The Economics of Endodontics: Why Proper Pain Diagnosis is Crucial for Your Practice

The topic I want to address today has far-reaching implications for you, your patients, and your practice: your ability to accurately diagnose oral pain.

As a dentist, you’re the first point of contact patients have when seeking care for their oral pain. That means it’s your responsibility to evaluate what’s going on and identify the root of the problem—even if you ultimately end up referring the patient to a specialist for treatment. Why? Because that referral isn’t a get-out-of-jail-free card that relieves you of all responsibility. It’s a crucial step in the process that impacts everyone, every step of the way… in terms of time, energy, and money.

So, let’s spend some time talking about why proper pain diagnosis is a crucial part of your practice, the very real consequences of misdiagnosing patients’ oral pain, and how minding the economics of endodontics can positively impact both your patients and your practice.

Common Mistakes to Avoid When Referring Patients

Let’s start our discussion on the economics of endodontics by clearing up a common misconception when it comes to diagnosing patients’ pain: Not all oral pain is endodontic in origin.

Although oral pain can often signal the need for a root canal, that doesn’t mean that a patient experiencing pain automatically needs one. In actuality, oral pain happens for a LOT of different reasons! It can be occlusal, it can come from a crack (though not as often as you’d think), it can be periodontal in nature, and it can even be your average, run-of-the-mill postoperative pain. 

When you make the assumption that your patient’s oral pain is endodontic in nature and refer them to the wrong specialist (or give your patient the wrong treatment), you’re not making an inconsequential “oopsie.” You end up setting off a domino effect that can have very real consequences for your patient, the specialist you refer them to, and ultimately, you and your practice.

To demonstrate some of the most common mistakes to avoid when referring patients and help you understand how problematic it can be to make an all-too-quick referral, let me share three tooth stories involving patients who were referred to me for endodontic pain… only to find out that the root of their problems were actually something entirely different.

The Economics of Endodontics: Exhibit A

Our first story demonstrating the economics of endodontics centers on a young man who was referred to my office because of swelling around tooth #30. The only problem is, by the time he showed up for his appointment, he wasn’t actually swollen at all! In fact, he was starting to feel better on his own.

That was my first hint that something wasn’t quite right.

My next hint came when I looked at his referral slip:

There’s a contradiction happening here. The patient’s dentist has indicated that the tooth felt cold—but a buccal abscess of endodontic origin should NOT actually feel cold. That tells me there’s either been a mistake… or the dentist has misinterpreted the results of the cold test.

Given that the purpose and results of diagnostic tests are commonly misunderstood, I think you can guess which one!

After conducting my own set of diagnostic tests, my hypothesis was confirmed. The tooth did indeed feel cold, which meant the patient’s swelling had nothing to do with an endo issue, and the dentist had misdiagnosed the source of the problem.

The preoperative radiographs only served to strengthen my conclusion:

Do you see how important it is to do a thorough evaluation? Misinterpreting test results is a common mistake to avoid when referring patients, and look where it got us: In no time at all, an endo problem just got deleted from my differential diagnosis, and now I had to inform the patient that he needs to be referred to a different specialist.   

An unnecessary referral like this is more than just a simple inconvenience for your patient. In this case, my patient not only incurred a fee of a few hundred dollars for the consultation and radiographs at my practice, but he also took time off of work for the appointment. That’s a financial loss for both him and myself! Because instead of spending my time treating a patient who could have had level 10 pain and been in desperate need of my help, I had to spend that appointment time on a non-endo problem—perpetuating the cycle of lost time and money.

Now, I still didn’t definitively know what the patient’s problem was. Maybe it was a periodontal abscess that came and went, or he lacerated the tissue with his toothbrush. Or, perhaps he got some food stuck in the sulcus. (That happened to a patient of mine once—he had a piece of crushed red pepper stuck in there, but once I removed it, all was well!) All I knew was that whatever was going on, it wasn’t related to endodontics. So, I had to send him away without any answers.

My point here is that whether you actually do endo procedures in your practice or not, you’re still doing endo when you investigate the source of a patient’s oral pain. So, believe me when I say it’s imperative you understand the economics of endodontics and just how much this stuff can impact you!

The best thing you can do is brush up on your diagnosing skills and actually do your due diligence when it comes to getting to the root of the problem (including following up with a patient to see if symptoms resolve before writing a referral). Because if you don’t, you could end up causing a lot of frustration—and losing you and your patient money—in the long run. 

The Economics of Endodontics: Exhibit B

Let’s look at another tooth story that demonstrates the most common mistakes to avoid when referring patients. This particular patient presented with some sensitivity to cold and biting, and she was a bit tender to percussion, but none of her test results were too far outside the norm. 

These were her preoperative radiographs:

Based on this information, it wasn’t clear exactly what the patient needed. A full-on root canal (with restoration)? Or just a restoration? Since she’d need the crown either way, I figured it would be best to start there and see if the symptoms resolved on their own. But of course I had to get the go-ahead from the patient first.

After explaining her different treatment options and how I suggested we proceed, she agreed that it would be best to start with the restoration. When this is the treatment plan, I always have the patient function with a temporary crown for one month before coming back to my office for a re-evaluation. And for those of you wondering, no, I don’t charge for the re-evaluation! I prefer to give my time in order to save someone else some money. (It’s all about the economics of endodontics, my friends!)

Well, lo and behold, when the patient returned for her re-evaluation a month later, she was delighted to tell me that she no longer had any symptoms. Now, when this happens, it’s still important to do another full evaluation, because sometimes lack of pain is due to the tooth going necrotic. And you don’t want to place a permanent crown on a necrotic tooth! But luckily for this patient, that wasn’t the case. Her tooth was still vital and responding normally to all diagnostic tests—no root canal needed.

Here’s the radiograph from the re-evaluation:

The reason I’m presenting a case like this to you is that I feel it’s a good example of something that can be completely managed by a general dentist. Even if the patient had ended up needing a root canal, the initial steps of placing the crown and doing a re-evaluation could have easily been done by her dentist. 

But instead, just as with the first tooth story, the patient ended up spending money on an unnecessary eval with a specialist—and I ended up spending time on a non-endo case when I could have been seeing other patients in need (not to mention unnecessarily booked up and unavailable for other referrals). Plus, this could have been the dentist’s own patient! Do you see what happens when you ignore the economics of endodontics?

The solution here is simple: Do your endodontic diagnostic tests and make sure you know what they mean! (Are you seeing a trend here?) Because when you do:

1) You won’t make unnecessary referrals to a specialist and the patient can utilize their benefits at your office (rather than a specialist’s).

2) The patient can avoid incurring another fee or having to take yet another day off of work.

3) The specialist can see a different patient who really needs them—instead of a patient who could have been yours!

It’s a win-win-win.

The Economics of Endodontics: Exhibit C

Let’s look at one more example of a patient that made their way into my office who really shouldn’t have because a dentist made one of the most common mistakes to avoid when referring patients. This patient was referred to our office because their general dentist saw a lesion surrounding teeth #14 and #15, and it looked big and concerning. 

Here are the images so you can see what I mean: 

I mean this lesion was a monster. And at first sight, I thought it was endodontic in nature too! But I’ve learned through experience that I can never assume that teeth with lesions are endodontically necrotic, so it was time to do some investigating.

First, a conversation with the patient revealed that he had no pain whatsoever. In fact, he was surprised he even had to be referred to a specialist. While that didn’t tell me anything conclusive on its own, it was definitely a clue.

Second, I did my endodontic tests and was very surprised to see that, even in the present of this massive periapical lesion, ALL of the teeth in the quadrant (#13, #14, #15, and #16) were vital. He felt cold on every single tooth.

Taken together, that meant the lesion was NOT of endodontic origin, and the patient needed to be referred to a different specialist—an oral surgeon. 

Once again, we find ourselves in a sticky situation for everyone involved because of a lack of understanding of the endodontic diagnosis and the economics of endodontics. When I explained to the patient that I needed to refer him to the oral surgeon, he was understandably less than thrilled. Why had he been referred to an endodontist—spending several hundred dollars on a consult, radiograph, and CBCT in the process—only to be told he had to see yet another specialist? It’s at this point that some patients lose trust in their providers and switch dentists.

Luckily, I was able to pacify the situation and make the patient feel cared for, and he ultimately understood the importance of seeing another specialist. But to be honest, many patients don’t react so positively. And regardless of his emotional reaction, it didn’t erase the financial impact of being referred to the wrong specialist—or the indirect impact it had on my ability to see other patients in need. Plus, if he had reacted more negatively, it could have lost the general dentist a patient, as he likely wouldn’t return to a dentist he no longer trusted.

It’s a vicious cycle… but it CAN be prevented. Let’s talk about how!

Stop the Vicious Cycle By Doing Your Part 

What these three tooth stories have in common is that they all involve situations that could have been triaged by the general dentist, without any involvement by an endodontist like me. Whether that meant treating the patient themselves or sending them to another specialist like an oral surgeon, none of these cases needed to have made it to my office.

So, how can we stop this vicious cycle from negatively impacting patients, dentists, and specialists alike and make the economics of endodontics work to our advantage?

By each of us doing our part! 

For dentists, that means investing in your endodontic training so that you can properly diagnose (and in some cases treat!) your patients’ oral pain. After all, endo isn’t always about doing the root canals—in reality, endo involves so much more that impacts patients at your practice every day. At a bare minimum, make sure you’re always conducting your diagnostic tests and that you actually understand what the results mean. It’s a simple thing to implement that will have a huge impact on your patients and your practice.

For patients, that means taking on an active role in their oral health by becoming more informed. That way, they can better understand what their dentist is telling them, why they may need to be evaluated by a specialist, and whether they should seek a second opinion. You can facilitate this process by being a communicative and caring provider and helping your patients understand the value of their teeth!

And for me, that means continuing to educate dentists on the role of endodontics in dental care and giving them the training and tools they need to feel empowered and prepared to diagnose and treat their patients’ pain. 

By understanding the economics of endodontics, we can not only save patients a lot more time and money, but also ourselves! Because when you accurately diagnose and treat their oral pain yourself where possible, you bring more revenue to your practice through that and possible future treatments—since they’ll have more benefits remaining thanks to avoiding unnecessary trips to a specialist.

Together, we can help patients across the world get the treatment they really need (with less money spent out of pocket), help specialists dedicate more time to patients who truly need them, and help your practice become more profitable.

Improve Your Diagnosis With My Free Checklist

Do your part in avoiding common mistakes when referring patients and stopping the cycle by improving your diagnostic skills with my free Pulpal and Periapical Diagnosis Checklist. It’s an easy reference guide to ensure you get the diagnosis right every time, helping you enhance your treatment plans, reduce chair time, and increase profits at your practice.

– Sonia