Having received only basic endodontic training as undergraduates, most GDPs leave dental school without much exposure to more complex aspects of endodontic treatment, in particular in molars and endodontic re-treatment. It is this restricted education and lack of experience that potentially deters them from pursuing a career in this exciting discipline further. Consequently, whilst all GDPs will offer endodontics as a treatment, when faced with cases that are not straightforward, sadly the option of extraction is often pursued and many potentially treatable teeth are lost. Research from the American Association of Endodontists shows 97 per cent of GDPs referred within the past year and endodontists received 85 per cent of their patients from GDP referrals. This is a pattern that is developing further in the UK and when faced with the decision to treat or refer, many GDPs will choose the latter.
When it comes to the reasoning behind referral decisions, a survey conducted in England in 1992 showed that the most common reason was for retreatment, followed by the inability to control pain and/or swelling, and the inability to diagnose the cause of the endodontic problem. More recently, GDPs stated that a ‘relatively short waiting time’ was a primary factor for influencing their decision to refer to a specialist endodontist or someone with ‘enhanced skills’.
Whether as a result of endodontic failure or the challenges raised by a complex case, some GDPs are choosing to avoid endodontics and extract teeth instead of saving the tooth. In identifying referral patterns and understanding why GDPs prefer to refer, the opportunity to adapt training programmes to help develop their skills and increase the uptake of endodontics amongst GDPs arises, thus making this treatment more accessible for patients.
Changing perceptions
Perceived as a complex and demanding field, endodontics poses numerous risks and delivers the highest rate of malpractice claims. The key to changing this perception is in the training undertaken, the equipment utilised, and the practitioner’s ability to recognise when a case is too complex and beyond their level of experience. In these cases, the preferred route is to refer ?to a specialist endodontist.
Advances in endodontic technology now enable GDPs to move away from hand files and instead embrace reliable rotary based equipment for safe and effective cleaning and shaping of the canal. An often-cited reason for preferring not to change from hand filing is the fear of file separation. The perceived risk of file breakage is however much lower than the reality. New file designs, elimination of file reuse, and more flexible materials have all further minimised the risk of file separation. With the new single file reciprocating file systems now on the market, there has never been a better time to switch from hand filing.
For GDPs making this switch, Dentsply has simplified the process with its WaveOne technology. Suitable for the majority of straightforward endodontic cases, the canal is shaped with a reciprocating action that is much closer in action to hand filing than rotary systems, giving the user greater control and predictability. It was previously common for GDPs to confuse the action of the rotary files designed for shaping, and finishing the canal, now only one instrument is required. The result is that no time is wasted changing files and shaping time is reduced, allowing maximum time for irrigation of the canals, which will ultimately result in better outcomes. In my experience the WaveOne file is robust, efficient, and reliable and file breakage would only occur through misuse, which I believe should be almost eradicated through the simplification of the system.
When tackling more complex cases, I use the Dentsply ProTaper Next file system. Comprised of five instruments, all with a shortened 11mm handle for improved access, and constructed of M-Wire Nickel Titanium, the system is again a simplification of the preparation process. The rectangular cross section of the files produce a snake-like ‘swaggering’ action effectively creating a larger space to remove any debris while contacting a greater surface area of the canal wall. In practice, such a system simplifies the entire treatment process. Previously, users were prone to skipping file sequences but now this complication has been removed and each file presents an increasing and decreasing percentage tapered design on a single file concept, to minimise taper lock.
Embracing change
Once the barriers of risk, cost and time are overcome, the only challenge the GDP should face when becoming involved with endodontics, is deciding which cases to treat and which to refer according to minimal, moderate and complex difficulty levels. A GDP who is qualified and experienced enough to assess each individual case will be successful in maintaining the optimum level of care for the patient.
Ultimately, when equipped with the correct endodontic training and having gained experience in using advanced technologies and equipment, GDPs will have the necessary skills to undertake root canal treatment with a high success rate and minimal patient discomfort.
References available on request.