Dentists should be able to assess when the difficulty
of the treatment exceeds their skill and be able to refer
the patient to an endodontist as necessary.
Sometimes, diagnosis and the decision to treat endodontically are
easily achieved, but the technical difficulty of the case
dictates that the patient be referred to an endodontist
for management.
Other factors that may complicate
and increase the difficulty of an endodontic case
include:
(1) calcifications; (2) inability to isolate the
tooth with a rubber dam; (3) resorptive defects;
(4) extra roots and canals; (5) retreatment cases;
(6) presence of a post; and (7) ledges and perforations.
Dentists should recognize these potential problems and
include them in the decision-making process. Referring
the patient before commencement of endodontic
treatment is better than after a procedural problem has
been created (Fig 5) because the procedural error will
compromise the prognosis of the tooth.
After careful
consideration of issues such as strategic value of the
tooth, periodontal factors, patient factors and whether
the tooth can be restored, referring the patient to a
specialist endodontist may be in the best interest of the
patient. Retreatment is warranted after an acceptable
observation period with no signs of radiographic
improvement. Unlike initial treatment of an infected
root canal system, retreatment cases are technically
more difficult to manage (Figs 6a and 6b). In cases
where extraradicular infection is the source of ongoing
disease, apical surgery is considered the treatment of
choice.
Dentists must be aware of their level of clinical
skill, knowledge and experience when they encounter a
case beyond their abilities and such cases should be
referred to an endodontist.