CASE: THE DREADED ROOT CANAL
Roger Vianni has been a patient of Dr. Clarke's for seven years. He is a very talkative man who constantly expresses his anxieties about the condition of his teeth and what Dr. Clarke may have to do about them. Dr. Clarke always responds calmly and sympathetically, but she has learned that gentle words are rarely enough to calm Mr. Vianni's churning anxieties. His fear also heightens his sensitivity to pain and pressure, so local anesthetic has been necessary for even the most superficial procedures, and he invariably has a fresh story for her about an acquaintance who has recently suffered some oral tragedy. How grateful he is, he tells her at each visit, that he has never suffered such things, especially the dreaded root canal.
Luckily, Mr. Vianni has not needed much work up until now. But nearly a year has passed since Mr. Vianni's last visit, and this time he presents with a complaint of significant pain in the upper right quadrant. Dr. Clarke's examination reveals a shallow amalgam in the upper-right second premolar that has fractured, breaking the seal and thus needing replacement. But more importantly, and more likely the cause of Mr. Vianni's pain, a sizable carious lesion has developed on the mesiobuccal surface of the adjacent first molar, next to a large silver restoration that was in place before Mr. Vianni became Dr. Clarke's patient. There is, in fact, little sound enamel remaining. Radiographic examination confirms apparent pulpal involvement, with endodontic therapy and then a full coverage restoration as the treatment of choice.
Dr. Clarke is certain, however, that if she describes the root canal procedure and the drilling that would be necessary to prepare the tooth for the crown, Mr. Vianni will simply refuse. It is not that he would prefer to lose the tooth or that he has financial or other reasons for not wanting a root canal and crown. He has often said that he values his teeth greatly and is willing to spend whatever it takes to keep them healthy as long as possible. It is simply that he has such strong reactions to the drill, and especially to the thought of endodontic therapy. The fact that this procedure resolves rather than causes pain and that it can be performed, in the ordinary case, without significant pain or discomfort, will not change Mr. Vianni's reaction. From her previous knowledge of this patient, she is certain that he will either demand that the tooth be extracted or simply leave the office if she explains his situation to him.
Luckily, Dr. Clarke had mentioned the simple problem with the premolar to Mr. Vianni as soon as she had noted it and before she had examined the first molar carefully, and he had mustered up his courage and agreed to its repair, "provided you freeze it up real good." She could very easily anesthetize the first molar at the same time she anesthetized the premolar without Mr. Vianni knowing the difference. She could then perform the pulpectomy on the molar without Mr. Vianni having to suffer from knowing what was going on until all the parts of the procedure that he utterly dreaded were completed. Nor would she have to lie to him since she could truthfully say that she was doing some superficial drilling on the premolar, and she would of course tell Mr. Vianni the whole story of what she had done to save him from anxiety and suffering as soon as the work of preparing the molar was completed. At that point he could choose a porcelain-fused-to-metal restoration preceded by a temporary crown until the permanent crown was fabricated, an amalgam buildup, or even a tooth extraction if that really was his preference. But he would not have to face the anticipation of the root canal that he dreaded so much.
Dr. Clarke is certain that if she could describe the situation to Mr. Vianni without his knowing that it was his own mouth, he would understand and agree that endodontic therapy along with proper restoration of the tooth is the most reasonable and appropriate treatment. The problem is that, in his own case, his judgment would be clouded by his reaction to the idea of receiving root canal therapy and of the drilling that would take place in his own mouth. (While slightly anxious about being sued, Dr. Clarke is actually quite certain that Mr. Vianni would understand her judgment on his behalf and that she is at no risk of a lawsuit if she takes this step.)
Dr. Clarke is certain that Mr. Vianni trusts her to do whatever is best for him. She is also sure that if he could judge the matter objectively, Mr. Vianni would not want to suffer the anxiety of deciding about this treatment for himself. What good reason is there, then, for putting him through the pain of doing so? What should Dr. Clarke do and why?