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November 2003Photos Assist with Treatment Planning

Fig. 1

One of the most important functions of the referral form is to prepare the Endodontist for prospective treatment of the patient. But while endodontic referral forms have the ability to transmit some information, there is nothing like a good photograph to show the clinician the condition of the tooth and help them anticipate the patient's needs. This is especially important for patients who are traveling from very far away to see the specialist. In my case this can be anywhere from 3 hours away or more by car to several hundred km. by air (from northern Canada). They do not want a series of 15 minute consults with two or more specialists, staggered over several weeks. The cost of air transportation alone from these remote locations may be equal to or greater than the cost of the treatment. Therefore, the more information we have, the easier it is to plan treatment for these patients and for this treatment to be efficiently coordinated.

After this photo and radiograph ( below) arrived I was able to ask several questions of the referring dentist that allowed us to perform a better service for the patient. Some of these were:

1. How anxious is the patient to have the tooth restored? ( Did the patient want the tooth restored immediately?)
If the patient was in no hurry and if aesthetics was not a concern, then coordination of restoration with the referring dentist wouldn't be a factor in scheduling an appointment. However, if the patient wished to have the tooth restored as soon as possible, it may be necessary to phone the referral office to make coordinated appointments. This would ensure that the patient would have an acceptable aesthetic situation as soon as possible after the endodontic treatment was completed. i.e./ endo in a.m. at Endodontist Office. - temporary post/core restoration in p.m. Prosthodontist's office.

2. Is a post space required? If so, is there enough tooth to allow for placement? Has the tooth been previously treated or post removed?
All these factors can impact on the time and cost or treatment and possible overall prognosis.

3. Has the patient been told that crown lengthening might be required should caries result in inadequate biologic width prior to restoration?
Patients do not like surprises and neither do I. They need to know that crown lengthening MIGHT be required , BEFORE they start treatment. This may have an effect on their decision to treat, due to financial or time frame commitments. In this case there is insufficient tooth structure to allow us to place a rubber dam clamp on the tooth. A clamp can be easily placed on an adjacent tooth but it is certainly nice to know about this lack of tooth structure prior to referral. A photo is an excellent way to easily convey this information.

The Emailed photograph also allows me to forward this image to the Periodontist for his opinion. Is crown lengthening required? How long would it take and what would be the approximate fee. Perhaps he has his own opinion on the best treatment. If the root is fractured, would the area be a good candidate for an implant? This is important to know before we start.

4. Would the patient be interested in in a "combined" Endodontic/Periodontal procedure?
I work very closely with two Peridodontists in my building. We frequently can perform both procedures using only one local anesthetic. In this case, I would anaesthetize the patient, complete the endodontics and then the patient would immediately go down two floors to the Peridodontist's office to have the remainder of the procedures performed. Less overall treatment time is needed for the patient, fewer drugs need be administered. These factors combined with better communication, result in more efficient patient treatment and a better clinical result.

Fig. 2

The X ray image above ( Fig.2) is an exact copy of the image that was sent with the photo. It was taken with a Nikon 995 digital camera as it was held over an x ray viewbox. Is it a "perfect" X ray image? No. But it is certainly more than adequate to show the Endodontist the size of the tooth, root length, level of canal calcification, presence of previous treatment, broken instruments, prior posts, etc. and for him to get a sense as to how easy or difficult the case may be. It is also a VERY inexpensive way of generating "Digital X- Ray" images without the actually Digital X ray sensor equipment. By sending the x ray images in this manner - films never get LOST and they cost nothing to "duplicate".

Conclusion
Imaging technology allows for better application of the "Team" concept of treatment. Invest in a good quality digital camera with macro capabilities today and start sending those images to your specialist via E mail. You both will be glad you did.