1. Raise your fees.
Endodontics is a great service. Patients hate to be referred to a specialist ("Can't you do it? I don't want to have to see a stranger.") Of course, it is best for you and best for the patient to refer to a specialist whenever indicated. But if you are capable of performing the treatment properly, you're doing the patient a great service. If you complete treatment in one visit, that is an incredible service, and you should charge for it!

As Dr. Howard Farran points out, you will be held to the same standard as the specialist, so on those cases that you do yourself, you should charge the same as the specialist. Dental fees have not even kept pace with inflation, let alone technological advances, and it may be time for you to reexamine your fees.

2. Make risk-free payment arrangements beforehand.
There are few things more frustrating than to interrupt your schedule to help someone in need and bust your butt tackling a difficult case, only to get shafted. As stated in The Richards Report, "If you can't collect it, don't produce it." Don't devalue what you do by not allowing your staff to make solid payment arrangements before you start treatment.

Many companies (such as American General Finance, 800-597-5977) would love to offer long-term financing to your patients who require it. Watch your stress disappear when you work on appreciative patients for fair fees that you know will be collected.

3. Select cases appropriately.
A dentist who occasionally refers cases to Pat once said to him, "Pat, I just spent ten visits on an upper second molar. I should have sent it to you, but I like to show myself that I can do it." Pat couldn't help but think to himself, "Ten visits? Gee, I'm kind of glad he didn't send it to me!" Do what you can do quickly and do it well and send out the rest.

Don't do all your own endo just to satisfy your ego. Any dentist can do endo, but a smart dentist, just like a smart lawyer, chooses his cases wisely. The following chart will remind you of situations which can make endodontic cases more difficult, and may influence your decision regarding referral.

The EndoMagic! Stress-Busting
Case Selection Chart: Send it Out?!

BETTER
vital
anterior
maxillary anterior
mandibular molar
first molar
gradual curve
large pulp
average length roots
no crown
no swelling
first treatment
happy-go-lucky patient
non-strategic tooth

WORSE
necrotic
posterior
mandibular anterior
maxillary molar
second molar
sharp curve
calcification
long roots
through crown
swelling
retreatment
demanding patient
abutment

4. Create a set-up checklist for endodontics.
Make a tray and a tub of all of the endodontic equipment that you need, along with a checklist of everything you need to have set-up, right down to the high- speed with the #4 round-bur and the slow-speed with the #2 gates-glidden. Have everything at your fingertips, not in some drawer down the hall after you've already started. Among the instruments we consider essential to every set-up are a mirror, explorer, and probe, a Stewart endodontic explorer, cotton forceps, the Caulk Endo-M-Bloc measuring device, and an instrument cannister filled with EndoMagic! files.

5. Don't walk into the operatory until the room is set-up.
Insist upon excellence from your assistants. If you do not have a good x-ray, get one. Do not tolerate mediocrity. And don't enable your assistant to neglect the set-up by tolerating incomplete set-ups.

Surgeons do not work without the proper instrumentation, only dentists do. Dentists even pride themselves on being able to work with any instrument. You should pride yourself on becoming better organized and using the best instrumentation.

6. Don't hesitate to sacrifice the mesio-buccal cusp or any other tooth structure that is in your way.
We're amazed at the number of dentists that we meet at our courses who pride themselves on their "small access." What can we do but ask them, "Why?" Small accesses impede free movement of the file, and therefore make thorough cleaning impossible.

Proper access can be checked by closing one eye and verifying that all orifices remain simultaneously visible with only one eye open. In addition, the orifices should be wide open, because the orifices must be opened with files before a working length is determined and access is considered complete.

7. Use a lubricant such
as RC Prep (or KY Jelly).
An endodontist once told us that he doesn't use RC Prep because he doesn't need it and it's expensive. Well, we don't need our high-speed handpiece; I suppose we could do it all with the slow-speed if we had to, and the high-speed is expensive.

However, products that save time don't cost -- they pay. Your patients deserve the best, and so do you. Learn ways to get the best for less. We use KY Jelly instead of RC-Prep as a lubricant, and it costs pennies per gram instead of dollars.

8. Open the coronal aspect of the canal before the apical aspect.
This coronal enlargement before the working-length is the biggest secret to easier endodontics. No longer will you have to fight to get your 10 k-file down to take a working length radiograph. You will take what the canal will give you, and soon your files will float down to the apex.

Not even nickel-titanium files can dance comfortably around multiple curvatures. Opening the orifice in a direction away from the furcation prior to working length determination eliminates the first curve, and leaves only the apical curvature for the file to manage. Apical instrumentation immediately becomes easier and more elegant. The working length remains more accurate, because the bulk of canal straightening, which occurs throughout the procedure, has already been accomplished.

Your patients will have less post-operative discomfort, because you've removed the noxious irritants instead of packing them down or pushing them through the apex. Try coronal instrumentation before apical instrumentation. You and your patients will like it.

9. Turn on to the rotary revolution.
Nickel-titanium rotary files have been available for almost ten years. They maintain the curvature as they negotiate the canal and remove debris in a coronal direction. Tycom's EndoMagic! files are less technique-sensitive than earlier designs. These files are more resistant to breakage and less likely to straighten a canal than other brands. You no longer have an excuse to keep working so hard. If you continue using another brand of rotary files, perhaps you should keep culturing as well!

10. Complete cases in one visit whenever possible.
The quickest way to cut your overhead in half and double your net is to switch from multiple-visit to single-visit endodontics. Post-operative problems will all but disappear; completing needed treatment is much more efficacious than attempting to delay it. Patients will thank you, as they would actually pay extra to avoid another injection or to prevent missing more work. Canals should be filled when they are clean and dry; no sooner and no later. No study has ever compared a medicament favorably to root canal sealer.

No treatment is complete until you give your patient your home phone number. Our patients pay for five-star service, and they get it. No patient of ours will ever be unable to contact us. The idea of one of our patients in pain telling other people instead of telling us would stress us out. Call your patients at night to check how they are doing and to check how you did. They will be touched by your concern.