There are certain referring dentists with whom I work well and there are others who have tried me out in the past, but for various reasons send elsewhere now. No hard feelings, no worries.

Just as you can’t please every patient, you can’t be everything to every dentist either. The patient comes first, and if they get more streamlined, effective care via a different generalist-specialist combination, I’m fine with that.

You two or three constant readers of my blog know that I have no problem with patients or dentists looking elsewhere for treatment if they don’t want to abide by my office policies. My treatment philosophies and office policies are what they are for very good reasons and were developed through my years of practice from both scientific evidence and experience.

And yet there are still dentists that try to bully me every now and then. I still have a few things to learn about dealing with them. I react impulsively and aggressively.

Thanks to my co-workers I’ve been able to keep myself under control with this latest episode. They really are the best and I am unfathomably lucky to have them watching over me.

The case in discussion is that back molar.

A different dentist than the patient’s current idiot DDS did the root canal work and then the crown. From the film, you can see that the restorative work was not done well. There’s a poor restorative margin that is probably leaking (causing the recurrent root canal infection) and there is no satisfactory ferrule for the crown.

Retreatment of the previous root canal work is the obvious way to attempt elimination of the current infection. However, with the inadequate coronal restoration kept in place, the prognosis of the retreatment over the long-term is poor. This is simply because the probability that leakage of bacteria under the crown is occurring will not change unless the restoration is improved.

My recommendations for treatment were for the patient to have her dentist remove the crown and possibly the core, then assess restorability and/or the need for crown lengthening. If he thought that the tooth was workable from that perspective, I could redo the root canal and say that the prognosis is good.

Here’s his first email to me:

Hello [me],

I opened the crown on #37 today and accesed the pulp chamber and 2 treated canals. Because the mesial wall (composite) is intact and selaed from a pulpal aspect,  I closed the case and have referred back to you for retreatment of the case.  I will then restore the access and mesial wall with bonded amalgam to establish as good of a coronal seal as possible as pt. cannot afford to replace the crown at this time.

Although the mesisal and distal canal seemed centered in a rather mutilated pulp chamber, I am concerned that if the coronal seal was ok is there an untrreated canal?

You are seeing L later this month for the retreatment.

Sincerely,
[him]

This is my reply. I was concerned, maybe a little pissed, that my instructions weren’t followed. On top of that he’s suggesting that another canal might be the problem. Did he tell the patient this? If so, what if I see that there isn’t another canal? Will the patient then be confused as to why there’s infection in the tooth (since he apparently saw that everything was sealed well internally)? Also, the pulp chamber seems far from mutilated on the pre-op film. What problems has he caused me now by trying to help me out in his own way?

Hi [him], thanks for the email.

Without crown (and possibly core) removal there is no way to be certain that the current restorative margin is not carious. The current restorative situation with this tooth is wholly inadequate. Coronal leakage can be occuring at a microscopic level (since I’m talking about bacteria, not saliva).

It is possible that there is another canal, however, the best sealed canals will eventually become infected if the restorative seal fails even minimally over time (with recurrent caries or structural failure).

I’ll take a look around and clean things up the best I can once I get into the tooth. L will be told that the prognosis of the tooth from my perspective, though, is now guarded.

Thanks again for the heads up.

This was his reply:

Hi [me],

Firstly, please forgive my frank approach with you today but I am going to be brutally honest.

I am fully aprised of what bacterial leakage is, and what it can yeild as far as reinfection.

But from a restorative perspective I am not going to take the crown off #37or further impair the coronal seal as it exists because I may not be able to restablish as good of a seal temporarily( due to concerns about control of mesial marginal blood/fluid contamination below the tissue level for bonding seal) as currently exists to satisfy your desires prior to an endo retx. I determined this after opening the case because you would not. And taking the crown off entirely commits the patient to a new crown which she can’t afford. So alternatively should we just extract the tooth? No, I think with your endo expertise, and my restorative epertise we can collectively establish an accetable seal endodontically and restoratively so that the pt. may function with this tooth for some time.

And she is aware of the risk. I agree the crown is not pretty, but aside from the mesial margin it is not that bad form a marginal perspective. In fact from the outer dimensions of the crown and the dentist who did it may have been under-prepared.

So even if is leaking somewhat, big deal! Do the endo retx!
Then I can restore this case with a panavia bonded amalgam resoration in short order (as already explained), which will allow a one peice sealed resoration with amalgam posts, and mesial wall recreated in amalgam. BELEIVE ME I HAVE DONE IT MANY TIMES SUCCESSFULLY. If in the future L can afford a new crown, I will replace the crown at that time gladly.

You can’t have everthing perfect for every case my experience, because not every patient can afford the time nor the expense for your desires. But you can’t simply cast these patients away, can you?

Yes I agree, removing the crown and endo retx and possibly castpost core and a new crown would be great, but L can’t afford it. She has already having to absorb the cost of time off work, travel, etc.

So again, I have completed a liberal access so as to remove almost all the existing composite core (under 12x magnification) except for the mesial wall which is intact with some affected dentin left in place. Now you can complete the endo retx with your expertise and see if a canal has been been missed. Then I will restore the case with bonded amalgam. Yes the case is compromised and has a guarded prognosis, but the patient is fully aware of this as I have reviewed it with her at length.

I don’t refer to you regularily because I established endo referral sources when I worked as an associate at Yonge and Eglington for 4 years. But I can tell you this, in TO I would have referred this case had it retreated in one appointment, and now I would be shortly restoring it, case finished for obsevration.

I remember in my 4rth year at UofT when you were trying to take alginate impressions of B, your endo classmate, for a hockey mouth guard and failed on several attempts in clinic next to me. And I thouht to myself , this guy has no clinical experience at all as a restorative dentist. Now that I have been practising general dentistry as long as you have endodontics, I need to rely on your expertise, and you need to rely on mine as well.

Additionally, now that your office office has spoken with L and confused her, and clearly undermined my clinical judgement, she will certainly now have doubts about both of our capabilities, a rather unfortunate and inexperineced move on your part don’t you think? Next time you may wish to consider just picking up the phone and calling the dentist personally to discuss the case.

In closing, I suppose you can choose to not treat L, but instead I would suggest you do, and we move foward with and perform the best service we can collectively for L given the limitiations of this case.

Sincerely,

[him]

My reply:

That gave me a chuckle.

As I said before: L’s consent form for endodontic retreatment in my office will say that the prognosis is guarded.

Then he sent me something again saying it’s not a chuckling matter.

I decided to not bother continuing the inane conversation. My thinking is that if Patient L doesn’t have the money for a new crown, she shouldn’t be spending what little she does have on an expensive retreatment that will fail at some point.

Patient L ended up calling to let us know that she decided that she will go ahead with the crown after all. I’ve decided that her consent form will read that the prognosis of the retreatment is good (about 85%) depending upon the quality of the final restoration.

Because idiot dentist hasn’t properly worked the case up for a new crown by evaluating the prognosis or need for crown lengthening and providing that cost information to Patient L (all as I previously requested), poor Patient L will likely not improve her odds with this tooth by spending the extra money on a crown at this point.

She, not I, is unfortunately the one who will suffer most from this guy’s inflated ego.