Written by Arthur K. Weathers, DDS Tuesday, 31 January 2006 19:00
There’s an old marketing maxim that says, “Confused customers don’t buy.” Clear, concise communication is important in all aspects of dentistry, but with the endodontic patient, establishing a positive rapport is especially critical. Unfortunately, an endo patient in pain, as is frequently the case, is a poor listener. Add fear to the mix, and most patients comprehend and retain very little of the critical information presented to them.
Upon hearing the phrase “root canal” or “the fee for this is…,” the average patient becomes increasingly stressed and stops listening. This brings me to my second maxim: “Stressed patients don’t listen.”
The worst time to explain endodontics to patients is when they are numb and sitting in the dental chair. I prefer to explain endo to my patients during their initial treatment consultation by saying, “There is a possibility that one or more of your teeth may be infected, and if that infection spreads to the center of your tooth, I’d like your permission to treat the infection before it spreads into the bone.” “Infection” and “bone” are strong words, and patients usually get the picture.
Our goal in patient communication is to establish a positive rapport, to reduce fear, and most importantly, to relate factual information and expectations to the patient. If you tell the patient, “This won’t hurt,” and it does, you’ll likely have difficulty rebuilding the trust that has been damaged. Endodontics is often performed as an emergency procedure, and if you lose the patients’ trust at this time, they may not have confidence in you to later perform comprehensive restorative and cosmetic treatment.
It’s a good idea to have a few tried-and-true phrases ready for any occasion. My favorite endo consultation begins with, “If I promise not to hurt you, what else would you like to know?” This approach tends to help patients relax and lets them know you are concerned about their comfort. I’m constantly amazed how infrequently patients have any follow-up questions after hearing this simple, direct question. Plain English delivered in a warm, confident manner will enhance your effectiveness in educating patients, motivate them to have the dentistry they need, and project a professional, caring image.
Having endodontic treatment performed can create anxieties in many patients. To minimize your patient’s anxieties and to explain any problems that might come up during treatment requires skillful and clear communication on your part.
WHAT DO YOU SAY NEXT?
For starters, observe your patient’s body language. Often, patients can be assessed quickly before any words are spoken. Any patient not fully seated in the dental chair when you enter the operatory—that is, the patient is standing up or sitting askew—is the typical nervous patient. Once, I came into the room and found a patient sitting in my chair. I thought he was just kidding around, but he said, “Doc, if you don’t mind, I’d like to sit up until I get to know you a little better.” He did not want to admit it, but it turned out he was literally afraid to even sit in a dental chair.
Perhaps the most important aspect of dealing with an apprehensive patient is to acknowledge the patient’s feelings. When the patient asks, “Is this going to hurt?”, resist the temptation to say, “No, you won’t feel a thing.” The message the patient receives could be “I don’t care how you feel” or “Your opinion doesn’t matter.” A more effective approach is to touch the patient’s shoulder lightly and say, “I know how you feel. Your comfort is my first concern.” Make the patient who is afraid of the needle feel accepted. Say, “We have a name for people like you—‘normal.’”
PAINTING A PICTURE WITH WORDS
Root canal treatment is usually preceded by a simple case presentation, because the patient has a toothache and is just seeking relief from the discomfort. Sometimes, however, a tooth needs endodontic therapy even though the patient is not feeling any pain. Remember to keep the explanation simple. Say something like, “I know you’re not feeling it, but that tooth is hurting you. The infection is eating away at the bone, and eventually the spreading infection will cause pain—usually at the most inconvenient time.”
Some patients question the need for root canal therapy when there is no cavity. Explain that you don’t know “which straw broke the camel’s back, but the nerve inside the tooth is irritated after years of trauma. It had a deep cavity before, and that was irritating to the nerve. The deep filling was another irritant. We chew thousands of times a day without even thinking about it. We eat ice cream and then drink coffee. All of these things are irritating to the nerves. And now, this tooth needs therapy.”
COMMUNICATING TREATMENT EXPECTATIONS
Tell the patient what is needed. Remember, informing the patient before treatment has begun is considered an explanation, but anything you say after treatment will be considered an excuse! If the tooth needs a crown, do not begin the root canal treatment before explaining why immediate restoration is critical.
The main cause of root canal failure is not restoring the tooth in a timely manner. Root canals typically fail from the top down, so even if you cannot complete the entire restoration, you should definitely seal the floor of the pulp chamber.
Incidentally, I never start a root canal without a firm commitment from the patient to have the tooth restored within 30 days of completion of the endodontic therapy. I say something like, “Root canal therapy takes care of the pain and infection, but it also ‘hollows out’ the tooth, leaving what’s left susceptible to splitting. It’s very important that we cover the tooth with a cap or crown to protect it from breaking. This is a back tooth with a lot of biting force. We’ll also need to build the tooth up to hold the crown on. You might have some friends who say they had a root canal and then lost the tooth anyway. Well, that’s usually because they didn’t get the proper restoration.”
Many patients want to know how long the tooth will last after treatment. It’s a good idea to answer in relative terms, such as, “Generally, the tooth will last longer than a new car or a trip to Hawaii.” Dr. Mike Goldstein, co-director at our LVI Root Camps, recommends the following statement: “After your tooth is properly restored, it will be as healthy as any other tooth in your mouth.” Further, Dr. Goldstein recommends you tell your patients after treatment that a very small percentage of patients may have a “reaction” to the treatment. He further recommends that patients who notice any swelling or are running a fever should call right away. By using the term “reaction,” any complications will seem to be caused by a normal body response and not by something the dentist did wrong.
DISCUSSIONS DURING TREATMENT?
When placing the rubber dam, it is imperative that you explain its use in terms of the benefits to the patient. “We’re going to put something around the tooth now so that you won’t have to swallow the disinfectants we’ll be using during treatment. Once this protective shield is in place, you’ll be very comfortable. You still will be able to breathe right through your mouth if you want to, and through your nose, too.”
Be very careful how you refer to the “rubber dam.” I like to say, “For your comfort and convenience, I’m going to place a protective shield over your tooth.”
For kids, we call it a “raincoat.” Whatever you do, don’t refer to the “dam” clamp or the “dam” clamp-holder. If you do, the patient may think you’re cursing!
EXPLAINING THE BENEFITS OF DIGITAL X-RAYS
|Figure 1. Digital radiograph showing radiolucency on maxillary bicuspid.||Figure 2. Rendition of radiolucency in 3-D emphasizes the lesion.|
|Figure 3. Colorizing the image further emphasizes the radiolucency.||Figure 4. Digital image of broken instrument in canal.|
|Figure 5. Rendition in 3-D of broken instrument in canal.||Figure 6. Colorized rendition of broken instrument.|
When discussing the need for endodontic treatment with the patient, an enlarged digital x-ray image can be of great help as a visual aid. By using some of the color and contrast features, such as those available on my Dexis system, patients will understand that you’ve done a careful diagnosis using the latest technology available. In many situations, you may be able to point out clearly the visible areas of infection around the roots of their teeth.
Before and during treatment, you can avoid any objections to necessary radiographs by giving an explanation in advance. “We will take several x-rays during treatment in order to see inside the tooth where we’re working. We use a state-of-the-art digital system that requires significantly less radiation. In fact, we can now take 4 or 5 digital images with the same exposure as 1 film-type x-ray. As an added benefit, these images will appear on our computer screen in about 4 seconds, eliminating annoying delays and permitting us to complete your treatment in the shortest possible time.”
We don’t try to “teach” our patients how to read x-rays, but there are 2 instances where we always show them their x-rays: if there is an obvious radiolucency, we show the patient how that tooth differs from the other healthy teeth, and if there is an instrument separation, we want the patient to remember that he was informed immediately after it happened. I’ll tell you the language we use in just a moment.
To emphasize the advantages of our digital imaging system, I frequently use the 3-D imaging and/or color rendering features of our Dexis digital x-ray system. Patients are impressed with our high-tech equipment, and it becomes a great practice-building tool (Figures 1 to 3). Don’t wait for the patient to object to necessary radiographs after you’ve started treatment.
If the patient complains about the number of x-rays, you can reply that you just want to make sure you give patients their money’s worth.
Above all else, every 15 minutes tell the patient, “Everything is coming along great”—even when it seems like nothing could be further from the truth! Train your assistants that any mishap always is routine and never to act surprised or upset in front of the patient. Throughout the treatment, ask the patient, “How are you doing?”
When treatment is completed, I do not routinely write the patient a prescription. If you establish straight-line access and carefully measure the working length with an electronic apex locator, you can usually remove the infected pulp tissue without creating apical inflammation. In such cases, no prescription is necessary. On the other hand, if the apical region is unduly violated, creating bleeding and inflammation, then administering an anti-inflammatory drug prior to anesthetic wearing off is a good idea. Writing a prescription can send the message to the patient, “You’re going to have a toothache!” On the other hand, you do want to explain that a little soreness is normal. “You will be a little sore when the anesthesia wears off from all the injections and the work we did and from keeping your mouth open. Take what you normally take for a headache. If you need something stronger, I’ve written my personal home phone number on the back of this card…don’t hesitate to call me.” Sharing your phone number may sound risky, but patients with your home number will go out of their way not to bother you.
Even after the best treatment and every sign of a successful outcome, an occasional patient will return a year after treatment and complain that he or she still feels “something” when he or she “taps.” Explain that the tooth had all kinds of treatment over the years. Although it seems to be doing well, it would be normal for the tooth to feel a little bit different than other teeth do.
WHAT TO SAY IF A MISHAP OCCURS
If an instrument separates in the canal during treatment, the first thing you should say is nothing. You will be very emotional, so it’s best to be quiet for a moment. Finish your work for the visit and then sit the patient up and establish eye contact. Do inform the patient before he or she is dismissed. Be matter-of-fact, rather than apologetic. “Mrs. Smith, let me tell you about what happened today. Root canals are curved and tortuous. While we were working, a tip of one of our sterile instruments, one of those little files that we use, separated off inside the canal.”
It’s also a good idea to point out the broken instrument to your patient on your digital x-ray. You do not want the patient to see this for the first time at some time in the future at another dentist’s office. Be sure to document in the chart that the patient saw the x-ray (Figures 4 to 6). Depending on the situation, explain that you don’t think it will be a problem or you think that you can get it out. Otherwise, explain, “You many need a surgical procedure,” or simply recommend that an endodontic specialist be consulted. The good news about separated Ni-Ti rotary files (and they do break on occasion) is that they almost never cause treatment failure. They frequently can be left as is without affecting the prognosis of the case.
If you perforate during treatment—and we all have—explain that while you were searching for the canal, “an extra opening was created in the tooth.” Depending on the situation, explain that you repaired this opening and would like to monitor the area, or that you think a periodontist should be consulted. Teeth with perforations have a guarded prognosis, and immediate treatment with a product such as MTA (ProRoot [Tulsa Dental]) is critical. It is often best to explain that this root probably cannot be saved, or that the tooth is too weakened to save. Explain the options to consider, such as a bridge or an implant.
Let’s say you are condensing gutta-percha, and you hear a loud “crack.” The patient underneath the rubber dam asks, “What was that?” You might say something like, “Mrs. Jones, I think we’ve located the fracture line.” Although this response may sound humorous, any tooth that fractures during obturation almost certainly contained a microfracture before treatment.
Informing a patient of a procedural accident does not immunize the clinician from malpractice litigation. It does maintain rapport with the patient, make any such litigation less likely, and make negligence more difficult to establish. Simple gestures like calling your patients the night of treatment will build your practice and are part of being a caring professional.
Show your patients that you care—that’s what all customers are looking for! Patients, after all, may not remember what you said or even what you did. But, they always will remember how you make them feel.
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