General recommendations for the general practitioner regarding endodontic referrals

My love for endodontics comes from the thrill of looking for the canals. I do believe it takes a special breed of cat to enjoy the quest canal searching provides. In an instant, the quest can turn into an unanticipated adventure.

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Some people like a thrill; some people hate it. It’s kind of like roller-coaster riding — you love it, or it scares you to death. I find completing endodontic therapy very similar to this love-hate relationship.

And that’s why it’s important I know my limits and risk tolerance as a general practitioner. But when first starting out, there are no limits. Every ride seems viable. The teeth on X-ray, for example, often look the same, and distinguishing which canals may be troublesome is an art in and of itself. As I completed more root canal therapies, I got much better at prediagnosing the patient and the X-rays. In other words, I chose my rides more carefully.

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My ambitious “Superwoman” attitude was humbled by a few ridiculously difficult procedures that either ended in marathon sessions for the patient and me, or ended in a referral to a specialist. The temptation to keep all of the procedures in-house is great when first starting out. But, in reality, it is much more productive to refer out the difficult procedures and patients. Here are my top tips for the general practitioner when it comes to referring patients to an endodontist:

1. Look at the X-ray — twice. Look for calcified canals and winding or disappearing roots. If you have the equipment to negotiate these roadblocks, do it yourself. If not, refer it out.

2. Consider the opening size of the patient’s mouth. Hindsight on this one can be painful. Working in an overly confined space on an upper molar is very difficult for an experienced endodontist. Faster is better when working in this type of environment. If you are not fast yet, consider referring it out until you are more proficient. That time may never come, and that’s OK.

3.Having backup is crucial when deciding which teeth to treat or not to treat. Developing a friendly relationship with a couple of endodontists is highly recommended. When in a jam, they are helpful with advice to get you through a tough case. Most endodontists will take your desperation call and talk you through the problem. Do not take advantage of this phone-a-friend collegiality. This is the exception — not the rule. However, learning often entails some risk-taking, and when trying to expand proficiencies, glitches do happen, and it’s a relief to be able to phone someone to help, or to at least help you decide if referral is eminent at that point.

4.Keep the patient’s best interests top of mind. Again, it’s easy to think about keeping all procedures in-house to save money and increase your bottom line. If the patient’s pain can be relieved more quickly because a specialist can see the patient before you can, refer them out.

5.Consider an immediate referral for the squirmy, difficult, low-pain-tolerant patient. If the mere thought of root canal therapy makes the patient wince and cry, this patient may do better with a specialist. Similarly as with the minimal mouth-opener, faster is better with this type of patient. If you are proficient, it may be just fine. But, if you are slower, attempting to deliver care to this type of patient will make you hate endodontics or the patient or both.

6.Check your ego before you check out the patient. Ask yourself if this procedure could be done more efficiently with a specialist. When in doubt, refer it out. Your gut instinct is usually right.

May you have many wonderful quests as you seek out the loveliest pathways down the spirals of No. 19 or up into the twists of the mesial-buccals of No. 3. An attitude of thrill seeking and intrigue helps keep me interested in endodontics. I am grateful for the rides and thankful for the endodontists who will sit next to me and hold my hand during the rides with the biggest hills. Both my patients and I benefit from this ongoing support and reassurance.

Roller-coaster photo by Vicki Cheeseman