. The key is to have everything you need on the tray, and numb the tooth using intraosseous anesthesia so you do not have to wait for the patient to get numb.
SYSTEM 10: TAKING THE STRESS OUT OF ENDODONTICS FOR YOUR PATIENTS
Finally, every office should have systems for keeping patients happy, generating referrals, and thereby reducing stress for the entire dental team. Here are a few items you might want to include on a “make the patient comfortable” list:
(1) Sit down to talk with your patient prior to washing your hands and gloving up.
(2) Lightly touch the patient’s arm or shoulder before putting on your “doctor gloves” to establish human contact with your patient.
(4) Offer to answer any last-minute questions the patient may have.
(5) Offer patients a blanket, lip balm, headphones, and sun glasses to make them more comfortable during the procedure.
(6) At the conclusion of treatment, offer your patient a fresh, hot towel to wipe off powder from gloves or other dental debris.
(7) Give the patient your “private” phone number to call if there are any problems. Tell them to call any time, night or day, and they will not abuse the privilege.
Systems do not confine us, but rather free us to provide more and better dentistry, with less stress for our patients and all of the members of the dental team. Without checklists, we tend to overlook important steps along the way. Good pilots would not consider flying without using their checklists, and good dentists should do no less.
1. Simon JF, Peltier B, Chambers D, et al. Dentists troubled by the administration of anesthesic injection: long-term stresses and effects. Quintessence Int. 1994;25:541-648.
2. Malamed S. Handbook of Local Anesthesia. 4th ed. St Louis, Mo: Mosby; 1997:67-68.
3. Jou Y, Yang M, Karabucak B. In-vitro evaluation of the rubber dam leakage: comparison of five different techniques. J Endodontics. 2002;5:259.
Dr. Weathers has lectured worldwide for almost 30 years on technologies, products, and processes designed to simplify the practice of endodontics by the general dentist. He is the developer of a wide range of dental products, and is both the editor of the Practical Endodontics Newsletter and the author of numerous articles on endodontics and local anesthesia. Lecturing extensively to dental organizations, Dr. Weathers integrates an academically grounded approach to his subject with humor, magic, and mnemonics to enable his audience to recall his well-accepted techniques. As the founder of the EndoMagic! Root Camp, Dr. Weathers offers numerous 2-day hands-on training sessions at his facility in Griffin, Ga. He can be reached at (877) 478-9748.
Disclosure: Dr. Weathers pioneered the EndoMagic! nickel titanium file system. He is also the clinical technique developer of the X-tip Intraosseous Anesthesia System and receives a consulting fee from X-tip Technologies.
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