And You Want Me To What?

Iatrogenic March 3rd, 2007

Sorry about the poor image quality, I took the picture a few years ago.

So the patient was referred to me by their dentist for me to complete the endo. They reported that they had a hard time finding all of the canals because of a lot of pulpal bleeding that was not controllable.

This is what I saw once I got in and cleaned the chamber up. The only accessible canal was the distal right in the middle. The other (red) areas are perforations. To get into the mesial canals I had to go through the perforations on the mesial and angle back into the root (the mesial root had pretty much been severed).

The tooth is toast.

I really hate these kind of referrals:

“The tooth is very complicated and so I’m going to refer you to a root canal specialist that I work with. He’s very good and he’ll finish the root canal for you, then you can come back here and we’ll do the crown.”

How do you think the patient feels when they show up and I tell them that the tooth has to come out? And I’m not making that quote up because although heresay via patients is not usually accurate, you hear it enough (or see it actually written on the referral slip) and you believe.

On the other hand, I have dentists that say this:

“The tooth is very complicated, I’m not sure if it can be saved. I’m going to refer you to a specialist that I work with and we’ll see what he says about the tooth.”


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  • Dr. Mommy, D.D.S.

    that tooth looks like hamburger!

    eek, i’m so paranoid about perfing. it’s one of my biggest nightmares when doing molar endo, so go pretty slowly when doing my access. but you have to dig pretty deep to perf like that. if i can’t find the canals in a short amount of time i just close it up and send it out – i’d rather have the endodontist get a good chuckle because my access was too small than go digging and chopping the tooth up. so far, it’s worked for me.

    was the patient in pain when they presented to you for treatment? that must have caused at least some discomfort, an i’m surprised the tooth didn’t snap in the interim.

    here’s a question for you – in a situation like that, is it better to say that *you* perfed the tooth, or that there *is* a perforation?

  • Ameloblast

    You know what, I’ve never chuckled or laughed or anything when I get patients in where the pulp horns were mistaken for canal orifices. I guess it’s because I’m happy that the endo will be an easy one.

    This tooth was broken down pretty badly. The dentist drilled down as deep as they would for a regular tooth without realising that the pulp chamber is closer than the think.

    I can’t remember if the pt was in pain when they arrived. It was so long ago…

    Your question: Depends on your relationship between you and your patient. When I see patients in this situation, I say, “There is a communication from the inside of the tooth to the outside of the tooth that is difficult to repair with any degree of predictability.”

    Took me some time to come up with that…

  • Dr. Mommy, D.D.S.

    what i try to do with my endo access is hold the bur up to the periapical to get a rough idea of how deep i want to go. i use a cusp or something else as a reference point, and that way i know if my shank passes a certain point i’ve gone too deep and should switch to a slow spped or a side cutting diamond. this is especially helpful if the tooth is really broken down and i’m not sure how far down i should go.

    i had a case like that once, the tooth was so far broken down that all i literally had to do was “pop” right into the pulp chamber with a 565 bur and buzz the roof right off. easiest access ever!

    i feel bad for the dentist that did that. when something like that happens, how do you communicate with your referring GP? do you get along well and feel comfortable enough to call him or her out on a mistake or to openly discuss cases? a while back a guy came into my office with a large swelling in Q2 and a history of untreated perio disease. there was a 7mm plus pocket, it was percussion positive, periapical showed no caries or even any restorations, so i sent him to the periodontist for an eval, who quickly sent him to the endodontist when she found that the tooth was cracked. i had jumped to conclusions about his perio problem and just assumed that was the cause of his swelling was a perio abcess and not an endo problem – i had failed to pulp test the tooth. the endo i refer to called me up and was totally cool, told me very nicely what i missed and what to do to avoid something like that next time and even taught me some very interesting stuff about fractured molars. i now pulp test each and every tooth that comes in, even if it’s blatantly obvious. it was a really great learning experience. also, if i have a question about a case, i can easily call up anyone i work with because i feel comfortable enough to ask (and believe me, i have a LOT of questions sometimes).

    in my opinion, that kind of communication just makes us better dentists – sounds cheesy, but we all have so much to learn from each other.

  • Ameloblast

    Unless I’m good friends with the referring dentist (which is rare), I’m very careful with what I say or do.

    I’ve posted before about egos in dentistry. Don’t take that post lightly. 50% of my referring dentists have egos bigger than you can imagine. These people absolutely resent unsolicited advice.

    Assuming nothing and sticking to the facts is all that I can and should do:

    On the correspondence back to the other office I say something like, “Multiple extracoronal communications were discovered upon removal of the temporary filling. The extent and severity of these areas created a poor endodontic prognosis for the tooth. I have informed the patient of the situation and have asked them to speak with you about replacement options.”

    If the dentist is interested in learning from the situation they will contact me for more information. If they either already knew what the problem was prior to the referral (and played ignorant) or don’t really give a shit, they won’t. And they might even stop sending to me (I can only hope).

    I’ve had situations like this where the dentist has told the patient that *I* couldn’t do the endo, so the tooth will have to come out.

    The reason I’m careful about what I say is because I really wasn’t there when the whole situation happened, and although my intuition is probably correct, I could be very wrong about the other dentist. Benefit of the doubt and so on.

    Talking about all of this reminds me of a dentist who I ended up having a heated (he and I were very loud) conversation with where he wanted me to do an endo that I refused to do because of a really severe perio defect that was unrelated to endo pathosis. I had one more case like that from him and then he stopped sending to me. I guess someone else is now doing his endos for him.

    For some, money speaks more than ethics. Don’tcha think?

  • Dr. Mommy, D.D.S.

    i hear ya. and then we wonder why people are so paranoid about visiting the dentist.

    i do try to make it a habit to establish a good working relationship with my referrals. it builds my trust in them and just makes for better dentistry. but there are a lot of us GPs out there who are pieces of work. sorry you have to deal with some shitheads. though i’m sure not all of them are like that, it’s the bad apples that ruin the whole barrel.

  • Ameloblast

    The few rotten apple specialists also ruin it for the rest of us.

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