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Associate’s Corner: Minimizing “the unknown unknowns”

Helen Yang, D.M.D.By Helen Meyer, D.M.D.

Former Secretary of Defense Donald Rumsfeld famously said: “There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know. And if one looks throughout the history of our country and other free countries, it is the latter category that tends to be the difficult ones.”

This quote can be applied to our knowledge base as young endodontists. We’re well trained in providing endodontic treatment and managing challenging patients–the “known knowns” if you will. We’ve been trained to foresee potential complications with tricky cases and rely on specialized tools and equipment to reduce unpredictability– managing the “known unknowns.” Indeed, it is the “unknown unknowns” for which doctors must remain vigilant, factors that lead to errors and unexpected complications that can absolutely ruin the day, whether it is treating the wrong tooth, extruding sealer into the IAN canal, missing non-odontogenic pain, medical emergencies, a board complaint/lawsuit, etc.

Young endodontists joining their first practice out of residency often receive input or pressure from owners, assistants, and even patients to practice a certain way that increases risks of making mistakes. I want to share a few thoughts where it is important to stand your ground in order to minimize the unknown unknowns and make each case as predictable as possible.

  1. Don’t take shortcuts with diagnosis. I’ve heard of doctors who diagnose off of x-rays alone, who rarely pick up the Endo-Ice, or who solely rely on the tooth number circled on the referral form. Many doctors allow their diagnosis to be handicapped by non diagnostic x-rays or patients who refuse to take CBCT scans. These allow room for critical mistakes. Nothing beats a full dental and medical history, appropriate x-rays, and all the clinical tests (including oral cancer screening). Develop an orderly approach to the exam and a mental checkbox that you do every time, for every patient, even if there is an obvious tooth that needs treatment.
  2. Obtain a thorough medical history. That includes vital signs. I recommend asking your front office staff to inform patients over the phone to bring in their list of medications. I often find myself superficially skimming this portion of the chart, but it deserves more attention. A tardy patient of mine rushed through his intake forms and neglected to disclose a recent TIA (transient ischemic attack) and anticoagulants during his consultation. I only found out at the apical surgery appointment because his wife came with him and offhandedly mentioned it. The surgery had to be rescheduled so I could contact the cardiologist, and this could have been avoided if I reviewed the medical history forms with him in person instead of assuming they were accurate.
  3. Informed consent should be informed, not just a paper signature. Most patients are understanding when treatment doesn’t go smoothly if they were warned ahead of time. Telling afterwards comes off as making excuses. Every patient should understand 1) rationale for recommending treatment, 2) what they can expect during treatment and afterwards, 3) any challenges you foresee, 4) prognosis, and 5) alternative treatments. Answer their questions, and use it as a gauge for hesitancy. Many of the teeth we encounter have a questionable prognosis, and as such, especially deserve this dialogue. If you practice consistently, you’ll eventually be able to convey all the relevant information in an efficient 5-10 minute exchange. It will go a long way in reducing post-op calls and frustrated patients.
  4. Time out before touching the bur to tooth. As you are about to apply the rubber dam onto the tooth (instead of delegating this to the assistant), I recommend pausing and calling out the tooth number. Look to your assistant for confirmation.
  5. Don’t treat unless you are reasonably sure of your diagnosis. When it is not possible to pinpoint the offending tooth, don’t feel pressured to guess for the sake of production. It’s much better to have the patient come back for a re-evaluation rather than receive unnecessary or incorrect treatment. “If it’s truly a root canal problem, it will eventually rear its ugly head, and I will be here to help if it happens,” is what I tell patients.
  6. Call your patients afterwards. Studies have shown that post-op calls can improve patient satisfaction, compliance with taking prescriptions, and reduce reported post-op pain. Calls can be done by you or your staff within 48 hours after treatment; it shows patients that you care and can help you get ahead of flare-ups or other issues.
  7. Get second or third opinions. As young endodontists, we are all still learning everyday. It’s okay not to know everything, and it is a mark of maturity to recognize when we’re about to venture into unknown territory. In the past, patients have appreciated my honesty when I tell them, “Your case appears atypical. With your permission, I’d like to discuss it with some other specialists for their opinions. I will call you in a few days to discuss my recommendation.” I often chat with my wonderful co-residents about cases. Since graduating residency, I’ve also slowly built a brain trust of endodontists, general dentists, periodontists, prosthodontists, orthodontists, orofacial pain specialists, etc, with whom I am comfortable reaching out and asking for their opinions.

The common theme among the above points is thoroughness. While we cannot predict the unknown unknowns, thoroughness is the key to minimize them, to avoid making potentially avoidable mistakes. Thoroughness will breed your patients’ confidence and trust in you as a specialist, which in turn, improves their perceived experience of your care.

Questions or comments? Suggestions for future Associate’s Corner posts? Please email Dr. Helen Meyer at