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Saying No To Root Canal

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: March 2, 2020

When your patient thinks root canal is needed – and you disagree…

If you have been practicing dentistry for some years, a patient has likely presented to your office with a toothache of unclear origin. During your routine evaluation process, you struggled to identify the origin of the pain despite the patient’s insistence on the location and the need for something to be done right away.

So what are your options?

We have all told patients that we would prefer to take a wait and see approach. It buys us some time to see if the pain localizes to a more identifiable tooth site. At times, the patient is agreeable to this plan. At other times they are insistent that some action be taken immediately. If you do not choose to treat initially, or even if you do, and then symptoms linger, the patient will return within a few days with the same complaint looking for an answer.

Either way, you must be prepared with a strategy going forward:

1. Validation

The patient in either situation will likely not understand how they can be in so much pain while you are not able to identify the source. It is crucial, at the very least, that you validate that their pain is real. There is no room for you to leave any doubt in their mind that you do not believe them. 

If you say that everything looks fine (particularly if you had chosen to treat a tooth and the pain continues), this will suggest that you think they are making it up.

What works well in this situation is to say something like this:

 “Ms. Jones, I know you are suffering and feel pain in that specific tooth. However, my examination, provocations, imaging, diagnostic use of local anesthetic, etc. suggest your pain is due to something other than the nerve in that tooth. If I take out the nerve, there is a good chance your pain will not go away. That is because we did not identify the true source.” 

(If you already treated a tooth without success, this should even become more apparent to the patient.)

2. Education

At this point, you will need to go beyond validation and begin the education process so the patient can understand what the other sources of their pain may be.

Elusive toothaches are not necessarily easy to diagnose and treat. Your obligation from here is to provide the patient with a list of other possible sources of their pain and present a plan of action to address their suffering.

With the knowledge that beyond a pulpal origin, tooth site pain is most commonly due to referral from dysfunctional muscles of the jaw and neck or excitation of the trigeminal nerve system for a broad array of reasons, this must be how your explanations are delivered.

3. Explanation

Exploring the risk factors that may have induced trigeminal nerve excitation and or muscle dysfunction, as you know, may take a bit of time. And, this is often where the challenge lies.

Do you have time to dissect the patient’s medical history? It may include intermittent migraines, insomnia, chronic sinus disease, IBS, systemic inflammatory/autoimmune conditions like rheumatoid arthritis, prior chemotherapy, or fibromyalgia, to name just a few. All of these conditions can excite the trigeminal system and lead to toothache complaints.

Do you have time to obtain the patient’s thorough psychosocial history and associated medications? They may be impacting muscle tension, breathing, posture, oral behaviors, etc. and creating opportunities for pain to arise in the orofacial arena. 

As this broad canvas of risk factors may contain the clues necessary to make the right diagnosis, this thinking must be communicated to the patient.

4. Patient Participation

The next essential ingredient to get the patient to participate in uncovering vital clues. In essence, the focus needs to shift away from the doctor as the sole participant in this investigation. The patient must examine all potential risk factors and help determine what has likely sensitized their trigeminal system beyond a dying dental pulp.

Only with this way of thinking, combined with the information gleaned by both the doctor and patient, can there be understandable rationale not to provide tooth directed therapy in the presence of persistent pain. The patient must share the responsibility of uncovering clues when the treating dentist only uncovers limited objective information.

When additional information is uncovered, treatment strategies may lean away from the dental office and into areas of expertise that may require collaboration with colleagues in dentistry or other healthcare fields.

In Conclusion

I do not suggest this scenario is easy to pull-off. It may require the use of pain medications along the way to buy time. Supportive phone calls/emails are, of course, helpful as well, so the patient is less likely to drift to other offices where treatment may be delivered simply because the patient is suffering.  

I do believe, however, if you have a plan in place the next time this situation presents itself, the ultimate outcome will likely be more favorable for you – and your patient.

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