Expert Q&A with: Dr. Aovana Timmerman
Aovana graduated with a Bachelor of Dental Science from the University of Melbourne in 2001 and after completing her fellowship with the Royal Australasian College of Dental Surgeons (RACDS) in 2010, she continued with her specialist training obtaining a Doctor of Clinical Dentistry in Endodontics.
Aovana has been involved with endodontic education since 2011 and was awarded the Graduate Certificate in Clinical Teaching in 2019. Currently, Aovana is a clinical demonstrator for the Doctor of Dental Surgery Endodontic program at The University of Melbourne and examines dentists in the Membership (GDP) program for RACDS and Australian Dental Council.
Aovana is currently working part-time in private practice at Collins Street Specialist Centre and is also pursuing her PhD part-time at the University of Melbourne and has published research in both local and international peer-reviewed journals.
Endodontics can be quite a stressful procedure for many dentists. What advice can you give around case selection and workflow so that dentists can confidently assess and choose cases which they will be able to complete confidently?
Case difficulty assessment can help general dentists decide if they would consider proceeding with endodontic treatment or consider referral. There is a useful form published online by the American Association of Endodontists which can be downloaded on this link – https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/02/19AAE_CaseDifficultyAssessmentForm.pdf.
I would suggest using the form until the clinician feels comfortable in assessing a case without using the form.
From my own experience as a general dentist, I definitely found it better to work on simpler cases at the start, before managing more challenging cases, as this approach helped me to build up my confidence and workflow as a clinician.
In addition, I often encourage general dentists to discuss their cases with their endodontists if he/she is uncertain about managing a complex case. I found that when I was a general dentist, the patients really appreciated that I have discussed their cases with the specialists before making a referral. First of all, it gave the patients reassurance that they definitely need specialist care. Secondly, it helped me to gain a deeper understanding of the case such as potential complications and risks and helped me look into alternative treatment options in managing a complex case after discussing it with the endodontist.
With workflow, it definitely becomes easier with time once you have established the way you like to work, and every practice tends to have a slightly different set up with materials, equipment and staff support. If you have just joined a practice, I would suggest observing the experienced dentist(s) at the practice and note the workflow and see if you would make any changes that would suit your needs.
As an endodontist who also educates dentists, what are some of the key aspects of endodontic treatment that you find most dentists find challenging? How can they overcome these challenges?
Good communication with the patient is something that I find that most dentists struggle with. I would suggest building up rapport with senior clinicians at work, a mentor through an organisation or with the specialists that you refer to and ask them lots of questions on how they would communicate with their patients in different scenarios and learn from their experiences.
The first aspect is communication of case difficulty with the patient. It is a good idea to clarify to the patient at the consultation visit if his/her case is simple or complex to manage. And if the case is complex, then go through with the patient what makes the treatment of their tooth/teeth complex and to provide an option of seeing an endodontist.
Second aspect is communication of complications and risks to the patient and reading the patient well enough before starting treatment. For example, when you discuss the risk of instrument fracture to the patient, have you discussed through what you plan to do if that occurs, so that the patient is prepared that he/she may require further management with a specialist afterwards?
We do manage patients with differing expectations, and it is good to understand what the patients expect before starting. For example, if I am going to discuss endodontic treatment of a tooth with poor prognosis, I often put the question back to the patient and ask, “how would you feel if this tooth would require extraction and replacement within five years?”. It gives me a clearer idea of what the patient expects me to achieve and if he/she would be disappointed if treatment does not work out in the short term.
At times, it can be useful getting the patient to sign an acknowledgement form, if he/she definitely wishes to proceed with treatment regardless of the poor prognosis of the tooth, just so that there is another level of acknowledgement and to make sure that the patient is on board with you regarding the potential short term survival of the tooth, before proceeding.
Magnification is an important tool in successful endodontic treatment. What other tools do endodontists use on a day to day basis that general dentists can benefit from using?
I definitely think it is a good idea to get a tool for transillumination to detect cracks in teeth in a clinic, such as the microlux 2 transilluminator. A lot of dentists find it hard to confirm the finding of cracked them then end up placing metal bands around cracked teeth as a result. However, there are a lot of issues with placement of metal bands. With transillumination and high magnification with a microscope, it definitely helps in confirming the location and extension of the cracks, so we can inform the patient promptly regarding the treatment options and prognoses without delay.
Second tool that I enjoy using is definitely the electronic apex locator. I hope all dentists learn how to use one well because it does help with determination of the working lengths besides relying on the radiographs. If you are uncertain about using one, definitely contact your endodontist and consider observing him/her using it.
Thirdly, I like using the WAM key crown remover. It does make removal of crowns much more efficient and could be a useful tool in have in the clinic.