Creating mental focus

In my empirical opinion, one of the most important components of creating great endodontic results is applying an unconditional mental focus to treatment and applying the skills and talents the clinician has without distraction to the task at hand.

I believe that many clinicians could perform treatment worthy of hanging in a museum if they might only slow down and fully focus. Distractions, being tired, poor practice design, treating multiple patients at the same time, uncooperative patients, new and unfamiliar equipment and many such sources of stress can all steal the clinician’s focus.

In addition, if the clinician has not carefully evaluated the tooth being treated, has only one radiographic view of the tooth, has not planned the entire procedure from start to finish (amongst a host of other planning issues that should have been ideally addressed before ever starting the procedure), they can find themselves in very deep water in the middle of the procedure. The longer a minor problem goes unsolved; it can easily become compounded to the point that the loss of the tooth becomes a real possibility.

All of these issues can and often do occur concurrently on a phobic or anxious patient. Anxious patients rarely, if ever, enhance the treatment outcome. As an aside to creating the best platform for treatment, the value of asking oneself honestly if you are capable of treating the tooth and the given patient to the highest standard cannot be overstated. A lack of comfort level on either account is a strong indication for referral.

Comfort levels, personal styles, etc differ in dealing with patients. With this caveat, what follows is the manner in which I approach my clinical treatment. All of the suggestions below can reduce distractions and are designed to make treatment flow uneventfully, all of which I believe improve the focus that can be placed solely on the achievement of an excellent result and making nervous people more comfortable.

1. I only treat one patient at a time. It is not possible for me to concentrate fully on more than one clinical case at a time. I am also uncomfortable for patients to wait untreated with a rubber dam on. Once the rubber dam is on, the patient wants it off as soon as possible. Moving through their case as efficiently and productively as possible can often reassure an anxious patient, i.e. once they are truly numb and it is clear that the procedure is going well, many phobic patients will relax significantly.

2. We have a TV in the ceiling with cable stations, noise reduction headphones, massagers in the chair (Pelton and Crane, Charlotte, NC, USA) and a teddy bear. These simple amenities, along with the best technology available like an intra-oral camera, Dexis digital radiography (Dexisdigital radiography, Alpharetta, GA, USA), quiet multifunctional handpieces such as the Electrotorque TLC handpieces (Kavo, Amersham) and a Global Surgical Operating Microscope (SOM) (DP Medical, UK) all tell the patient that they are being treated with the most advanced technology available today and most often has a calming effect.

3. The patient has given informed consent before starting. This consent includes an acceptance on the part of the patient to have all ancillary procedures needed after the root canal such as crown lengthening done or we will not do the treatment. In addition, if there is any question as to the restorability of the tooth, all such questions are addressed before treatment so as to have as few surprises as possible after. In addition, the patient has been informed if the crown will be taken off, may have decay under it and may need to come off and as a result there are no surprises. I personally do the consent and do not delegate the informed consent discussion. I have found having the Caesy System (Caesy UK) very helpful in giving the patients initial general information before we address their specific case in detail. Both of these are in addition to the extensive written paperwork we have to register the patient.

4. Anesthesia is profound or we do not begin the procedure. It is my empirical observation that once patients realise the treatment is not going to hurt, then many of them fall asleep and/or become very compliant.

5. A movable cart (which is restocked between patients) is available where every clinical supply we will need is available within arms reach. It is very rare that we need to get up and ever get a supply from the lab. Amongst other equipment, this cart has the Elements Diagnostic Unit apex locator, Elements Obturation Unit, MiniEndo (all SybronEndo, Netherlands), as seen in Figure 1. It is essential that every file, supply and material that could possibly be needed be ready and within arms reach at all times. Having to get materials from the lab during treatment always breaks the flow of the procedure and makes re-establishing a firm focus on the tooth that much more difficult.

6. The procedure is carefully rehearsed with the assistant, and often reviewed so as to make our treatment as reflexive and efficient as possible.

7. Treatment rooms are quiet and away from the flow of foot traffic. We have the ability to eliminate all the extemporaneous noise from the treatment room so that the patient knows that they have my full attention. This has value in that they know that we are moving in the straightest line from the start to the finish.

8. I have a general idea how each case will go but the actual treatment is flexible depending on what is encountered during the process of treatment. While many cases will be done with a very similar sequence of instruments, there is flexibility depending on the clinical situation encountered. For example, if the canal system entered has a significant buccal to lingual curvature which is not present radiographically, it may require the use of a smaller taper preparation than initially expected. Treatment is never rushed to reach a conclusion. Many times an excellent clinical result is lost because, when rushing, the basics are forgotten or ignored in the interests of saving time. Given the costs of failure of the procedure, the needed minutes that could otherwise create a successful outcome can lead to hours of reparations in retreatment or needed replacement therapy should the tooth be lost.

Amongst many such problems that can occur while rushing, one common problem is the clinician who advances RNT files too fast and with too much force (often without adequate pre-operative hand exploration or glide path creation) and does not irrigate or recapitulate as often as needed. This is the precursor to blocked canals, lost working length, ledges, fracture of RNT files, canal transportation, i.e. iatrogenic events of all types. Conversely, copious irrigation and recapitulation can go far towards alleviating the possibilities for such iatrogenic events.

9. Refer often and early. Sometimes the best and most profitable case is the one referred. If the patient was your mother, would you be the best person to treat her given your time, skills, equipment and comfort level with the given tooth? Many is the tooth which has been started and has to be referred mid-treatment in far worse condition that when treatment was started, and whose restorability is challenged due to significant iatrogenic events.

Numerous suggestions have been made for improving the mental focus needed to provide excellent treatment. I welcome your feedback.

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