The 22-year-old male patient had a history of trauma to his maxillary incisors and arrived at my practice with symptoms related to tooth #21. The tooth, opened in an emergency by the patient’s mother, was tender when prodded, with a moderate level of sensitivity on the respective buccal gingiva. Sensitivity tests were negative for the other central incisor (tooth #12 was positive), and a periapical radiograph showed radiolucency in the periapical areas of both of the central incisors. The apices of these teeth were quite wide and the length of teeth appeared to exceed 25 mm.

My treatment plan was as follows: root canal therapy with two apical plugs with a calcium silicate-based bioactive cement. The patient provided his consent for the treatment of the affected tooth and asked to have the other treated in a subsequent visit.

After isolating with a rubber dam, I removed the temporary filling, and then the entire pulp chamber roof with a low-speed round drill. The working length was immediately evaluated using an electronic apex locator and a 31 mm K-type file. The working length was determined to be 28 mm.

As can be seen in the photographs, the canal was actually quite wide, so I decided to only use an irrigating solution and not a shaping instrument. Root canals are usually shaped so that there will be enough space for proper irrigation and a proper shape for obturation. This usually means giving these canals a tapered shape to ensure good control when obturating. With open apices, a conical shape is not needed, and often there is enough space for placing the irrigating solution deep and close to the apex.

I decided to use only some syringes containing 5 per cent sodium hypochlorite and EDDY, a sonic tip produced by VDW, for delivery of the cleaning solution and to promote turbulence in the endodontic space and shear stress on the canal walls in order to remove the necrotic tissue faster and more effectively. After a rinse with sodium hypochlorite, the sonic tip was moved to and from the working length of the canal for 30 seconds. This procedure was repeated until the sodium hypochlorite seemed to become ineffective, was clear and had no bubbles. I did not use EDTA, as no debris or smear layer was produced.

I suctioned the sodium hypochlorite, checked the working length with a paper point and then obturated the canal with a of 3 mm in thickness plug of bioactive cement. I then took a radiograph before obturating the rest of the canal with warm gutta-percha. I used a compomer as a temporary filling material.

The symptoms resolved, so I conducted the second treatment only after some months, when the tooth #11 became tender. Tooth #21 had healed. I performed the same procedure and obtained the same outcome (the four-month follow-up radiograph showed healing).

Editorial note: A complete list of references are available from the publisher. This article was published in roots - international magazine of endodontology No. 04/2017.

The issue of the three Rs—recruitment, retention and remuneration—is currently populating my inbox, messages and conversations every week. These are some actual examples from my clients:

• “Numerous adverts online, posts on social media and newsletters to patients have not generated a single enquiry for the employed position in our practice.”
• “We recruited a new member for our front-of-house team. After the interview, references and paperwork, they failed to turn up on the first morning. When contacted later that week, we were informed that a pay increase at their original place of work had been accepted.”
• “My new practice manager resigned after just three weeks, stating that he was unable to meet the demands of the position—even though the responsibilities were spelled out very clearly during the interview and induction process.”
• “My dental associate has requested flexible hours to accommodate childcare, wants to drop from four to three days a week and is asking for an upward review of their remuneration package.”
• “Our dental hygienists have formed an unofficial committee and have sent me screenshots of social media sites on which hygienist pay scales much higher than ours are being posted. They are demanding a review.”
• “Dental nurse wages in the area are on a steep climb, and I simply cannot afford to keep up, given the current financial position of the business.”

I could go on—this is just a sample—but I suspect that by now you get the picture. If none of these conversations reflect what is going on in your business, then congratulations—although I am tempted to add “just you wait!”. If you hear echoes of what is being said in your staff rooms and corridors (as well as on WhatsApp into the dead of night), then join the club.

Why is it that the three Rs have recently become a burning issue? In the UK, I think we can start with Trussonomics and the cost-of-living cycle, events that have left many people less well off than they have been for a very long time. As a 70-year-old empty nester, I have been only marginally affected by the inflation and geopolitical crises that have changed the basics for many. However, as a father of five adult children and grandfather of five grandchildren, I understand the pressures.

As a dental consultant, I advise my clients how to best navigate this cycle. As I said at the beginning of this article, there is nothing to be gained by blaming the youth of today for having less resilience or different priorities than we may have had in earlier decades—today is where we are, and we must “take the current when it serves or lose our ventures”. As a result, I am advising my clients to remember these wise words that “all problems exist in the absence of a good conversation”.

I have invested some time over the last year in good conversation with my children (a professional dog walker and rental property manager, an expert in nuclear waste disposal, a medical representative for a prosthetics company, a branding, marketing and design freelancer, and a probation officer—mixed bag, right?) so that I can fully understand what it is like being them financially. In addition, I have kept a close eye on my support team (only two people), quietly making sure that the macroeconomic situation is not affecting their ability or desire to work for me. As leaders, we have a duty of care to do that.

I will share with you some tough love that I have been giving my clients recently: to deal with the three Rs, you have to activate the three Ps—pricing, productivity and profitability. This means boldly increasing your prices, actively supporting your fee-earners to increase their production and keeping a very close eye on the profitability of every one of your products and services.

At the end of the day, your team do need pay rises to keep pace with what is going on. You are going to have to pay top dollar to attract and keep the right people. Resistance to that is a road to nowhere. So where is the extra money going to come from?

Tactic 1: The price rise

Cutting to the chase, many of my clients have implemented 25% price rises across the board in the first quarter of this year, and the unanimous feedback has been that “we had a few grumbles, but nobody left”. Put your prices up—you are worth it.

Tactic 2: Work with your fee-earners to increase average daily production

I have advised my clients on improving communication with their existing clinicians to foster a mutually beneficial relationship. Here is how you can support your clinical team:

• Invest time and effort into the internal and inbound marketing systems to generate new patient enquiries.
• Ensure that the front-of-house team are properly trained to handle all patient enquiries and deliver a first-class patient experience.
• Use the treatment coordinator to triage new patient enquiries and help to manage the sales pipeline.
• Give the team access to an intra-oral scanner (with training) to assist with patient communication.
• Train the team on effective treatment plan presentation skills.
• Ensure that the team members have access to the very best clinical equipment and administrative support.
• Provide clinical mentoring.
• Provide supportive sales performance management.

Here are some ways you can expect team members to show support for the clinic:

• Attend the morning huddles, with particular reference to marketing opportunities, each day.
• Work with the treatment coordinator to manage new patient flow, pipeline and end-of-treatment reviews.
• Learn how best to use the intra-oral scanner in patient diagnosis and communication.
• Learn how to create effective treatment plan presentations using technology, including video.
• Invest in communication skills training.
• Take part in regular peer review meetings.
• Be a team player.
• Accept performance targets on days worked and average daily production.

Survival and prosperity through the next few years are going to be dependent on a realisation that the economic landscape has changed, that the younger members of our teams have had little experience in how to navigate the work environment and that, ultimately, patients are going to have to pay more. We have a collective duty to guide our younger colleagues, not just as grandparents and parents but as employers and fellow professionals.

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