Tooth Story: The Importance of Interdisciplinary Communication in Endodontics

I recently experienced something in private practice that made me learn some important lessons—the biggest one centering on the role of interdisciplinary communication within dentistry. As you’ll see from today’s tooth story, we endodontists sometimes get left out of the treatment plan… and this, my friends, is a mistake we would ALL benefit from correcting. 

As specialists, we have a lot of insight to offer to improve the outcome of a case, and without it, decisions can be made that negatively impact the patient. No well-meaning dental professional wants that, so how can we do better?

I’ve done quite a bit of reflection on this patient’s case, focusing on what went wrong and how I and the entire dental team could have done better for her by appreciating the importance of interdisciplinary communication in endodontics. I’m hopeful that by sharing what I’ve learned, you can avoid similar situations and help ensure your patients get the best care possible—from everyone involved!

A Lovely Lady with a Nasty Infection: What It Can Teach Us About The Importance of Interdisciplinary Communication in Endodontics

The star patient in today’s tooth story is a lovely lady in her sixties who was referred to my office for tooth #19. She had once had a bridge in place spanning from teeth #17–19, and there was now a significant amount of recurrent decay extending into the chamber of #19—hence why she needed a root canal.

As you can see, #19 had become necrotic, and there was a draining sinus tract that traced through to the edentulous ridge of #18. This lesion had clearly been long standing under that bridge!

The 2D imaging really didn’t do this case justice, though. The infection was pretty bad, yet you wouldn’t know that by just looking at the radiographs. It was the CBCT that revealed the whole story. I mean look at the difference—it’s crazy! In 2D, the lesion could barely be seen, but that sucker was clear as day in 3D.

After conducting all of my testing, I diagnosed the tooth with a Necrotic Pulp and Chronic Apical Abscess and proceeded with the root canal.

Fortunately, the procedure went great! The treatment went on without a hitch, and the patient was thrilled! So, I sent her on her merry way, not expecting to see her back until her one-year follow-up, when I would assess how her bone was healing and whether it was regenerating. At the time, I really didn’t think much more of it.

Little did I know, I was in for quite the surprise that would highlight just how important interdisciplinary communication is for endodontics and dentistry as a whole!

More to the Story 

Fast forward 6 months, and the patient had once again landed in my chair, this time telling me that her implant #18 had fallen out, and that my root canal needed to be re-evaluated. 

Wait… what?!? The plan was for an implant to go in #18? Nobody had told me that!

Had I known that was the treatment plan, I would have asked the surgical team to allow at least six to twelve months of healing time for the lesion prior to any grafting or implant placement. Do you see what I mean about endodontists being kept out of the loop?

So after talking to the patient, I learned that following her root canal treatment, she had been seen by her dentist to extract #17, place a graft, and get the implant all in one visit. Now, she was back in my office, sans implant, looking like this:

After seeing the cone beams, my concerns extended beyond the root canal/implant debacle. Her bone loss looked aggressive, which suggested that something more was going on. So, I sent the images off to the oral maxillofacial radiologist to see if I could get more insight into the etiology and get a better handle on how to guide my patient from that point forward.

The verdict? It was osteomyelitis! (Do you see how important interdisciplinary communication is in endodontics?)

That meant that it was probably NOT the root canal on #19 that had caused the implant failure. I say this because I’ve seen other cases similar to this one that ended very differently. 

Here are a couple examples:

This case is almost the twin of this current tooth story, and it healed beautifully with time. 

It’s also worth noting that implants don’t inherently fail when they sit next to a lesion. They just need the right care and some time in order to be successful.

At the end of the day, we’ll never quite know the truth of this case. Had I gotten the chance to do my one-year follow-up, I could have seen whether there was proper bone regrowth, or if the root canal was failing.  Unfortunately, I never got that opportunity, and so we’ll never be able to say for sure.

Lessons Learned

Just because we don’t have all the answers about this case doesn’t mean we can’t use it as a learning opportunity. There are several things that could have been done differently—on my part and the part of the referring dentist—that may have impacted the outcome of this case.

Reflection #1: I Should Have Taken a CBCT Earlier

First, I’ve come to realize that I should’ve ordered a CBCT before I evaluated the patient and committed them to a root canal. At the time of treating this patient, my office policy was to order one afterward, because my belief at the time was that it wasn’t right to take 3D imaging until the patient had committed to treatment. After all, society (looking at you in particular, dental insurance companies), has created the mindset that teeth aren’t valuable, and we need to do everything we can to cut dental costs.

The issue is that if I don’t take that 3D imaging so as to understand the full tooth story before making a diagnosis and suggesting a treatment plan, I can potentially miss out on important information—as can the referring dentist!

Reflection #2: Imaging Should be Shared

This leads me to my second reflection, which is that the images I take really shouldn’t be kept to myself! Yes, I primarily use my cone beams to help me with my root canal treatment, but that doesn’t mean their utility has to stop there. By ordering a CBCT as part of my consultation, I can share them with both the patient and referring dentist, ensuring that everyone can understand the clinical situation. 

Imagine what would have happened if I had taken a 3D image before suggesting a treatment plan and shared it with my patient’s referring dentist. They would have understood the full extent of the infection and just how long they’d have to wait before proceeding with the implant. Remember: It takes 6–12 months for bone to heal following a root canal!

That’s why these days, I actually take a CBCT as part of my consultation appointment. I’ll no longer let insurance companies or the fear of charging a patient impact my clinical needs and decisions. From this case forward, I saw the need to change my workflow, and I am LOVING it!

Reflection #3: Endodontists Should Be Kept in the Loop

I hope this tooth story has clearly demonstrated why it’s a good idea to keep endodontists in the loop—or any specialist for that matter—regarding your treatment plan! Had my patient’s referring dentist indicated what they were planning to do, I still would have performed the root canal, but I also would have made sure they understood the healing time required before proceeding with an implant. This would have saved our patient time, money, and unnecessary suffering, and ultimately led to a better outcome.

When we act in silos, our patients are ultimately the ones who suffer the most. Conversely, when we respect the importance of interdisciplinary communication in endodontics and work together, everyone benefits!

– Sonia