A few years back and in a fit of desperation after another pointless management audit, I decided to carry out an audit on the types of treatment I was providing. I wanted to find out whether treatment profiles had changed over time.
I thought it might be interesting to investigate whether the nature of the endodontic treatment I was carrying out was becoming more complex requiring greater time and effort, as I had thought, or whether I was just becoming more knackered and complaining with age!
Treatment sessions were categorised and I analysed four random months of appointments 3 years apart.
The result of the null hypothesis was, I have to admit, inconclusive, but as a pilot study it gave me some food for thought, and what I would like to share with you was a finding that might surprise (or not, depending on how much of a sceptic you are).
Above some of the more complex stratified layers of categories was: Primary Treatment; Retreatment unrelated to Primary Treatment; and Retreatment due to unsatisfactory Primary Treatment.
A staggering 43.4% of my treatment time in a random period of 4 months was spent treating the consequences of other dentists' substandard work. Whether due to underfilling, under extension, missed canals, poor coronal seals, ledges, transportation, or perforation, I was spending almost half of my time sorting out the legacy of poor primary root canal treatment.
Being fair, not all retreatment work was done due to poor treatment, and 21.8% of my time was spent diagnosing and retreating issues possibly not directly related to the quality of the root treatment, such as fracture, complex anatomy, lateral canals, and extra radicular infection.
Returning to the eye watering 43.4%, this will not come as a great surprise to the hospital endodontists who are sitting on a huge mountain of never-to-be-managed ’GP Retreat’ referrals, as they were categorised at the Eastman Dental Institute.
For those of a more cynical outlook this could be considered good news for specialist endodontists such as myself, and certainly the implantologists. The rather ignominious decline of the dentition through iatrogenesis seems all to common in my middle-age patients. Starting with overenthusiastic 'drill and fill' in the younger and immature tooth, the placement of cosmetic leaking restorations, pulpal damage during crown preparation, and then poor ‘quick-fix’ endodontics.
There are a number of consequences to this category of retreatment.
- Patient management. With an increasingly litigious population, being informed that failure of treatment is due to inadequate or substandard work, is likely to trigger off a complaint or two. Could this be the next big legal bonanza after injuries at work, with text messages reading ‘Contact us if you have had root canal treatment’? It is of course how you tell it, and most patients are very reasonable (many times too reasonable!), but the process leaves a poor impression. A patient loses confidence in the general practitioner they have had faith in for many years, and with the dental profession as a whole.
- Treatment management. Retreatments are more complex and time-consuming than primary treatment. This makes the process more expensive and what with deconstruction, retreatment and then a new restoration if successful, the expense will not be that far away from an extraction and implant placement which could have a better prognosis.
- Treatment prognosis. The more complex treatment is, the higher the failure rate. Bypassing materials, ledges and blockages created by a previous visitor, is not always possible, bringing in the possible need for surgery to accomplish treatment objectives. Even if a technical masterpiece is achieved, our success/failure research shows retreatment success lagging 10-15% behind primary treatment. The reason for this is that the contaminating bacteria are no longer primarily anaerobic as in primary treatment, but more hardy and resistant facultative anaerobes.
The solution to this ever-growing mountain of iatrogenic endodontic disease and patient dissatisfaction is education.
It may be a simplistic approach but I believe that if general dental practitioners were taught how to carry out effective endodontic treatment first time around, a considerable amount of future grief could be avoided.
Indeed, there are political issues at the heart of this, but if dedicated practitioners truly understood the issues at hand, maybe they would not let themselves be pushed around by government agencies only interested in saving money.
Treatment carried out correctly at the primary stage is easier, and more successful, and should be done most of the time by competent general practitioners. There will be complex primary treatments, but these can be recognised and the general practitioner should have an understanding of their own capabilities. If they don’t feel confident, the patient should be referred to your friendly local endodontist or specialist hospital department. After all, 43.4% of their time could now be spent twiddling their thumbs!
Dr Richard Kahan is a specialist endodontist working in Harley Street, London and the former Director of Endodontic Courses at UCL Eastman CPD. Richard has lectured widely on endodontics and technology and set up the Academy of Advanced Endodontics to teach the fundamentals of endodontics.