Every office is different, of course, but there are a few things that bug me when it comes to referrals and referring offices. Peter Birek (who carries his camera around with him as much as I do) wrote an apt editorial here on the topic from a specialist’s perspective and he covers some important points.

For me, the most important point is the manner of communication between the specialist and referring dentist. The dentist who has to call me and personally speak with me about every single patient that they send (whether it’s before or after I see the patient) becomes annoying very quickly. I send written correspondence back for 90% of the consultations that I do, and for 99% of the treatments that I do. If there are questions about the patient’s situation, the telephone call from their dentist is something that I generally only allow to interrupt my work if it is extremely pressing (eg. the patient is in the chair at the other office and certain decisions need to be made on the spot). Receptionchick has gotten pretty good, also, at passing messages over the phone.

This whole post came to mind while I was corresponding with a dentist via Email. Email turns out to allow conversation about a case over a convenient period of time, without taking time away from patients that you’re treating. It also allows for inclusion of more elaborate thoughts and discussion than a quick phone call would. And if you don’t have email, faxes work just as well…

Here’s one part of the email thread that I was mentioning:

Date: Sun, 24 Sep 2006 18:52:54 -0400
From: XXX
To: XXX
Cc: XXX
Subject: Re: XXX
MIME-Version: 1.0
Content-Type: text/plain;
charset=ISO-8859-1;
DelSp=”Yes”;
format=”flowed”
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Hi XXX, thanks for the email.

From the time I first saw XXX, I suspected that her symptoms might have been musculoligamentous in nature. This was consistent with a decent looking endo with no evidence of osseous pathosis–and her parafunctional habits. Palpation of her muscles of mastication, however, found no obvious trigger points.

The retreatment was the most conservative approach to her issues but was purely elective. She had some relief following my medication of the canals, but symptoms returned to the same level, if not a little worse.

The option of completion of the retreatment with subsequent apical surgery is a logical next step. I feel that apical surgery in this case is actually more dangerous to the adjacent teeth than extraction and replacment. Because there are no osseous lesions, creating surgical windows in bone always has the very real risk of nicking adjacent roots and causing problems in those teeth (I recently had a case like this where an oral surgeon had done just this). Also, because I can’t see specific problems with any root in particular, the surgery will likely not correct XXX’s symptoms.

It is possible that extraction and replacement will also not dissipate XXX’s symptoms, especially if they are myofascial or ligamentous in nature. However, there comes a point when we have to be sure that patients are spending their money in ways that are productive…

So, from an endodontic perspective, there’s not much more that I want to do. From your perspective, there are a couple of options. You can extract and replace, or if you are willing to investigate further, check the occlusion and temp filling on the tooth and see that XXX has a properly functioning night guard.

I usually also try to get my patients with more obvious myofascial pain to see a registered massage therapist who is comfortable working muscles of mastication, have the patient use moist heat at home with stretching of the jaw.

A temporary crown will probably not be of any benefit. I saw no cracks when I worked the canals, and of course, there’s no nerve in the tooth to be irritated by a crack that I couldn’t see. This leaves the possibility of pain from a periodontal issue. Generally speaking, if this were a periodontal issue rather than an endodontic issue, we would probably have seen some radiographic change by now.

Anyway, gotta run. Let me know if you’ve got any other questions. I do appreciate the email. It’s actually the best way to get a hold of me.

—– Message from XXX ———
Date: Thu, 21 Sep 2006 14:31:35 -0400
From: XXX
Subject: XXX
To: XXX

> Hi XXX,
>
> Thanks very much for seeing XXX. I understand that there is not much more
> endodontically that could help this 16. Do you think there may be any value
> in a temporary crown on it to see if it will settle down with some full
> coverage protection or should we call it quits. I hate for her to lose it
> but maybe we have reached the end of the road.
> I would appreciate your advice.
>
> We get great feedback from patients about their care at your office.
>
> Thanks again,