The Endodontist – Referral Relationship:
Changes necessary for Survival of the Specialty in the 21st Century
– The NJAE welcomes Dr. Robert M. Kaufmann, an endodontist from Winnipeg, MB, Canada to our editorial pages. If you would like to comment on his article please do so by clicking on the “Contact Us” section of our website and send your message to us by following the directions.
We’ve all been there. You open your daily mail and inside you find a referral slip with a poorly taken radiograph and a few ticked boxes and circled tooth number. “Please treat tooth #xx. Leave post space. Patient’s Insurance information is included below, Signed Dr. XXXX. ” There is nothing more. It isn’t important that you know anything other than (a) the fact that their patient’s tooth needs treatment, and perhaps, (b) the type of post op restoration that will be placed on the tooth. This is the way it’s been done for 50 years. Three tick boxes, a circled tooth number, a written line or two and a signature…and the patient is out of their hair. The RD’s (Referring Dentist) staff-person makes sure to include the insurance numbers because the financial information is perceived by them as the most important data. You can’t treat anyone if you don’t get paid. And even if you don’t take direct assignment of benefits, many patients need to know what the out of pocket costs for your treatment will be so they can budget accordingly. After all, in the end, it IS about the money.
For many endodontists, this is the kind of referral relationship that has been established and in the past it has provided them with a very good living. The RD prescribes and the Endodontists “dispenses”. Endodontists mostly make their money performing single tooth endodontics (70-80% of the time on moiars), $1500 or so at a time. (With additional ReTx or Disassembly fees) Little information is given by the referring Dentist about a treatment plan, priorities in the mouth or whether the tooth is strategic. ““Nike” the case ….”Just Do It””, seems to be the RD refrain.
The patient is frequently symptomatic and as long as they wish to keep the tooth, patients really are in no position to question this decision. Like the referring dentist, they just want to get on with the restoration or make their problem to go away, NOW. These patients aren’t interested in philosophical discussions with the Endodontist as to whether the tooth has been considered part of a comprehensive care plan for their mouth that takes into consideration the myriad of factors that make their oral situation unique. Besides, how can YOU as a treating Endodontist, appreciate all these factors when you have only known the patient for the time it takes to ask them some questions and perform an examination? The RD knows the patient, and sometimes has been seeing them for decades. How is the Endodontist supposed to make valid treatment recommendations when we have no idea of the discussions have taken place in the RD’s office, if any have taken place at all? Many times the RD Office referral is nothing more than: “Mrs. Smith called us….she’s sore from last week’s crown prep. We’ll send a film. Here are her phone/Ins. numbers. Please work her in STAT.” And we wonder why Endodontics is in trouble!
For the most part we are out of the treatment planning loop. If anything, referral to the Endodontist can be perceived as an expensive delay or interruption on the way to restorative case completion. If and when you pick up the phone to inquire about a treatment plan or other considerations, it is often regarded as an unwelcome complication of the RD’s life. The patient was sent to the Endodontist to make problems go away or to allow them to restore the tooth in the manner they have decided. “Just do the endo and let me worry about the rest” is often the response. Sometimes the criticism is more direct “Stop talking to/treatment planning my patients. You’re just the Endodontist who sees them for one or two procedures. You don’t know them like I do. I have talked to them about this already. You are overstepping your authority and I resent you discussing these topics with my patient without my direct instruction. Do this again and I will refer elsewhere.” How many of us have lost referrals in this manner?
I was prompted to write this editorial because of listening to Prosthodontist Dr. Winston Chee’s lectures during the past three years. In some of Dr. Chee’s recent presentations he suggested that in order for us to properly treatment plan patients, certain questions need to be asked:
Where will this patient be dentally 10 years from now? 20 years from now?
This answer is fundamental to the decision as to whether the treatment will be of benefit to the health of the patient in the long term. How many Endodontists have the courage to ask the referring dentist this question upon referral of a patient? Most Endodontists will tell you “I don’t want to go there. It’s not perceived by the referring dentist as my prerogative. I can make suggestions but I can go only so far or I risk alienating or “insulting” their treatment plan.” It is a question that is difficult for an Endodontist to ask when you know that the patient’s condition is less than optimal and you don’t really know all of the reasons why the patient is in this condition. Sometimes you are confronted with a mouth full of long term, failing multi-surface amalgam or composite restorations in a patient who has been seeing the referring Dentist for many years. In seniors with severe breakdown, it is even worse. Many have been this way for decades and are on fixed incomes. Some have poor health and may not have 10 o 20 years left to live. It may be easy to regard these cases with a contemptuous label of “supervised neglect”. (If this is the first endo procedure on this patient, there is also the temptation to say “It looks like will likely be meeting again, soon.”) But that is unfair. We don’t know the patient well. Were the reasons financial? Compliance related? Hygiene? Dental IQ? Is it fair for the Endodontist to question the RD when such patients face the prospect of expending virtually all of their financial resources on one tooth (when the rest of the mouth is falling apart) or do we extract and replace prosthetically? (A “no treatment” extraction certainly won’t help pay for your new cbCT lease payment!) Who decides? If the long term success of our Endodontic treatment depends on the integrity of the restoration, does the Endodontist have the right to insist on replacement of that deficient restoration or do we perform endo through it and try to make that last as long as the patient is alive? When do we just “do it”?
What is the predictability of this proposed treatment over a 20yr period?
Again, I know few RDs who believe that the average patient sent to me (80% of my practice is on molars that are heavily restored, carious or cracked) will have their restoration 20 years from now. (Not that they TELL the patient that fact…mind you. I would say 80% of the patients referred to me are NOT told by the RD that the tooth STILL can become carious after my endo. That is almost NEVER explained to patients prior to referral.) Are we merely relieving the symptom…the single toothache? Or are we treating the patient as a whole? The question is fundamental to our future survival as a specialty. If Dentistry believes that for many of these patients, Endo is merely an interim temporary procedure on way to implants, then what future does Endodontics have as a specialty? No wonder Dentists and Patients choose to go directly to “Plan B” – the implant, and that our specialty sees implants as a “if we can’t beat em, join em” salvation strategy.
Why is this dentistry failing? Or why have teeth been lost?
Strictly as a practical matter, I don’t think many Endodontists are qualified to answer that question. They don’t KNOW most referred patients. They haven’t observed their condition over the years like the RD. I see patients that have been patched and held together with composite and amalgam and FINALLY a decision is made to treat “a tooth or teeth”. Not a whole mouth in most cases ($$$ prohibitive)…but maybe a couple of teeth. Did they not brush today before seeing me? Or….Do they NEVER brush? Do they have generalized margin/root caries? Have they resisted seeing a Periodontist (cost/don’t want surgery etc.) How do I know? I can’t tell you how many cases are referred to me that are in dire need of a full mouth rehab/full mouth consideration….but they never get it. For many it’s the equivalent to cost to a new car, financially impossible. SO how can we possibly consider “20 year dentistry” when we (for the most part) put out fires. So must I do “the circled endo tooth on the referral pad” and hope that the few minutes they spend with me may influence the patient? (And at the same time not irritate the referring dentist when the patient returns with important questions that need answers.)
(Note: If you are one of those clinicians who have “boutiqued” their practices to the point where insurance coverage or treatment fees are a secondary concern of patients, please disregard this editorial. Your referrals are always the best clinicians. They ONLY treat people with immaculate hygiene, unlimited compliance, high Dental IQs and fat wallets. Your referral lists consists exclusively of dentists who you would have work on your OWN mouth or the mouths of your family, no exceptions. I congratulate you and apologize for wasting your time. You and I are living in different worlds and this article may have little relevance for you.)
Instead of the Endodontist being consulted as an afterthought, we must somehow find a way to be included in the treatment plan as it is being formulated and BEFORE the patient is scheduled for treatment. This also includes the decision to extract and replace with an implant. This challenges us in several areas:
- We must convince RDs that because we have chosen to practice Endodontics, we have not lost the knowledge that comes with the practice of General Dentistry. Being an Endodontist (by definition) means that diagnosis is a primary role and for that we must be able to judge the adequacy of ALL types dentistry so we can diagnose symptomatic patients. In order to address the unique diagnostic challenges facing us when symptomatic patients are referred, we must be contemporary in ALL aspects of Dentistry, not just our own specialty. That concept seems to be lost on many RDs who, for example, think of their Endodontists as merely living in a world of pain, anesthesia, radiographs, files, gutta percha, sealer and an occasional core or single surface restoration. When was the last time a referring dentist sent YOU (the Endodontist) a set of study models/tx plan and asked your opinion prior to referral? Never? I rest my case.
- The basic nature of the referral relationship has to change. Endodontists must be included in treatment planning decisions from the start. This specifically includes the decision of whether the tooth is amenable to treatment/retreatment or whether it should be extracted. With the reduction in numbers of referred endodontic cases, it has become clear of late that many of these teeth are never even getting to the Endodontist’s office for a possible examination of whether they can be saved. The response to this threat is obvious – Implant focused Endo CE that many Endodontists believe we need, so we now can place these fixtures ourselves. (There are still many places in the world, Canada for example, where only a very small percentage of endodontists are placing implants. In those locations, Endodontists that place implants are sometimes perceived as doing so because they “need to” i.e. / they don’t have a sufficient traditional molar endo caseload to keep them busy.)
- Endodontists must teach their referring dentists how to diagnose and treat endodontic emergencies competently and without compromising the long term viability of the tooth. If Dentists are able to provide efficient emergency treatment, they may not only be able to provide comfort for the patient. There are other added benefits to this (a) it generates added income for their office, (b) lessens the appointment scheduling pressure on the Endodontist office and (c) gives them some appreciation of how they must be the ones to determine restorability and plan the case before referral. Dentists may also be more reluctant to simply extract the tooth for expedience if they see value and opportunity of retaining the tooth rather than regarding endo emergencies as an inconvenience.
- Endodontists must also teach more and become more involved with Dental schools. Rather than accepting an endorsement/CE cheque and shilling for the latest manufacturer “flavor of the month” product, we have to return Endodontic basics and a more academic (rather than commercial) environment. It is a disgrace to our specialty that General Practitioners are teaching Endodontics in Dental Schools. Yes, it is expensive for Endodontists to “donate” their time to the local dental school. But, we must regard teaching undergraduate programs as an investment in the future of the specialty, rather than as a charity or as a loss of practice production. If students are not taught proper case selection, if they perceive that “Super Generalists” can perform as well as specialists, or if they are NOT taught that Endodontic referral is a viable option, they will NOT refer. Inexperienced clinicians will attempt complex treatment that will eventually result in failure, extraction and implant placement. Worse still, it will perpetuate the fallacy that sometimes endo “just doesn’t work for unknown reasons”. If RDs are NOT taught that skilled Endodontic retreatment combined with newer 3D imaging techniques give us an excellent chance for success, then we should not be surprised when our appointment books have holes or that we are fighting with other General Dentists, Periodontists or Oral Surgeons for that implant placement.
Endodontic skills used to be unique to our specialty. Because we have abrogated our teaching responsibilities, shilling for manufacturers for the sake of a dollar and abandoned school teaching we have found the need to expand our practice mode to include implants. As Endodontics adopts implants more and more, we are losing that uniqueness and diluting the remaining strength of the specialty, for the sake of being “busy”. Now we have an additional challenge. We must not only address these issues, w ith the popularity of implants we now find ourselves needing to justify our existence. If we truly hope to see our specialty survive in the next century, our practice model must change. We must move from the model of being the hired gun “Endo-Plumber “to becoming in integral part of the treatment planning team from the onset. We must resist the temptation of the “fast buck/single tooth” practice mode and move toward a strategy that regards us as not merely a “tooth tradesperson” but someone who should have equal input in the architecture, selection and treatment planning decisions that form the long term strategy for our patients. We must reassert our “restorative credentials” and credibility. It remains to be seen whether we have the insight or the courage to demand our rightful place in the treatment planning team. We can continue with our present myopic strategy but we should not be surprised when endo treatment numbers and incomes decrease, appointment vacancies increase and the pressure to place implants causes more and more Endo CE to be implant focused.