Life's Context » Periapex

Our Home Was No Place For A Lady.

Periapex — Thu, 29 Apr 2010 16:55:26 +0000

Resting In Peace near Hector, by the stream that runs behind our house, surrounded by the very Nature that she loved.

She is survived by 1 cat, 2 dogs, 6 fish, 3 parrots, and 2 humans.

7 Months old on April 10, 2010.

Is Your Dentist a Spoiled Brat?

Periapex — Sat, 24 Apr 2010 11:44:57 +0000

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.

Luck Was On Our Side.

Periapex — Sat, 06 Feb 2010 14:53:18 +0000

Most times when a rotary file breaks in a canal, the fragment is either irretrievable or the risk to remove it is greater than the benefits. This is purely because they mostly break apically, around curves, and the fragment is often no more than 3-4mm in length.

Using ultrasonics to remove a fragment in a situation like that can very easily lead to excessive damage to the apical aspect of the root. Apical surgery is often a more predictable approach if the fragment must be removed. Many times, however, the prognosis of completion of endodontic therapy with the file fragment still lodged in the root (ie. obturation that incorporates the fragment) can lead to a decent prognosis still. It all depends on the presence or absence of preoperative infection within the tooth and the management of the tooth through the whole process.

I have found that when instruments break in canals like this, it often is more a manufacturer’s defect than poor technique.

Here you’ve got a fairly thick file that broke off leaving a long segment in the canal. The canal is fairly straight and the head of the fragment is visible in the coronal aspect of the canal. I was able to trough around the fragment to about 2mm beyond the head of it. The energy from the ultrasonic tip them unscrewed the fragment and it popped loose. Often applying the ultrasonic directly to a fragment will cause the fragment to further fragment, but this piece was thick enough, not around a sharp curve, and visually accessible enough that I was able to retrieve the file and proceed to complete the endo normally.

On the post-op film you can see how close I was to a perforation of the root even though I had good visibility of the fragment through my microscope. Imagine trying to do all of that troughing in the apical third of the root.

Note that this file has radial lands, a larger tip diameter, and a greater than 0.04 taper. It’s probably a GT file.

Am I An Ex-Blogger?

Periapex — Wed, 03 Feb 2010 11:00:49 +0000

As all bloggers have experienced over the last 3 years, the concept of sharing our thoughts, frustrations, and joys through short journal entries in a blog has changed. The social media webscape has forced that upon us and this is actually a good thing.

Tumblr, facebook, Twitter, and reams of other organizations provide canvases for us to share, share, and share. To top all of that off, I have gotten myself involved in activities and hobbies that no longer leave me time to blog as I frequently as I once did — and I don’t really need to.

The people that matter most to me are on facebook and see snippets of my life, as I see theirs. My brother and I have a photography business on the side with its own blog and we both spend lots of time on flickr.

I just don’t have the time to write down my thoughts about movies, theatre, and books with the same obsessiveness I once had. I’d like to, but I like too many things.

So what the heck am I going on about?

I’m saying that this blog is still a part of my life, but it’s a much smaller part than it once was because I share my thoughts in lots of other places. This is probably a good thing too because as I become more famous and sought-after for my opinions on movies, theatre, and books, it becomes more dangerous to have my life laid out in a single public forum on the internet.

At this point, I’m thinking that I’ll focus this blog more towards my experiences in dentistry. I’ll probably throw some interesting personal-life stuff in every now and then, but those of you that truly are interested in my personal life (god knows why you’d be) are already my friends on other sites where I expose more of myself anyway.

Refocusing has involved pausing my twitterfeed aggregation and limiting my use of Twitter. Facebook’s changes over the last year, along with a really useful RSS app, allows my brother and me to do things that we could only do in convoluted ways via Twitter in the past.

Times change and technology follows suit. Although the infrequent posts to this blog leave me appearing stifled, I am in fact the complete opposite because of these continuous innovations in the social media landscape.

Poor Restorative Margins?

Periapex — Tue, 26 Jan 2010 22:12:44 +0000

Just got a phone message from a referring dentist that I was hoping had stopped referring patients my way. The reason for that is a long story in itself and for a post some other day.

The back-story revolves around a patient from this dentist whom I saw for a consultation last week. She’d had root canal treatment done fairly recently and is experiencing persistent, residual symptoms. In my letter back to the dentist I mentioned, among other observations, “poor interproximal restorative margins”.

So this patient’s dentist calls today and says that she doesn’t see poor restorative margins on the PA that she has of the tooth (a recent PA of which I have a copy). She’s not sure where my assumption of poor restorative margins came from and would like a copy of my PA to see what I saw.

Here’s my PA which is not really significantly different from her PA — and this is just what you can see on film. My explorer got stuck under the mesial margin so heavily that I could probably have pulled that whole filling out if I had applied more force.

Rex and Lady.

Periapex — Thu, 19 Nov 2009 17:41:13 +0000

Say Hi to Rex and Lady (bet you’ll be able to tell which is which without me giving you any hints).

I’ve always preferred dogs to cats, but some convolutions of the universe knotted together to drop these two into our home: Our neighbour’s cat (a stray who goes to them for bed and breakfast) got knocked up and had some babies; We’ve had a crazy mouse infestation in our walls this year; When we saw these two, we knew they were way too cute for their own good so we decided that we’d better look after them.

They are currently in training. I’m getting them used to flash photography…

The Harder They Come.

Periapex — Fri, 02 Oct 2009 14:57:37 +0000

We were in Toronto last month to attend this show. It’s basically about a Jamaican folk hero whose life ended tragically…kind of a Robin Hood story with an unhappy ending.

Unhappy endings don’t really bother me, as long as the story is worthwhile, but I found the show just OK. I’m guessing that the show is actually more than just OK, but the strong Jamaican accents and patois were completely incomprehensible to me most of the time (and I’m from the West Indies).

Back From the Galapagos Islands.

Periapex — Sun, 27 Sep 2009 14:51:23 +0000

We’re back from our 11 day trip to Ecuador (Quito, the capital city, and the Galapagos islands). The most difficult part of preparing for the trip was deciding what photographic equipment to take with me. The Girl insisted that we carry my 180mm macro lens, which I never ended up using.

What I did end up using was my brother’s Crumpler Whickey and Cox camera/laptop backpack, his 70-200mm f/4, my 17-40mm f/4 and 24-105mm f/4, 1 light stand, 1 shoot through umbrella, 1 580EX II flash, my SD500 compact with underwater case, and of course the 5D II. Add in assorted gels, filters, blower brush, lens pen, and wireless triggers, and there was barely enough room for clothes.

Luckily for us we didn’t need a lot of fancy clothes.

We toured the islands as part of a GAP Adventures group. There were 15 of us tourists in the group and GAP gave us duffel bags to repack our suitcase contents into. This made for much easier travel between islands.

The trip was an extremely active adventure full of hiking, biking, and snorkelling. The weather cooperated, the animals posed for photo ops, and our assorted bangs, bruises, and electrocutions were minor issues compared to our rewards for enduring them.

Not only did we luck out with all of that, but our group leaders were absolutely fantastic.

I’m slowly posting pictures of the trip to flickr. The lack of high-speed at home means that it’ll take at least a couple of weeks for all of them to get there, but as you’ll be able to understand once you see some of the shots, I’m glad that I carted all of that camera equipment around with me.

The islands truly do live up to their nickname, “The Enchanted Islands”. Their enchantments will remain with me for as long as I live and I’m pleased to see that the Ecuadorian government is taking extreme measures to preserve the biologic uniqueness of which the islands boast.

At some point in the near future, I’m sure we will all be able to look at the stewardship of these islands as an example of how we should all live and interact with the world about us.

Riverdance.

Periapex — Fri, 28 Aug 2009 14:11:06 +0000

Riverdance was back in Toronto earlier this year. Although the concept is the same as when I last saw the show years ago, they’ve added a few things (or at least I don’t remember them being in the show back then).

The most memorable parts of the show for me this time were the two flamenco numbers. The experience was just an awesome fusion of Spanish and Irish dancing.

Watch the clip to see what I’m talking about: Lines, movement, footwork — unbelievably clean and expressive. I could watch this over and over again (except I still don’t have a high speed internet connection at home).

Progress Check.

Periapex — Sun, 16 Aug 2009 14:28:32 +0000

Summer has finally arrived here in Cowland. We’re seeing consistently dry, hot weather now and you can see that people out and about are in much happier spirits. Summer is only about a month late.

I’ve been busy trying to stay out of trouble.

So far I’ve succeeded.

Our annual summer party rainfest (it has rained every year except for one that we’ve had the party) went off successfully again — no injuries, one broken fence gate, some assaulted frogs, and 2 overfed dogs.

I’ve been schooled and am schooling.

The latest person to school me was Rudy. I was refreshingly pleased to be given a few insights into his political thought processes. He argued some political points with me on facebook recently, but did so with intelligence and practicality. He’s someone that has made his own political decisions through reason and research rather than as a crowd-following Lemming.

I’m schooling myself in photography, as many of you know. It’s my newest hobby and I’m working my way through a stack of books, from visual composition, to using Adobe Lightroom. Playing with off-camera flash is the coolest thing I’ve come across in a very long time. It’s actually what’s keeping me away from this blog the most. Fragileheart has patiently volunteered her time to a couple of photosessions for me to work on my lighting.

Here’s an example of what off-camera flash can do for you. Take for example a painting that was created with heavy brush strokes or a palate knife. The surface of a painting like this is as important as the image itself. The strokes convey texture, emotion, and movement to the underlying image.

Straight-on, or flat, lighting produces this:

Lighting from the side produces this:

The trade-off (isn’t life full of these) is that the more texture you show, the less saturated your colours become. The trick is finding the right lighting ratio and angles to strike a good balance between colour saturation and texture and thereby do some justice to a piece that will still be best viewed live.