The Cost of Making These Common Endodontic Referral Mistakes

When dentists ask me how I grew my business to where it is today, my response is that it all came down to the details. Of course, the big things matter too—you’re not going to get any return patients if you do a crappy job—but it’s those tiny, often-overlooked details that really make a difference… like mastering the art of the referral.

Making referrals is such an integral part of dentistry, and yet I see providers making all kinds of endodontic referral mistakes that have far-reaching consequences for their patients and practice. Somehow, a process that should be relatively simple has become the source of a lot of problems that could easily be avoided.

I’m addressing this topic today because referrals have been the source of quite a few headaches in my practice this week. So I feel compelled to set the record straight about referrals, how crucial it is to get them right, and how putting in that little bit of extra effort will have a major impact on your practice. 

If you’re going to vent, it’s best to vent with purpose, right?

Of course, my favorite way to make a point is by sharing tooth stories, so let’s dive into a couple of interesting scenarios that demonstrate some widespread endodontic referral mistakes and what happens when you neglect the art of the referral.

Tooth Story #1: An Early-Morning Endodontic Referral Mistake

The patient in this first tooth story came into my practice at 7am on a Monday (a time when most other offices in my area are closed, by the way). Upon his arrival, he presented his referral slip—a shock in and of itself! A whopping 50% of patients usually come without one, which is honestly problem #1 when it comes to referrals. Why doesn’t dentistry follow the lead of medicine and let the doctors facilitate the referral so they’re not relying on the patient?! But I digress…

Anywho, this patient remembered his referral slip, and this is what it looked like. Do you see something wrong with this picture? 

There was no tooth number circled! And when we asked the patient what tooth number he was referred for, he said “I think it was a front tooth and on the right side.” Not exactly a lot of information to go off of.

Since the referring dentist’s office wasn’t open yet (remember, this was 7am), we had to operate based on what the patient had told us. So we took an x-ray of the area he had indicated, and this is what it looked like:

Exhibit A of why we should never expect our patient to remember these details.

As you can see, there’s no “deep decay” to be found, meaning that either the referring dentist had been entirely mistaken, or—more likely—the decay was in another area of the mouth. Unfortunately for us, we had to wait until the dentist’s office opened to get more information.

A Slew of Consequences

Now, on top of being an annoying inconvenience, an endodontic referral mistake like this has far more consequences than you may realize. First of all, it made this poor patient late for work. Fortunately he was a laid back guy, but who wants to waste their time at the dental office getting radiated more than they have to? 

Second, it held up the referring dentist’s phone lines for no good reason. What if a new patient had been trying to call, and my team intercepted that new patient intake? In the blink of an eye, that dentist just lost a patient and perhaps gained a bad review.

Third, depending on how long it took to resolve the problem, a delay like this could have cost my office as well. Getting tied up with a patient sets off my schedule, leading to more delayed appointments and frustrated patients. 

And finally, delay or no delay, I’m left wondering if the referring dentist actually understands what decay looks like, further impacting the tension that already exists between the GP and the specialist. We need to be a team—not think less of each other!  

Do you see how one small detail in the form of an endodontic referral mistake can impact so many people and prevent practice growth?

A Referral Mystery Solved

Eventually, we were able to get through to the referring dentist’s office and ask if there were any notes about the lower anterior teeth. Of course there weren’t, although they did read us a note about tooth #29. Some info is better than nothing, but I’d need more to be able to make a diagnosis.

So before I took another radiograph, I did all my endo testing to see if that could tip me off. But because I didn’t have a tooth number to go off of, I had to test ALL the teeth in the lower arch. Talk about a big time suck, but what else could I do? I had to cover all my bases. Now, if you were the patient, would YOU want to have to deal with cold testing all your teeth? I think not. (Yet another small detail that has a big impact.)

All of the teeth tested normal except #29, which was a bit more sensitive to cold. Given that my tests seemed to align with the tip I got from the referring dentists, I felt that taking a radiograph of that tooth at this point was warranted.

And there you have it, folks. THERE is the decay! Now I can see what needs to be treated.

An Easy Solution to a Preventable Problem

Do you see how crucial a complete referral slip can be for both the specialist and your patient?  

Now, in this case, I think I was able to prevent this patient from finding a new dentist. But usually an endodontic referral mistake like this is an easy (and preventable!) way to lose a patient. So what can we do to fix this?

I know that life in an operatory can get very busy for most dentists, and it’s both acceptable (and advisable!) to rely on our teams to fill out our referral slips. But let me share with you a system that helps me prevent this type of thing in my practice: 

While I expect my team to fill out the form so I can feel supported and they can feel empowered, I also require them to get it approved and initialed by me. That way, I have the chance to read it over and make sure it’s filled out completely before it ever makes it into the hands of the patient. It’s a super simple but effective way to avoid mistakes, eliminate frustrations, and keep my practice efficient and profitable. 

Tooth Story #2: A Pre-Travel Conundrum

Let’s move on to the next patient and endodontic referral mistake. This patient was actually seen later on the very same day as the patient in Tooth Story #1. It was quite the Monday!  The referring dentist had wanted to get this patient in for treatment super fast because she was going on a trip to Japan the following week. 
I wasn’t concerned about getting the treatment done—that wasn’t the issue here. What worried me was making the right diagnosis based on the referral slip the patient brought in:

Do you see what’s wrong here? Not only are there no findings or notes of diagnostic testing on the referral slip, but the referring doctor had NUMBED the patient! That meant I was going to have one hell of a time trying to make an accurate endodontic diagnosis. 

NOTE: Before I continue with the tooth story, let me be clear: If you ever run into a problem where your patient is dying of pain, do not (I repeat, DO NOT) numb them right away! Instead, write the referral, noting the patient’s pain level, and send them to the specialist. The endodontist can then do their endodontic testing, make the correct diagnosis, and administer the anesthesia immediately after the testing is complete. Make sense? Good! Now onto the rest of the story…

An Inconclusive Diagnosis

When I talked to the patient about her symptoms, she told me her pain level that morning had only been a 4 out of 10. This had me scratching my head as to why on earth the referring dentist had numbed her. And once again, because of a common endodontic referral mistake, my team had to tie up the phone lines to call the dentist for more information, preventing new patients from scheduling at BOTH offices.

When we were finally able to get through, we found out there was some food or debris stuck around her tooth, and the referring dentist had numbed the area to make debridement more comfortable. Well, at least we cleared up THAT mystery—the urgency to numb hadn’t come from the pain but from the trip to Japan. 

The question now was how to proceed. By this point, the patient was taking this whole ordeal as a sign to cancel her vacation. If you know me, I wasn’t about to let that happen—I’ll do ANYTHING to make sure people go on vacation! So I took a preoperative radiograph and this is what I saw:

What does this PA say to you?  

What I see is a poor lone molar and one with some periodontal disease and bone loss around it. One might argue that there’s a periapical lesion around the distal root, but I personally don’t think that’s a definite marker that there’s a necrotic endodontic lesion here. So what’s going on? Was this a periodontal problem, an endodontic problem or a combination of both? 

This is where I would usually rely on my cold test, but that wasn’t going to work given that it was 3:30 pm and the patient was still numb. By the time the anesthesia wore off, my office would be closed for the day. So I had to ask the patient to come back in the morning to do some real testing.

Another Heap of Unintended Repercussions

Here we are again—dealing with the consequences of a common endodontic referral mistake.

Not only was asking the patient to return a total waste of time for everyone involved, but it was also a surefire way to put added stress on the patient. She was already worried about the timeline of her trip, and now I had to delay treatment, should it be necessary. Had the referring dentist sent her straight to me, I could have treated that same day and had her going on her merry way. But without a proper diagnosis, I just couldn’t bring myself to treat that tooth. 

The patient and I weren’t the only ones impacted. Once again, the referring dentist could have lost a patient, because she’d be left wondering why she had been numbed and whether she should even return to that dentist again. Now, in this case, I prevented that line of thinking from happening, but imagine if I hadn’t intervened. A little detail really goes a long way in retaining your patients and making sure they end up getting the right care.  

An Avoidable Detour

What happened the next day when the patient returned? Well, I did my endodontic tests and the tooth tested vital. It felt cold with no lingering pain. What does this mean? It means the patient didn’t need to see me after all. Since only necrotic teeth can create bone loss—and this tooth sure as hell wasn’t necrotic—the patient needed to head straight to the periodontist. This is why I always say we can’t just treat the radiograph—we MUST do our endodontic testing to make sure what we’re seeing is really an endodontic problem and not something else.

I’m so grateful for my ethical heart, but it pains me that, because of this endodontic referral mistake, the patient wasted money coming to see me. She could have used those funds on a periodontal referral instead—or better yet, in the referring dentist’s office or during her upcoming vacation! It was a perfectly avoidable detour on her path to healing.

Take Your Time and Do Things Right!

The lesson here is that endo has everything to do with the business of dentistry and your ability to make a lasting impact on your patients. Even when you’re not the one treating a patient, it’s your job to ensure that the person who is has everything they need to make a proper diagnosis and treatment plan. When you rush through the referral process, you negatively impact your patients, the specialist, and your own practice.

So slow down, take everything to completion, and make sure you do your diagnostic tests on ALL of your patients so they end up in the right seat, receive the right treatment, and have the best chance at making a quick and full recovery.
Need help with your endodontic tests? No problem! Download my free Pulpal and Periapical Diagnosis Checklist to enhance your skills, better understand results of your tests, and improve your diagnoses and treatment plans.

– Sonia