Endodontics: no place for a snowflake

Drs. Joel Fransen, Rich Mounce, and Tom Shackleton provide seven tips for peak performance

Practicing endodontics at a high level requires a sustained focus. Distraction can result in iatrogenic mishaps that may negatively impact the final result. There are a plethora of external factors vying for our attention while treating patients. As a result, it is vital to prioritize one’s attention on the task at hand, so as to perform clinical endodontic treatment to the best of our abilities.

This article will provide clinicians with insight to optimize performance, especially in challenging circumstances. The examples used are endodontic, but the advocated principles are applicable to general dentistry.

1. Mental toughness

Managing patient anxiety and expectations are often more difficult than the clinical procedure. Patients can be abrasive, uncooperative, and uncommunicative before, during, and after root canal treatment. Continual exposure to stressed people can lead to professional burnout if one does not recognize the challenge and take steps to do better than just cope.

Being a 21st century dentist is no place for a snowflake. Mental toughness is the armor we need to deliver consistent results in inconsistent situations — in other words, getting the best possible results even in adverse environments. Staying positively focused is crucial to be the stable deliverer of great treatment on technically tough teeth on stressed or misbehaving patients.

What is mental toughness? How does one develop it?

Mental toughness is a measure of individual resilience and confidence that often predicts success in trying circumstances where others might fail. It is a set of attributes that allow a person to become a better clinician and able to cope with difficult situations and technically challenging procedures and emerge without losing confidence. A successful outcome includes being confident enough to stop a procedure and refer in a timely manner. For instance, if a catastrophic tooth or root fracture is discovered during treatment, be brave enough to explain the unfavorable development with the patient. Face the adverse situation directly and do not cower behind staff or the extraction forceps.

If we are all honest, performing technical tasks to the best of your abilities consumes all of your conscious attention and cognitive abilities. Did Michelangelo chat with Pope Julius while lying on scaffolding and painting the Sistine Chapel? Do not believe the hype; you cannot pump out great work in automatic mode. Preoperative discussion, case preparation, and consent are all undervalued for the dividends they pay when we are in the trenches cutting teeth and finding canals.

Each of us enjoys the routine procedures we perform in “automatic mode,” allowing us to chat and joke with the patient and staff. Often a patient can mistakenly expect the same level of interaction from you during a more complex procedure. It is important to inform a patient of the uniqueness of challenging procedures and the resultant change in your behavior and demeanor. Perhaps an assistant can take over the mantle of communicating directly with the patient at these moments. Based on the risk assessment, you, your team, and the patient should be aware of the new ground rules for “bigger” (more complex) appointments. For instance, one may say, “Ms. Jones, your next appointment is more technically challenging than previous procedures we have performed for you. It will require my full attention, and as such, you will notice that I may be less talkative with you and my staff today.” Set the expectation properly, and you’ll notice the difference.

Optimal sleep, nutrition, exercise, continuous learning, and review of upcoming cases are but a few of the many ways we can prepare ourselves mentally and physically to give our best.

2. Risk assessment

Evaluate the mental, dental, and medical particulars of the patient and how they relate to the challenge of successfully addressing the complexities of the proposed treatment. Anticipate potential problems and plan ahead based on a rational risk assessment. In essence, this customizes treatment for the situation at hand.

Pilots know the weather in advance. We should know what “weather” we are flying into with a patient/procedure. An accurate risk assessment is the ultimate preparation task.

3. Effective communication

Effective communication is key to patient management. The technically great dentist who is socially inept will have a difficult career. Actively listening to patients’ concerns and acting upon these concerns is predictive of a good result. Frank and honest communication is central to building trust and ensuring the decision a patient makes is truly an informed one. A routine procedure for an ill-informed anxious patient is just as cognitively taxing as a technically challenging procedure for a less anxious one.

Listening carefully to patients is central to successful patient-dentist interactions. Most patient complaints and ultimately malpractice claims stem from patients who feel unheard. How do you know a patient’s expectations are unrealistic if you do not effectively communicate with them? Listening, recognizing, and addressing concerns is effective communication. That does not mean you must bend to unreasonable demands. It does mean potential issues are addressed preoperatively. For all concerned, sometimes the best treatment is no treatment.

4. Decisiveness in challenges

When faced with challenges, be decisive, calm, and act. Patients rely on us to make decisions in their best interest. We accept flight delays because of mechanical issues or severe weather systems. Pilots don’t fly faster into a storm because a delay is unacceptable. Nor should dentists fall prey to the same pressure to rush treatments. No clinician can stay on time 100% of the time and deliver top notch results reliably. For example, if the patient states they are feeling something, do not continue until the issue is resolved. Addressing such concerns can delay treatment — it is to be expected.

5. Mental preparedness

We owe it to our patients and ourselves to come to work focused primarily on our patients and not allow personal baggage to steal our concentration and prevent us from performing at the highest level of which we are capable. Optimal sleep, nutrition, exercise, continuous learning, and review of upcoming cases are but a few of the many ways we can prepare ourselves mentally and physically to give our best.

6. Finding flow

The concept of “flow” was popularized by Psychologist Mihaly Csikszentmihalyi and can be defined as a “highly focused mental state conducive to productivity” (wiki). As clinicians, we have all experienced a moment when the procedure is flowing seamlessly, the patient is comfortable, and we are working at the apex of our skills toward an excellent result. This is flow in a dental context and represents a cruising altitude where we are on emotional and clinical auto pilot. The previous five steps can, in large measure, take the clinician predictably to an optimal state of flow.

The above stated, therein lies a challenge, especially in endodontics, as the situation can change instantly — a file fractures, a previously dry canal fills instantly with hemorrhage, the patient who was previously numb suddenly feels something, etc. Should this occur, and flow is broken, flow can be reestablished by the clinician:

• Identifying problems as they develop
• Reviewing possible means of effectively addressing the new developments
• Implementing these solution if appropriate
• Recognizing some problems warrant a cessation of the planned treatment and even a possible referral
• Asking the question, having done your utmost from technical perspective, “Has the issue at hand been effectively communicated with the patient?”

7. Self-kindness and learning from mistakes

The stoic Roman philosopher, Lucius Annaeus Seneca, said it best: “We are more often frightened than hurt; and we suffer more from imagination than from reality.”

Every problem in life and the operatory is a learning opportunity, and the valuable question is, what would I do differently if I had to do this again? What can I learn from this problem? Reflect on challenges, seek continuous improvement, and maintain a positive mindset to grow as a clinician. Every endodontist makes mistakes, but great ones learn from them. Not doing so leads to a negative feedback loop that steals our confidence and erodes our skills. Doing so is priceless.

In conclusion, mental toughness is a cornerstone of successful clinical dentistry. By embracing resilience, effective communication, and continuous learning, endodontists and dental professionals can navigate challenges with confidence and deliver exceptional patient care. We welcome your feedback.