Use the GOLDstein Standard…

When I was partnered with Dr. Kit Weathers at our two-day, hands-on endodontic “Root Camp” seminars, we were regularly amazed at the improvements in efficiency that our attendees would make following their hands-on training. In fact, the typical Root Camp participant increases his or her hourly endo production between $184 and $242, depending on whether the tooth is anterior or posterior. During Root Camp, I would analyze fee and productivity statistics from each doctor’s “pre-seminar survey,” and I presented data obtained from the surveys. The survey included information about the volume of endo cases being treated, as well as the fee charged and the time scheduled to complete the root canal. I compared the numbers with the averages of the previous six Root Camp classes so students could better understand how they “measured up.” I then provided specific recommendations concerning fees and efficiency improvements and I discussed the expected impact of making these positive changes in the practice.The Science of “Endonomics” I’ve even coined a word to describe my conclusions- “Endonomics.” Endonomics refers to the study of how improved endodontic skills impact the economics of the typical dental practice.

There’s no question that following Root Camp, each doctor has a better understanding of the importance of efficiency while performing his or her root canals. They understand how even small decreases in their endo treatment times translate into large increases in their hourly production. Further, they understand the tremendous cost to their practices when they schedule a single-visit molar root canal appointment, and then discover that they’re unable to complete the case. At Root Camp, Dr. Weathers teaches an entire segment about how to decide in advance, which root canal cases you should treat and which ones you should refer. He calls this segment, “Knowing When to Hold Them and When to Fold Them (does anyone remember the great Kenny Rodgers?).”

Despite the improvement in their endo treatment skills and efficiency, and the better understanding of which cases they should be treating or referring, many students are still hesitant to schedule certain root canal cases because they’re afraid they may “get in over their heads.” This hesitancy has a lot to do with the potential financial devastation that would occur from starting a root canal procedure that they cannot complete. In fact, looking at the calculations from a recent Root Camp group, if one of those doctors scheduled a molar root canal that he could not complete, he would waste 1 hour and 46 minutes and lose $830 for the lost, single-visit scheduled appointment.

The agony of an unexpected endodontic treatment referral

There are many negative consequences that occur when you begin a root canal in your office and then must unexpectedly refer the patient to another dentist to complete the treatment:

• The patient perceives that they wasted a visit at your office
• The patient usually ends up paying more for the root canal

• The patient may experience a time-delay in getting the necessary root canal treatment completed

• Patients don’t like having to leave your office in the middle of treatment

• Patients may later question your judgment on other dental matters

• You lose a minimum of $400-$500/hr of production
After weighing the benefits of treating more involved and complicated root canal cases against the potential dangers of being unable to complete the case, I created the GOLDstein Standard for Endodontic Treatment Scheduling that positively assures that you will never start a root canal until you are certain you can complete it.

The stein Standard- Never start a root canal until you are certain you can complete it.

The key to effectively using the GOLDstein Standard is to begin with a thorough clinical and radiographic diagnosis. This will help you rule out any tooth you may consider too complex for your abilities. Perhaps you cannot visualize the entire length of the canals on the pre-op x-rays, or maybe you’ve never performed a root canal on an upper molar. For whatever reason, you’ve identified the possibility (even if small) that you may have difficulty with the treatment.

So, Mrs. Jones presents to your office on emergency with a draining fistula adjacent to tooth #30. Because, you’re not 100% confident that you can locate all the canals, but you want to attempt the treatment, you tell her, “Mrs. Jones, we’re going to schedule you a short appointment to get this infection under control.”
If Mrs. Jones is in pain, you can tell her that you will “get the pain under control” as well. Basically, you’re not telling the patient that you will begin the root canal. You simply schedule a pulpectomy, which is code D3221. The complete explanation of this code is D3221 pulpal debridement, primary and permanent teeth. Pulpal debridement for the relief of acute pain prior to conventional root canal therapy (not to be used when endodontic treatment is completed on the same day).

What’s the worst that can happen in this situation?

Using the above guidelines, let’s examine the worst-case scenario with Mrs. Jones’ treatment. You’ve scheduled Mrs. Jones for a thirty-minute appointment, to give you an opportunity to access the infected molar, locate the canals, and medicate and temporize before later beginning the root canal. I recommend you spend no longer than ten to fifteen minutes trying to locate all the canals. If after that time you’re unable to find all the canals, you should medicate and temporize the tooth.

From Mrs. Jones’ perspective, you’ve accomplished all of your stated objectives. You’ve gotten the infection and/or pain under temporary control; and you’ve accomplished this painlessly and efficiently. Just as importantly, you haven’t “stressed out” over a difficult case and created your “own canal” or perforation through the furcations or the root. You then explain to Mrs. Jones that the nerve treatment will be accomplished by a dentist more experienced with this procedure and the complexities seen in this particular tooth. You should confirm the restorative treatment that will occur after the root canal, and bill the patient for the pulpectomy (D3221). Instead of an uncomfortable last minute change in your treatment plan and scheduling, the patient is happy and you haven’t lost productive scheduled time on your appointment book.

A summary of the benefits of using the GOLDstein Standard with this “worst-case scenario” is listed below:
• The patient’s treatment plan was not unexpectedly changed at the last minute.
• The patient is now out of pain.
• The infection is less likely to increase or spread.
• You’ve only used 30 minutes of scheduled time from your schedule.
• You’ve produced at more than $250/hr. during the visit.

A better case scenario

Another possibility that will often occur during Mrs. Jones’ 30-minute appointment is that you will “miraculously” locate all the canals and determine absolutely that you can comfortably complete a root canal on the tooth in question. One option is that you then perform the pulpectomy, place a temporary medication and reappoint Mrs. Jones to perform a complete root canal and restoration at the next visit. The benefits of the “better case scenario” are as follows:
• The patient is assured that the root canal procedure will be painless.
• The patient is less likely to cancel or not show at their next appointment, since the fear of pain is removed.
• You know positively that you can complete the root canal at the next visit.
• You know precisely how long to schedule the appointment.
• You are more likely to schedule the restorative treatment at same time, which leads to a very productive appointment.

As far as billing for the procedure, I recommend that in most “better case scenarios,” you bill for the entire root canal procedure at this visit. You can “brag” to your patient that this visit will be covered as part of the root canal fee. If the pulpectomy visit was scheduled as an emergency or “work-in” appointment, then most insurance companies will cover the fee for the code 3221, and then later pay the full fee for the root canal billed on another day. Under this circumstance, the exclusion of the same dentist being paid for a pulpectomy and the root canal has been lifted.
Important Clinical Tip: Always take your working length measurements before closing the tooth during this initial visit.

There is no better time to take a working length measurement than immediately after accessing and locating all the canals. This will save you valuable time during your next visit. . An added benefit is that you have confirmed the canals are patent and you are better able to calculate the exact time needed for the next appointment.
The best-case scenario

The most ideal occurrence at Mrs. Jones’ pulpectomy appointment is to open the tooth, locate all the canals, perform the complete root canal, and possibly the restoration, at that visit. I realize that it’s difficult to imagine how you can find the necessary time to complete the root canal when at most, you have blocked 30 minutes on your schedule. Here are some suggestions for how you can find the time:
1. Modify the treatment on your next scheduled patient (or your current patient if you’re working in the pulpectomy appointment)
When you realize that few dental procedures yield a greater hourly net profit than root canal therapy, it’s easy to understand how substituting an endo procedure for a less productive procedure can improve your overall production. That, coupled with the timesavings of not having to schedule a second appointment to renumb, isolate and relocate the canals, makes this substitution a profitable choice. Very often, the next patient on the schedule will not mind shortening his scheduled appointment when the option exits.

2. Wait to confirm your next patient is showing up before dismissing Mrs. Jones.

I remember having once dismissed an emergency pulpectomy patient who presented with a painfully infected lower molar. Although I was able to easily locate the canals, and could have completed the endo, I temporized the tooth and reappointed the patient because I had a crown and bridge treatment scheduled just ten minutes away. Shortly after the patient had left the office, we received a call to inform us that my “crown and bridge” patient was not going to make her appointment. It’s still uncomfortable to calculate the lost production due to that poor decision.

3. Tell the patient they may be in chair for several hours.
You will be surprised how long a patient will happily and patiently wait around your office for treatment. When patients are accurately informed about the time involved and are given the choice to stay and have the treatment done that day or reschedule, many choose to stay. Very often, a patient has taken a personal day from work to be at your office. Many patients would welcome the opportunity to complete their treatment that day, thus saving them another day off of work. When given a two, to three-hour plus period of time to “work-in” the root canal treatment, a number of five to fifteen-minute segments can be “borrowed” to comfortably complete the procedure.

The GOLDstein Standard gives you the ability to treat cases you might otherwise refer due to complexity or lack of time on your schedule
We’ve thoroughly discussed the importance of not beginning root canal cases you cannot complete. Equally important is the need to keep productive endodontic cases you can efficiently and comfortably treat in your office. The GOLDstein Standard gives you a tool to help you gauge the complexity of the treatment as you develop your endodontic skills. With endodontics having a lower overhead than most dental procedures, there are very few procedures that a GP performs that yield a greater net profit.

Reasons to try the GOLDstein Standard on your next challenging root canal case

In summary, using the GOLDstein Standard when scheduling difficult endo cases can offer you the following advantages:

• There will be no scheduling surprises for your patient.
• There will be no scheduling surprises on your schedule.
• You should produce at least $250+/hour performing a pulpectomy.
• The second treatment visit will be extremely efficient.
• Working in a root canal treatment helps you fill gaps in your schedule.
• You remove the risk that you may be needlessly referring productive root canal treatment that you can be effectively and efficiently treating in your office.
• You totally eliminate the stress of unplanned referrals.
With the GOLDstein Standard, even if you’ve started a root canal that you later discover you’re unable to complete, you will not upset your patient, you will not upset your schedule, and you will have not risk leaving the tooth in worse condition than you found it.