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.

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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.

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.

The Girl needed a root canal on a lower left molar and so I was voluntold to do it.

I’ve had some previous experience doing dental work in her mouth. We’ve come a long way since those early days.

She still needs nitrous, but is now ok without oral tranquilizers and we don’t yell at each other as much. In fact there were no raised voices yesterday.

The procedure went well. I had to numb the crap out of the tooth because it was undergoing an irreversible pulpitis.

We went out for dinner afterwards to celebrate a job well done.

Because her tongue, cheek, and lip were still numb on the left side, she tried to do all of her chewing on the right so that she wouldn’t accidently chomp down on her tongue or cheek on the left without realizing.

Instead she chomped down on her tongue on the right and definitely realized. That’s a pretty ugly hematoma that has developed.

She’s not in too much discomfort at the moment. Although I do sympathize with her, my happiness at coming through the whole experience unharmed, myself, is something that money can never buy.

Dear Other Endodontist In Town,

You are a nice guy and everything, but I wanted to send you a note to say that you are embarrassing me. In fact, you are degrading the specialty of Endodontics as a whole.

When you do work like this and tell the patient that everything is good and then the patient ends up seeing me a short time later with persistent or recurrent issues I end up having to do lots of damage control. After all, this tooth was treated by an endodontist, and he didn’t say that he had any trouble with the tooth.

In fact you did have trouble getting around the curve in the MB root. You had trouble getting the job done properly in the excessively short amount of time that you booked for the treatment. So much, in fact, that you over-instrumented the coronal aspects of all the canals and then created a strip perforation on the distal aspect of the MB root.

I have seen better work done by a dental student. Shame on you, and shame on the rest of us for allowing you to pass your specialty certification exams. A higher standard of treatment is implicit in the referral of the patient to your office.

Or maybe you were more conscientious and skillful in the past and for medical reasons you are not physically capable of doing better work now; or maybe greed has gotten in the way?

As specialists, when we fuck a tooth up, we always do a first class job — So much so that I have recommended that your patient have this tooth extracted. It is unlikely that I will be able to get around your ledged curve, fix your perforation, fix the obturation in the other canals, and leave the tooth strong for the long-term. In this case an implant is a better option than retreatment.

Stuff hits the fan in specialty offices all the time, it’s unavoidable when we see the tough cases. It’s always a good idea to be up-front with your patients and explain these complications or unexpected results to them. They usually understand that you tried your best.

They are hard-pressed to think you tried your best when those unexpected results and complications are explained after the fact from one of your peers.

Yours Sincerely,

Peri Apex, The Other Endodontist In Town.