Internatioml Endodontic journal t\992) 25,25-28
A survey ofendodontic procedures performed by practitioners in limited practice F.J. HARTY Institute ofDerttal Surgery, Gray's Inn Road. London WCl, UK
Summary Patients are sometimes referred for treatment to dentists who limit their practices to endodontics. A survey of consecutive referrals to seven such dentists was undertaken. The most common reasons for such referrals were (i) for the retreatment of a tooth with a previous root filling, (ii) because the referring dentist was unable to control pain and/or swelling, or (iii) because the referring dentist was unable to diagnose the endodontic problem. Only 60 (12.8%) ofthe 469 reasons reviewed were in teeth that were symptomless, uncomplicated and untouched by the referring dentist. Keywords: referrals, root canal treatment, specialist dental practice. Introduction The topic of specialization in dentistry has. of recent years, enjoyed a revival of interest in the UK, The arguments for and against specialization are not new, and were debated in Stockholm, Sweden in 1963 at the 51st Annual Session of the Federation Dentaire internationafe (FDI). Currently the subject is considered to require urgent discussion, and it is accepted that a decision will need to be made, possibly before the implementation of the Single European Act in 1992. The Royai Colleges are aware ofthe problems, and the Royal College of Surgeons of England organized a successful Study Day entitled 'Specialization in Dentistry, the Dentist—Jack of All Trades and Master of One', The proceedings of this Study Day were reported (Royal College of Surgeons 1988a,b) and a pertinent Leader (British Dental Joumai 1988) placed the subject in perspective. The British Dental Association followed this by convening a Specialization Workshop in April 1989, and this was attended by representatives of all official bodies as well as the Specialist Societies, Correspondence: 3 Gloucester Gate Mews. Regents Park, London NWl 4AD, UK.
TaWe 1. Number of root treatments, percentage of total scalefeesand number of teeth extracted
Year
Number of root treatttients
Percentage of total scale fees
Number of teeth extracted
1966 1971 1976 1981 1986/7
195 190 329 000 640 210 1088 110 1 305 340
0.71 1.40 2.24 3.08 3.95
8 074 100 7 099 710 5 656 100 4071 810 3 584 000
It is possible that the renewed interest in this topic has occurred because the subject is under review by the European Community Advisory Committee on the Training of Dental Practitioners. Directives are being drawn up to regulate not only the training of general dental practitioners but also the training of specialists and the requirements for admission to a specialist register. It is generally accepted that for a branch of dentistry to be recognized as a specialty, there must be a substantial public need and a demand for the service which cannot be adequately provided by the general dental practitioner, or by specialists in other fields of dentistry. In the case of endodontics. the demand for this service in England and Wales can be demonstrated by studying the figures supplied by the Dental Estimates Board for England and Wales and quoted by Farrell & Burke (1989) (Table 1), Comparing the number of root fillings performed in 1966 with that 20 years later, a sevenfold increase in root treatments is seen. A better indication of the increase in volume of treatment may be gleaned by the amount spent on Item 7 of the Scale of Fees as a proportion of the total spent on dental care within the General Dental Services of the National Health Service (NHS). The amotmt spent on root treatment has increased from 0.71% in 1966 to 3.95% in 1986/1987. It is interesting to note that over the same time pedod the number of extractions decreased by more than 50%. 25
26
F, /, Harty TaWe 3, Reasons for referral
TaWe 2, Treated teeth
Reason
Per cent
Number of teeth treated surgically
Per cent
251 89 81
59.6 21.2 19.2
1 5 23
17.2 79.3
421
100.0
29
100.0
Number of teeth Moiars Premolare Anteriors Total
3.5
However, no studies have been reported that demonstrate the need for practitioners who are able to provide endodontic treatment which cannot be provided by the generaiist or other dental specialists. To supply this information, a survey was undertaken to determine the type of treatment referred by general dental practitioners to dentists who have limited their practice to endodontics. Materials and methods A questionnaire was devised and used in a pilot study to determine the relevance of the questions asked, and to obtain comments from the dentists who were participating in the study. Twenty questionnaires were sent to each of seven dentists, who were known to limit their practice to endodontics. They were asked to record information pertaining to 20 consecutive patients referred for treatment. As there were no adverse comments on the structure of the questionnaire, a further batch was sent to those dentists who had agreed to participate, and to two further dentists who were known to accept referrals for endodontic treatment. All were asked to record information relating to every patient referred for treatment over a 3-week period. Results Table 2 shows the number of teeth referred for treatment. Not ali replies specified the tooth requiring treatment, and hence only 421 teeth were considered. Of these, almost 60% were molars, with the balance made up of almost equal proportions of premoiar and anterior teeth. A further count was made in order to determine the incidence of teeth referred for surgery and subsequently treated surgically. From Tabie 3 it can be seen that 32 teeth were deemed to require surgery, twenty-nine of which were treated in this marmer (Tabie 2), Table 3 lists the reasons for referral. The total number given in this table does not correspond to that in Table 2
n Per cent
Uncomplicated symptomless case untouched by GDP 60 12.8 For surgery 32 6.8 Calcified root canal 54 11.5 Retreatment of previous root filling 93 19.8 Inability ofreferringdentist to diagnose 63 13.4 Inability of referring dentist to control pain 64 13.7 and/or swelling 25 5.3 Periodonta! endodontic complication or lesion 11 2.4 Medically compromised patient 9 1.9 Ledged or dllacerated root canal 10 2.1 Fractured tooth Inability of referring dentist to obtain adequate 10 21 analgesia 12 2.6 Perforation of root canal system Other reasons for referral: Root resorption (2) Fractured instrument (4) Incomplete root formation (2) Fractured root 11 ( Carious exposure (4) Interceptive endodontics 11) Recurrence of abscess (1) Traumatic injury (2) Very nervous patient (2) Inability ofreferringdentist to locate canals |2! Avuised tooth (2) 26 5.6 Abnormal root anatomy (S) 469 100.0 Total
because, often, more than one reason was stated for each tooth requiring treatment. The most common reason given by the referring practitioner was for the retreatment of a previous root filling (93 cases, 19,8%). Inability to control pain and/or swelling (13,7%) and inabihty to diagnose the cause of the endodontic problem (13,4%) were the two next most common reasons for patient referral. Anatomical abnormalities feature in this table and, of these, 'calcified canals' (11,5%) appeared to be the most common problem. The table describes several other reasons for referral, of which only periodontai/ endodontic problems and those cases requiring surgery each accounted for more than 5% of the total. Only 60 (12,8%) of the 469 reasons for referral related to teeth that were symptomless, generally requiring uncomplicated treatment, and that were untouched by the referring dental surgeon. From the remainder ofthe answers received and noted in Table 3 it can be seen that the patients referred to dentists limiting their practices to endodontics consisted
Endodontic procedures in limited practice
either of patients with probiems that the referring dentist had identified but was unwilling or unable to deal with, or patients with imdiagnosed problems that required a solution. It was not possible from the questionnaire to determine what proportion of referred cases had previously been treated by the referring dentist with unsatisfactory results requiring correction.
Discussion The present study shows that there is a demand for endodontic treatment, and that the treatment required in the referred patients is generally not straightforward and often more difficult to perform because of some complication due to normal or abnormal pulp morphology, trauma, or because of a previous unsuccessful attempt at root treatment. It may be argued that this study is not representative of the general dental population because the data relate to patients treated outside the National Health Service. However, the Dental Estimate Board's figures quoted by Farrell & Burke (1989) indicate that the demand for endodontic treatment has risen considerably in the last 20 years, and there is no reason to believe that patients treated under the NHS would not present with the same problems as those listed in Table 3. Indeed it is possible that the patients surveyed in this study may have been former NHS patients whose treatment had failed and/or whose dentist elected to seek specialist advice rather than to treat or retreat the patient personally. The number of patients treated by the seven dentists who limited their practices to endodontics is very small compared to the volume of treatment carried out under the general dental services of the NHS. One must therefore question what happens to patients who require endodontic treatment as a routine or because previously attempted treatment had subsequently failed. Most dentists generally agree that endodontics should be taught at undergraduate level and practised as a routine in general dental practice. Unfortunately, in most schools, the time devoted to the teaching and practice of this branch of dentistry is, of necessity, limited because ofthe demands of many other aspects of dentistry requiring attention. This results in practitioners entering practice with a desire to save teeth by endodontic treatment, and attempting to do so, but often with inadequate experience and expertise. This frequently leads to treatment that cannot be completed satisfactorily, or to treatment that subsequently fails and
27
requires reassessment. This may take the form of nonsurgical or surgical retreatment. or the ultimate removal of the tooth. It is claimed that patients who require treatment or more complex procedures tnay be referred to a teaching hospital or to a dental consultant at a district hospital. This is partly true, but not all parts of the cotmtry have ready access to teaching hospitals or to fully staffed dental departments, and often the waiting lists for treatment other than emergency endodontic treatment are either long or closed. Many provincial hospitals have neither the funds nor the manpower to establish departments in all branches of dentistry, and often the denta! department consists of a consultant dental surgeon with the minimum of supportive staff. These consultants are generally overworked and are expected to advice and treat not only cases requiring surgery, but aiso problems arising from virtually every branch of dentistry, including failed restorative treatment, the latter often involving failed conventional root canal treatment. Most consultants are well aware that the treatment of choice in such situations is non-surgical retreatment of the endodontic failure. They are also aware that sending the patient back to the referring dentist may not solve the patient's problem, for the patient would not have been referred if the practitioner could have dealt with the matter in the first place. In these circumstances the consultant has three choices. First, he can retreat the tooth by non-surgical root treatment. This is seldom done, because root canal treatment is time consuming and most consultants simply do not have the time, and some may lack the expertise in this field. Secondly, he may treat the case surgically, but this approach is often a second best, and may be unnecessarily traumatic for the patient. Thirdly, he may decide to solve the problem by extraction. To overcome these inadequacies of the availability of endodontic treatment within the NHS, there is a need for a new type of practitioner who, by choice and further training, restricts his practice to endodontics and accepts referrals from practitioners who, for whatever reason, are unwilling or unable to carry out endodontic treatment. At present no such facility exists within the NHS, and it must be concluded that a large number of teeth are lost that could have been saved by 'specialist' treatment.
Acknowledgements I would like to thank the following busy practitioners who participated in this study: Mr M. Bennetts, Mr D,
28
F. J. Harty
C o h e n , Mr S, C u n n i n g t o n , Mr S, M a n n i n g , Mr C, Stock a n d Mr T W e b b e r
BRITISH IteNTAL JOURNAL (19881 Leader, Specialisation in Dentistry. British Dental jounwl 165, 77. FARRELL T.H. & BURKE F.J.T. (1989) Root Canal Treatment in the General Dental Service, 1948-1987. British DenUd loumal. 166, 203-208.
ROYAL COLLEGE OF SURGEONS {1988a) SpeclalUation in Dentistry, The Dentist—Jack of All Trades and Master of One. Report of a clinical study day. held at the Faculty of Dental Surgery, Royal College of Surgeons of &igland on 29 January 1988, Part 1. British Dental journal, 165, 99-105. ROYAL COLLEGE OF SURGEONS (1988b) Specialisation in Dentistry. The Dentist—fack of All Trades and Master of One. Report of a clinical study day. held at the Faculty ofDental Surgery, Royal College of Surgeons of England on 29 January 1988, Part 2. British Dental /ournai. 165,142-146.
A survey ofendodontic procedures performed by practitioners in limited practice F.J. HARTY Institute ofDerttal Surgery, Gray's Inn Road. London WCl, UK
Summary Patients are sometimes referred for treatment to dentists who limit their practices to endodontics. A survey of consecutive referrals to seven such dentists was undertaken. The most common reasons for such referrals were (i) for the retreatment of a tooth with a previous root filling, (ii) because the referring dentist was unable to control pain and/or swelling, or (iii) because the referring dentist was unable to diagnose the endodontic problem. Only 60 (12.8%) ofthe 469 reasons reviewed were in teeth that were symptomless, uncomplicated and untouched by the referring dentist. Keywords: referrals, root canal treatment, specialist dental practice. Introduction The topic of specialization in dentistry has. of recent years, enjoyed a revival of interest in the UK, The arguments for and against specialization are not new, and were debated in Stockholm, Sweden in 1963 at the 51st Annual Session of the Federation Dentaire internationafe (FDI). Currently the subject is considered to require urgent discussion, and it is accepted that a decision will need to be made, possibly before the implementation of the Single European Act in 1992. The Royai Colleges are aware ofthe problems, and the Royal College of Surgeons of England organized a successful Study Day entitled 'Specialization in Dentistry, the Dentist—Jack of All Trades and Master of One', The proceedings of this Study Day were reported (Royal College of Surgeons 1988a,b) and a pertinent Leader (British Dental Joumai 1988) placed the subject in perspective. The British Dental Association followed this by convening a Specialization Workshop in April 1989, and this was attended by representatives of all official bodies as well as the Specialist Societies, Correspondence: 3 Gloucester Gate Mews. Regents Park, London NWl 4AD, UK.
TaWe 1. Number of root treatments, percentage of total scalefeesand number of teeth extracted
Year
Number of root treatttients
Percentage of total scale fees
Number of teeth extracted
1966 1971 1976 1981 1986/7
195 190 329 000 640 210 1088 110 1 305 340
0.71 1.40 2.24 3.08 3.95
8 074 100 7 099 710 5 656 100 4071 810 3 584 000
It is possible that the renewed interest in this topic has occurred because the subject is under review by the European Community Advisory Committee on the Training of Dental Practitioners. Directives are being drawn up to regulate not only the training of general dental practitioners but also the training of specialists and the requirements for admission to a specialist register. It is generally accepted that for a branch of dentistry to be recognized as a specialty, there must be a substantial public need and a demand for the service which cannot be adequately provided by the general dental practitioner, or by specialists in other fields of dentistry. In the case of endodontics. the demand for this service in England and Wales can be demonstrated by studying the figures supplied by the Dental Estimates Board for England and Wales and quoted by Farrell & Burke (1989) (Table 1), Comparing the number of root fillings performed in 1966 with that 20 years later, a sevenfold increase in root treatments is seen. A better indication of the increase in volume of treatment may be gleaned by the amount spent on Item 7 of the Scale of Fees as a proportion of the total spent on dental care within the General Dental Services of the National Health Service (NHS). The amotmt spent on root treatment has increased from 0.71% in 1966 to 3.95% in 1986/1987. It is interesting to note that over the same time pedod the number of extractions decreased by more than 50%. 25
26
F, /, Harty TaWe 3, Reasons for referral
TaWe 2, Treated teeth
Reason
Per cent
Number of teeth treated surgically
Per cent
251 89 81
59.6 21.2 19.2
1 5 23
17.2 79.3
421
100.0
29
100.0
Number of teeth Moiars Premolare Anteriors Total
3.5
However, no studies have been reported that demonstrate the need for practitioners who are able to provide endodontic treatment which cannot be provided by the generaiist or other dental specialists. To supply this information, a survey was undertaken to determine the type of treatment referred by general dental practitioners to dentists who have limited their practice to endodontics. Materials and methods A questionnaire was devised and used in a pilot study to determine the relevance of the questions asked, and to obtain comments from the dentists who were participating in the study. Twenty questionnaires were sent to each of seven dentists, who were known to limit their practice to endodontics. They were asked to record information pertaining to 20 consecutive patients referred for treatment. As there were no adverse comments on the structure of the questionnaire, a further batch was sent to those dentists who had agreed to participate, and to two further dentists who were known to accept referrals for endodontic treatment. All were asked to record information relating to every patient referred for treatment over a 3-week period. Results Table 2 shows the number of teeth referred for treatment. Not ali replies specified the tooth requiring treatment, and hence only 421 teeth were considered. Of these, almost 60% were molars, with the balance made up of almost equal proportions of premoiar and anterior teeth. A further count was made in order to determine the incidence of teeth referred for surgery and subsequently treated surgically. From Tabie 3 it can be seen that 32 teeth were deemed to require surgery, twenty-nine of which were treated in this marmer (Tabie 2), Table 3 lists the reasons for referral. The total number given in this table does not correspond to that in Table 2
n Per cent
Uncomplicated symptomless case untouched by GDP 60 12.8 For surgery 32 6.8 Calcified root canal 54 11.5 Retreatment of previous root filling 93 19.8 Inability ofreferringdentist to diagnose 63 13.4 Inability of referring dentist to control pain 64 13.7 and/or swelling 25 5.3 Periodonta! endodontic complication or lesion 11 2.4 Medically compromised patient 9 1.9 Ledged or dllacerated root canal 10 2.1 Fractured tooth Inability of referring dentist to obtain adequate 10 21 analgesia 12 2.6 Perforation of root canal system Other reasons for referral: Root resorption (2) Fractured instrument (4) Incomplete root formation (2) Fractured root 11 ( Carious exposure (4) Interceptive endodontics 11) Recurrence of abscess (1) Traumatic injury (2) Very nervous patient (2) Inability ofreferringdentist to locate canals |2! Avuised tooth (2) 26 5.6 Abnormal root anatomy (S) 469 100.0 Total
because, often, more than one reason was stated for each tooth requiring treatment. The most common reason given by the referring practitioner was for the retreatment of a previous root filling (93 cases, 19,8%). Inability to control pain and/or swelling (13,7%) and inabihty to diagnose the cause of the endodontic problem (13,4%) were the two next most common reasons for patient referral. Anatomical abnormalities feature in this table and, of these, 'calcified canals' (11,5%) appeared to be the most common problem. The table describes several other reasons for referral, of which only periodontai/ endodontic problems and those cases requiring surgery each accounted for more than 5% of the total. Only 60 (12,8%) of the 469 reasons for referral related to teeth that were symptomless, generally requiring uncomplicated treatment, and that were untouched by the referring dental surgeon. From the remainder ofthe answers received and noted in Table 3 it can be seen that the patients referred to dentists limiting their practices to endodontics consisted
Endodontic procedures in limited practice
either of patients with probiems that the referring dentist had identified but was unwilling or unable to deal with, or patients with imdiagnosed problems that required a solution. It was not possible from the questionnaire to determine what proportion of referred cases had previously been treated by the referring dentist with unsatisfactory results requiring correction.
Discussion The present study shows that there is a demand for endodontic treatment, and that the treatment required in the referred patients is generally not straightforward and often more difficult to perform because of some complication due to normal or abnormal pulp morphology, trauma, or because of a previous unsuccessful attempt at root treatment. It may be argued that this study is not representative of the general dental population because the data relate to patients treated outside the National Health Service. However, the Dental Estimate Board's figures quoted by Farrell & Burke (1989) indicate that the demand for endodontic treatment has risen considerably in the last 20 years, and there is no reason to believe that patients treated under the NHS would not present with the same problems as those listed in Table 3. Indeed it is possible that the patients surveyed in this study may have been former NHS patients whose treatment had failed and/or whose dentist elected to seek specialist advice rather than to treat or retreat the patient personally. The number of patients treated by the seven dentists who limited their practices to endodontics is very small compared to the volume of treatment carried out under the general dental services of the NHS. One must therefore question what happens to patients who require endodontic treatment as a routine or because previously attempted treatment had subsequently failed. Most dentists generally agree that endodontics should be taught at undergraduate level and practised as a routine in general dental practice. Unfortunately, in most schools, the time devoted to the teaching and practice of this branch of dentistry is, of necessity, limited because ofthe demands of many other aspects of dentistry requiring attention. This results in practitioners entering practice with a desire to save teeth by endodontic treatment, and attempting to do so, but often with inadequate experience and expertise. This frequently leads to treatment that cannot be completed satisfactorily, or to treatment that subsequently fails and
27
requires reassessment. This may take the form of nonsurgical or surgical retreatment. or the ultimate removal of the tooth. It is claimed that patients who require treatment or more complex procedures tnay be referred to a teaching hospital or to a dental consultant at a district hospital. This is partly true, but not all parts of the cotmtry have ready access to teaching hospitals or to fully staffed dental departments, and often the waiting lists for treatment other than emergency endodontic treatment are either long or closed. Many provincial hospitals have neither the funds nor the manpower to establish departments in all branches of dentistry, and often the denta! department consists of a consultant dental surgeon with the minimum of supportive staff. These consultants are generally overworked and are expected to advice and treat not only cases requiring surgery, but aiso problems arising from virtually every branch of dentistry, including failed restorative treatment, the latter often involving failed conventional root canal treatment. Most consultants are well aware that the treatment of choice in such situations is non-surgical retreatment of the endodontic failure. They are also aware that sending the patient back to the referring dentist may not solve the patient's problem, for the patient would not have been referred if the practitioner could have dealt with the matter in the first place. In these circumstances the consultant has three choices. First, he can retreat the tooth by non-surgical root treatment. This is seldom done, because root canal treatment is time consuming and most consultants simply do not have the time, and some may lack the expertise in this field. Secondly, he may treat the case surgically, but this approach is often a second best, and may be unnecessarily traumatic for the patient. Thirdly, he may decide to solve the problem by extraction. To overcome these inadequacies of the availability of endodontic treatment within the NHS, there is a need for a new type of practitioner who, by choice and further training, restricts his practice to endodontics and accepts referrals from practitioners who, for whatever reason, are unwilling or unable to carry out endodontic treatment. At present no such facility exists within the NHS, and it must be concluded that a large number of teeth are lost that could have been saved by 'specialist' treatment.
Acknowledgements I would like to thank the following busy practitioners who participated in this study: Mr M. Bennetts, Mr D,
28
F. J. Harty
C o h e n , Mr S, C u n n i n g t o n , Mr S, M a n n i n g , Mr C, Stock a n d Mr T W e b b e r
BRITISH IteNTAL JOURNAL (19881 Leader, Specialisation in Dentistry. British Dental jounwl 165, 77. FARRELL T.H. & BURKE F.J.T. (1989) Root Canal Treatment in the General Dental Service, 1948-1987. British DenUd loumal. 166, 203-208.
ROYAL COLLEGE OF SURGEONS {1988a) SpeclalUation in Dentistry, The Dentist—Jack of All Trades and Master of One. Report of a clinical study day. held at the Faculty of Dental Surgery, Royal College of Surgeons of &igland on 29 January 1988, Part 1. British Dental journal, 165, 99-105. ROYAL COLLEGE OF SURGEONS (1988b) Specialisation in Dentistry. The Dentist—fack of All Trades and Master of One. Report of a clinical study day. held at the Faculty ofDental Surgery, Royal College of Surgeons of England on 29 January 1988, Part 2. British Dental /ournai. 165,142-146.
