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.

© Periapex for The Periapex, 2010. | Permalink | 4 comments |

Endodontic diagnosis generally consists of both a pulpal and periapical diagnosis.

Pulpal Diagnosis:

• Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.
• Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.
• Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.

Additional descriptions:

• Symptomatic – Lingering thermal pain, spontaneous pain, referred pain.
• Asymptomatic – No clinical symptoms but inflammation produced by caries, caries excavation, trauma, etc.

• Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.
• Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments.
• Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).

Apical (Periapical) Diagnosis:

• Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.
• Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area.
• Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms.
• Acute apical abscess - An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.
• Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract.

© Periapex for The Periapex, 2008. | Permalink | 5 comments |

© Periapex for The Periapex, 2008. | Permalink | No comment |

While I was an endo resident I rotated through Mt. Sinai’s facial pain clinic and one thing that I’ll probably remember forever is a patient who presented with a nagging toothache. She pointed at the 16. I don’t remember her history, but for some reason her regular dentist suspected non-odontogenic pain. We suspected the same thing once we saw her and examined the area. My supervisor at the time recommended that we try an anesthetic test to see if we could rule the tooth in or out as a source of the woman’s pain. Muscle palpation in the area was unremarkable, so it wasn’t like the anesthetic would numb up active trigger points that were the source of the pain.

So I reclined the chair as I was telling her about the test I was going to do. I applied some topical anesthetic and told her we’d wait a little for that to take effect before I used the real stuff. After about a minute of letting the topical soak in, my patient looked at me and said that her chronic ache was gone. Hmm. Confused was I. But not my supervisor. Off to the neurologist our patient went.

Patients will often present with toothaches that they can’t localize to a particular tooth, or even point at a tooth that has nothing obviously wrong with it, and the responsibility falls on the dentist to diagnose the problem and treat the correct tooth.

Anaesthetic testing is most useful for eliminating quadrants as suspects rather than adjacent teeth (obviously). This however, can be a valuable tool, because referred tooth pain often does cross the horizontal midline.

Explanation by way of example:

A friend, K, called the office in tons of pain about 3 weeks ago. They were actually at their regular dentist and the dentist was pointing at 16 as the source of pain. K agreed.

I had seen her for the 16 about a year ago because of some pulpitic-type sensitivity she was having there. The problem turned out to be deep caries. I did some caries control and ended up with a pin-point vital pulpal exposure. I decided to pulp cap with MTA and see how things went. I also told her to have 48 extracted because it was partially erupted and picking up caries on the distal.

Everything settled after about a week.

With the phone call from the other office, it made sense that any current toothache had 16 as the likely source. My personal schedule (getting ready for the ProAm) didn’t allow me to see K quickly. Antibiotics and anti-inflammatories were of little help.

We managed to finally get K into the office. She hadn’t been sleeping well for about 3 days at that point. Again, she pointed at the 16, but said that the pain was pretty much on her whole right side at the back. Xrays of both upper and lower quads showed no areas consistent with apical pathosis. Because I figured we were dealing with an acute pulpitis, I didn’t want to torture K by cold testing the 16, but out of habit and instinct, I decided to test other teeth to try to definitively rule in 16 as the source of pain.

Cold testing was normal where it should have been except on 48. Cold applied to 48 provided some reduction in K’s overall pain level. Hmm. I decided to percussion-test the teeth. Both 47 and 48 were percussion sensitive relative to 16. Both 16 and 48 had been filled with resins by K’s dentist. Both fillings were falling apart.

So in comes the anaesthetic test. I gave 1/2 a cartridge of lidocaine as a buccal infiltration about 16. After 5 minutes, K indicated that she felt the pain still everywhere except for where I had given the freezing. The pain was practically the same intensity. This led me away from the 16 as the source, and to the 48 as the next likely candidate. A subsequent mandibular block eliminated the pain.

The problem turned out to be an irreversible pulpitis on 48. I didn’t go back and try cold-testing 16, but I’m assuming at this point that it’s pulpally ok…

When testing areas this way I usually start with inflitrations on top and save the lower block as the last injection. It’s much easier to control the field of anaesthesia on the upper arch than the lower. Field control is a good thing because the more we can isolate the anaesthesia to a particular tooth, the more information we glean from the test.

© Ameloblast for The Periapex, 2007. | Permalink | 2 comments |

Paraphrased question:

I mainly just had a question about appropriate screening at dental check-ups. What is the standard of care? Is a panorex a legitimate screening modality?Also, my wife just visited a new dentist who found an area that needed repair. Without asking he snapped some digital pics to show her. He could see the area clearly without the need for the pictures, and she surely would not have asked for them, especially if he had told her that they would cost almost a hundred dollars and not be covered by insurance. Do you think this warrants any action on our part other than refusing to pay. Any thoughts in general?

My response:

Did the new dentist take the Pan on your wife? Were the digital pictures xrays or intraoral photographs?

Their response:

The Panorex was done by a tech before my wife saw the dentist. He told her it was just routine screening. The digital pics were intraoral photographs. She had a cracked tooth in the back.

My answer:

Pans are an appropriate film for new patients and patients who haven’t had a comprehensive radiographic survey for a number of years. You get less radiated from a Pan than from a full mouth series (16-18 films) and you get more peripheral information from a Pan than the FMX (TMJ, sinuses, jaw anatomy). Unfortunately, the resolution of a pan is generally not good enough to definitively diagnose some types of caries and some other tooth-related issues so we’ll target individual areas with more specific films if we see something suspicious on the Pan. In their defense, Pans, especially the newer digital ones are becoming sharp enough to see incipient caries as precisely as we are able to on bitewing films.Intraoral cameras are a great tool in helping patients trust that what their dentist is saying is wrong with their teeth actually is. Many times teeth that need work are asymptomatic and patients don’t actually know if the recommended work is really needed. I take pictures of some of my cases so that when I send the note back to the referring dentist they don’t think I’m bullshitting them. Same idea.

Intraoral shots are sometimes a good idea for records, but are generally more important for patient education and information. As with anything in medicine and dentistry, the equipment is expensive though and some dentists feel the need to recoup their costs. IO cameras help to recoup their own costs, because by being able to show pt’s problems in their mouth more directly, pt’s are usually more interested in getting something done rather than waiting for pain to develop (at which point you might not be able to do anything). I haven’t heard of any offices that charge for IO pictures for this reason. But that obviously doesn’t mean it doesn’t happen.

Your financial responsibility with an office is part of any informed consent. Prior to a procedure being performed, if you were not aware that you would have to pay for the procedure, I can’t see how the office can make you pay. Along this same vein, and just as unethical, is when a therapeutic procedure is started and proceeds to the point of being irreversible (eg. a root canal procedure is started) and the office then tells you how much you’re going to have to pay.

Unfortunately, most patients don’t want to rock the boat and don’t complain and pay they bill. They become wiser for next time.

In your wife’s case, I can’t see how you’d take the case any further than refusing to pay for the pics because the only neligence was not informing your wife of costs. No damage or physical error was done by the dentist. If reported to a state dental board, they might warn the dentist about the way he practices, but that would probably be the end. And I don’t know if he’d change…

© Ameloblast for The Periapex, 2007. | Permalink | 6 comments |

This picture shows the tracer pointing to the apex of a tooth. Both the canine and lateral incisor were probable sources of infection, so the root canal was redone in the canine and a root canal was done in the lateral incisor.

This is the post op film. No recall pictures yet but the chin has healed with a little scarred dimple.

© Ameloblast for The Periapex, 2006. | Permalink | 4 comments |

The patient had been having symptoms and was medicated with antibiotics. They were referred to me for a retreatment. There was no information about when the original root canal was done but the obturation is thin and short and there is apical rarefying osteitis.

It looked at first like a straight forward crown access, post removal, and canal retreatment. On second glance at the film, I became a little worried about coronal leakage under the distal crown margin and the impact this might have on the prognosis of the retreatment.

So we took a vertical bitewing to check the crown margins:

Wow. Here we now have an ill-fitting crown, a much longer than expected post in MB that is heading to a perforation, furcation involvement, a probable perforation into the furcation, and on top of all of that…a crappy root canal.

I ended up recommending extraction of this tooth.

Moral of the story: Take different angled films and don’t forget about the usefulness of vertical bitewings.

© Ameloblast for The Periapex, 2005. | Permalink | No comment |