Roots to referring – Dr Nik Sisodia

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  Posted by: Dental Design      17th July 2018

We all know that dental practices do not simply become successful over night. There is a lot of time, effort and commitment involved with cultivating a retainable patient base and developing a good reputation within your local community. Therefore, it is important to consider building mutually beneficial relationships with dental specialists, who can help support you in the treatment of complex clinical cases that demand specialist skills. By referring to an expert in endodontics, for example, you are more likely to achieve results patients will be satisfied with – thereby increasing your chances of forming an excellent reputation for delivering quality care and putting the interests of patients first.


As a practitioner, you will have frequently encountered patients who require endodontic treatment. Knowing when to perform these procedures yourself – or refer them out to an endodontist – is an invaluable skill in practice and ultimately hinges on the fundamental question of whether or not you are the best clinician to treat the patient in that moment. It goes without saying that the decision to refer should be based on the skills, time and equipment you possess, as well as the needs of the patient in question. Starting endodontic procedures on a patient with the belief that they can always be referred out later is risky, as very rarely is a patient in an ideal condition for further treatment by the time they are referred.


There are various reasons why a practitioner might refer a case. Some patients may require specialist treatment as a result of limited opening of the mouth, for example, or because they suffer from severe dental anxiety, as well as underlying medical issues that could impact their overall care. Alternatively, a compliant patient may possess a tooth that is extremely difficult to treat, which would require advanced materials and techniques that a general practitioner might not possess. The type of tooth, the morphology of the canal and roots (e.g. combination of curved, narrow or long root canals), as well as the dental history of the patient are just some of the factors that influence how difficult a tooth could be to treat.


Some professional associations provide advice and guidance on which endodontic cases to treat and which to refer. The American Association of Endodontics (AAE), for instance, has created an assessment form and guidelines which can help practitioners to quickly evaluate the difficulty of endodontic cases and weigh them against their own professional experience. The AAE outlines various considerations including:[i] 

  • Complex signs of symptoms which make for a challenging diagnosis
  • Extreme difficulty in obtaining or interpreting radiographs as a result of, for example, superimposed anatomical structures
  • Position of the tooth in the arch, including extreme inclination or rotation
  • The presence of a restoration – a crown may not reflect its original alignment or there may be significant deviation from normal tooth/root form, which could make access very difficult
  • Extensive apical or internal resorption causing severe pain to the patient


It is important that dentists know when a procedure is beyond their capabilities and to make an early referral to a specialist. Guidelines can help make it easier for practitioners to evaluate a patient and decide whether a referral is appropriate.


Referral of endodontic cases is common among even the most experienced practitioners. In fact, a survey carried out by the British Endodontic Society (BES) revealed that the vast majority of practitioners are justifiably wary of undertaking complex root canal procedures that require a more advanced skillset.[ii]This may be due in part to the fact that variables in root canal treatment make it technically challenging and mistakes can be hard to rectify, thus resulting in an unhappy patient who is more likely to make a complaint.


According to the Dental Defence Union (DDU), endodontic treatment featured in 1,429 claims made between 2005 and 2014. These endodontic claims also proved significantly harder to defend successfully, as 62% of claims were settled, compared with 46% where other types of treatment were involved – £25,000 was the highest amount awarded in a case solely regarding root canal treatment.[iii]These figures make it easy to see why some practitioners choose to refer endodontic cases to specialist referral practices, rather than risk liability in the event something goes wrong. Ten Dental, for instance, is one of the UK’s most trusted referral centres. Among its highly experienced team are specialist endodontists, who are trained in tackling complicated root canal treatments with high success rates and minimal patient discomfort.


As with any treatment, practitioners must be competent enough to perform endodontics and they have the choice to undertake professional training in order to improve on their expertise. However, given the risks and complexity that is apparent in many root canal procedures, it’s crucial for practitioners to be able to admit when providing treatment is outside of their skill level. This is, after all, for the benefit and safety of both patient and practitioner.


For more information visit www.tendental.comor call on 020 33932623


[i]American Association of Endodontists. (Unknown) AAE Endodontic Case Difficulty Assessment Form and Guidelines. Link: [Last accessed: 20.03.18].

[ii]British Endodontic Society. (2015) Survey reveals flaws in provision of root canal treatment. Link: [Last accessed: 20.03.18].

[iii]Dental Defence Union. (2015) Pulp fact – looking inside endodontic claims. Link:—looking-inside-endodontic-claims. [Last accessed: 20.03.18].

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