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.

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.

Ignorance is bliss isn’t it. I feel sorry for this commenter’s patients. This is an answer to this question at Yahoo Answers.

HeatherS, you I suppose you are expecting an answer from me.I don’t how how long ago you graduated from dental school, so perhaps you’ve been in practice so long that you’ve just learned to accept the status-quo.

There is a horrendous problem in the dental profession, both at the educational level and the pratical level. There are ten different kinds of dental doctors, 9 of whom deal with problems almost exclusively within the confines of the mouth–a hole in the head the size of a tennis ball. Obviously, there’s not much turf to go around, so what happens? 1. you get a lot of overlap between the jobs of specialists, and 2. you get specialists who isolate their practices to very few types of problems and procedures.

Take endodontists for example. There is absolutely no justification for their existence. None whatsoever. How do I know this? Because the scope of their work is exceedingly limited (root canals, endo retreatments, post spaces, apexification procedures, and apicoectomies), . So limited in fact, that it could easily be incorporated into a dental school curriculum for general dentists to learn. Certainly, any general dentist (with a little bit of practice) can learn to do all of these procedures. I did.

The fact of the matter is that there are general dentists who don’t know how to do it and don’t want to learn, Why? Because they don’t want to bother with it and because they know they can make more money performing crown and bridge. And of course, there are plenty of endodontists who are just happy to feed off these lazy, greedy dentists, doing root canals day in and day out at literally 150% or more the cost of a root canal performed by a general dentist.

This approach does not serve the dental profession well. It makes us look absolutely ridiculous! The fact that a patient who comes in with an endodontic tooth problem and cannot be treated by his dentist sounds preposterous. Moreover, it doesn’t serve the patient well.

If you’re too incompetent to do your own molar endo with similar speed and quality as an endodontist, you shouldn’t have a license to practice dentistry.

I am also a firm believer that periodontics and orthodontics should not exist either. These are services that general dentists should be able to perform as well. How do I know this? Because there are many general dentists who perform all of their own perio surgeries and general dentists who handle all of their own ortho!

Same with prosthodontics and pedodontics.

With the exception of oral and maxillofacial surgery and oral path, none of the dental specialties are sciences that are diverse enough to warrant doctors who study them exclusively (the way a cardiologist studies cardiology, or a plastic surgeon studies plastic surgery, or an ENT studies the head and neck). Endodontics, ortho, pedo, prosth are all tiny disciplines that can easily be incorporated into the scope of a general dentists practice.

But they’re not. Why? Because everyone with a DDS or DMD is interested in making money…especially the specialists. And the schools are more interested in preserving the work-load for the specialists by keeping their students ignorant of anything but the most basic endo, pedo, prosth, and teaching them absolutely nothing about ortho.

Think about it this way, Heather: what type of work is unique to the general dentist? Fillings. That’s it. That is the only kind of work we do for which there isn’t a specialist.

This doesn’t strike you as absolutely ridiculous?

DR. SAM & DR. ALBERT:

Dr. Sam, you said it yourself: you don’t do molar endo because it “disrputs your schedule” and because the endodontist can do it faster. Ask yourself this: what if endodontists didn’t exist? General dentists would become more competent at molar endo! And, patients wouldn’t be charged the specialist premium for a procedure that a general dentist OUGHT to be able to do!

Dentistry should consist of three types of doctors: general dentists, oral pathologists, and oral surgeons. Why do I say this? Because there are general dentists who treat kids, perform ortho, perform all their molar endo, perform their own perio surgery, their own prosthodontic work, etc. Oral pathologists cover the diseases of the oral cavity and maxillofacial region, and oral surgeons are there to handle the more involved surgeries (i.e. orthognathics, vestibuloplasties, pathology, etc.). Between these three doctors (if general dentists were trained PROPERLY in dental school), everything within the dental profession would be covered. Everything. But that will never happen because there are too many general dentists who are perfectly content sticking with the money-making routine work and too many specialists perfectly content doing root canals and sedating kids day in/day out for obscenely high fees.

I perform the majority of my third molar extractions, virtually all of my preprosthetic surgeries, and 99.999 percent of my extractions of surgically-erupted teeth. I also treat many children, and when I get training to sedate patients, I will treat all of my pediatric cases. I also perform virtually all of my own endo, referring to endodontists the cases that are borderline hopeless (and often turn out to be untreatable).

I am am under 5 years in private practice, mind you. I have a long way to go in my career and thus plenty of time to learn to do the things we general dentists SHOULD have been taught in school.

The poster tried to suck me into a pointless argument here.

She: Thanks for returning my call.

Me: No problem, how are you?

She: Good thanks. I wanted to ask you; remember that girl that I recently sent you with the internal resorption?

Me: Yeah, but I diagnosed it as invasive cervical resorption which isn’t really internal resorption. I sent you a report.

She: Yeah well after you worked on the tooth to try to save it and found that the internal resorption was too extensive I called her Mom.

Me: Uh huh.

She: Mom was very cool..ish.

Me: As in cold?

She: Well yeah. I got the sense while talking to her that someone had told her that the orthodontic treatment was responsible for the internal resorption.

Me: I’m pretty sure it wasn’t internal resorption. Internal resorption is a pulpal phenomenon, external resorption can become very invasive and sometimes resemble internal cervical resorption, but is actually an issue with periodontal cells.

She: Yeah, well I spoke to the oral radiologist that I know that works cases with me and I asked her if internal resorption can be caused by ortho and she said absolutely not.

Me: Well she’s probably right. External resorption, on the other hand, happens when osteoclasts get a little confused. Trauma and internal bleaching can do this. Ortho is controlled trauma, so it stands to reason that it could be responsible for cervical resorption.

She: Well in my 30 years of doing Ortho the only two cases of internal resorption I’ve seen have happened in the last year and I’ve sent both to you. Neither of them appear to be related to Ortho (the first one existed prior to my treatment) and the radiologist says that the second one isn’t related.

Editor’s note: The first case was diagnosed by the same radiologist as dens-in-dente. I confirmed this once I saw the patient and recommended no treatment. The second patient has been in retention for the last couple of years, the orthodontist didn’t see any problems with her teeth on a recent check, but a scheduled recall at the girl’s GP a short time after turned up a pretty bad case of pink tooth. The dentist really scared the girl and her mom about how the tooth would be lost, blah, blah. The upset mom called the orthodontist who then called me to give me the heads up and the referral. Turned out that the prognosis of the tooth was poor to hopeless.

Me: Well I told the Mom that these resorptive defects are often idiopathic, but orthodontics can be implicated in some of them. They happen rarely enough that their development is unpredictable however. I implied no negligence. I don’t know if her dentist did, however.

She: Ok, well, I just wanted to find out who told the Mom that the orthodontics caused the problem.

Me: Sounds like you’re worried she wants something?

She: No I’m not worried, I just don’t like people assigning guilt.

Me: Me neither. I’m not in that business, and doing that hurts my business. You know that, you get your patients from the same sources.

She: I’m sending the Mom a letter that shows the results of my research. I wasn’t able to find any implication between orthodontics and internal resorption. And I quote the radiologist as saying there’s no connection.

Me: Don’t you think that doing all of that makes it look like you’re worried about something?

She: No I asked the Mom if she wanted more information on resorption and she said yes.

Me: Ok then.

She: It’s really too bad so many of us have to boost our egos by blaming others for this and that. Don’t you think?

Me: Yup.

Editor’s note: Ok, I’m getting a little worked up now cuz she’s been wasting my time for the last 10 minutes and I’ve got lots of other people to blame for things.

She: Yeah, you know, when her mom told me that she was told that ortho could have caused the problem, I went to the library and looked and looked for that connection.

Me: Uh huh. Well anyway, seems like things are working out for you. I’ve told the family to speak to their dentist about replacement options for the tooth.

She: Ok then. Talk to you later.

Editor’s Note: I hope not.
Do you think it was bad of me to have faxed the following to her the next morning?

Invasive cervical resorption: an analysis of potential predisposing factors.Heithersay GS.

Department of Dentistry, University of Adelaide, Australia.

OBJECTIVE: An investigation was undertaken to assess potential predisposing factors to invasive cervical resorption.

METHOD AND MATERIALS: A group of 222 patients with a total of 257 teeth displaying varying degrees of invasive cervical resorption were analyzed. Potential predisposing factors, including trauma, intracoronal bleaching, surgery, orthodontics, periodontal root scaling or planing, bruxism, delayed eruption, developmental defects, and restorations were assessed from the patients’ history and oral examination.

RESULTS: Of the potential predisposing factors identified, orthodontics was the most common sole factor, constituting 21.2% of patients and 24.1% of teeth examined. Other factors were present in an additional 5.0% of orthodontically treated patients (4.3% of teeth), and these consisted principally of trauma and/or intracoronal bleaching. Trauma was the second most frequent sole factor (14.0% of patients and 15.1% of teeth). Trauma in combination with intracoronal bleaching, orthodontics, or delayed eruption constituted an additional 11.2% of patients (10.6% of teeth). Intracoronal bleaching was found to be the sole potential predisposing factor in 4.5% of patients and 3.9% of teeth, and an additional 10.4% of patients and 9.7% of teeth showed a combination of intracoronal bleaching with trauma and/or orthodontics. Surgery, particularly involving the cementoenamel junction area, was a sole potential predisposing factor in 6.3% of patients and 5.4% of teeth. Periodontal therapy, including deep root scaling and planing, showed a low incidence, as did other factors, such as bruxism and developmental defects. The presence of an intracoronal restoration was the only identifiable factor in 15.3% of patients and 14.4% of teeth, while 15.0% of patients and 16.4% of teeth showed no identifiable potential pedisposing factors.

CONCLUSION: These results indicated a strong association between invasive cervical resorption and orthodontic treatment, trauma, and intracoronal bleaching, either alone or in combination.

Quintessence Int. 1999 Feb;30(2):83-95

She hasn’t bothered to talk to me later as yet. She probably won’t send anymore patients either.

And there sure are lots.

These pictures were posted on here (this is the actual blog). The poster is a female dentist who seems like a fairly nice person when you skim her blog. She’s active with her church, so I assume that means that she’s probably morally superior to me (who isn’t?). She’s obviously proud of her new practice–and she should be. She’s done a good job setting it up.

All I did was post a comment asking her if the fracture lines visible on the marginal ridges of the molar connected into a sagittal fracture under the old amalgam. Many times teeth like this end up needing more than just a bonded filling. These types of cases are interesting and common enough to generate some constructive discussion.

Anyway, she didn’t bother to answer and erased my comment. Seems that the only comments she allows on her blog are the ones that praise her.

Oh well. I wonder if the meek really will inherit the Earth.

Update: Turns out to be a rational explanation for the sequence of events. Karma has been restored. See comments.