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 Life's Context, 2010. | Permalink | 4 comments |

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.

© Periapex for Life's Context, 2010. | Permalink | 3 comments |

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.

© Periapex for Life's Context, 2010. | Permalink | 4 comments |

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.

© Periapex for Life's Context, 2009. | Permalink | 9 comments |

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.

© Periapex for Life's Context, 2009. | Permalink | 14 comments |

From a patient that I saw yesterday for a consultation:

I’m with a new dentist now. I left my previous dentist because one day when she was drilling my tooth and you could smell that tooth dust smell she told her assistant that that was the smell of money.

© Periapex for Life's Context, 2008. | Permalink | 13 comments |

This scores your office lots of fuck you points and pretty much guarantees that if you try to refer other patients in the future they’ll probably have to wait even longer. Why not teach the specialist “a lesson” by not referring any further patients to them.

© Periapex for Life's Context, 2008. | Permalink | 15 comments |

Our work is part of our life and how we work is also how we live. The energy that we interact with there is what creates a happy or unhappy work environment for each of us.

I love what I do and I think that I’m pretty good at it. Those two things usually go hand in hand. But last week a particular case highlighted a few things.

The case involved a female soldier suffering from a moderate cellulitis¹. The infection was from a tooth that had had a root canal started at her base. An instrument broke off in the tooth, and infection subsequently set in.

She ended up in the emerg department at a hospital and was started on IV antibiotics and narcotics. I saw her the following day.

By the time I saw her the lip and face were still very sensitive and the overall facial swelling still existed. In a nutshell I had to basically contend with an anxious patient, attempt to achieve some discharge from a tooth that was blocked internally with the broken instrument, and also get her numbed up enough to be able to do the work.

She and I worked together to manage her anxiety and fear and so I was able to achieve some positive results with the tooth and swelling.

I was fucking exhausted afterwards. Even though the work itself for this case turned out to be fairly easy, the whole management aspect just left me feeling drained.

This wasn’t the first time that this has happened. It’s happened after taking call during my pediatric dentistry and oral surgery rotations in hospital ER’s. It’s happened after other cases similar to this one.

And yet, there’s the opposite situation. I feel an emotional charge from cases and patients that arrive and leave on a more positive note.

No, it hasn’t been the first time that I’ve dealt with this sort of thing but it was the first time that I actually questioned whether this could be the cause of trouble in so many dentist’s personal lives. Could cases like this one add up over time to burn us out. Could these cases be the reason for the correlation that the profession of dentistry has with drug abuse, marital distress, and life-threatening behaviour?

• Burnout is an occupational risk for anyone who works with needy people. It is marked by three components: emotional exhaustion, cynicism, and a low sense of efficacy in one’s job².
• Burnout often occurs when a person is required to provide services for a highly needy individual who may not be helped by those services. Often caregivers perceive that they give much more than they get back from their patients³.
• High rates of burnout have been found among nurses who work in stressful environments, such as intensive care, emergency, or terminal care⁴.
• When burned-out workers go home, they are often irritable with their families. They are more likely to suffer from insomnia as well as drug and alcohol abuse, and they have a higher rate of psychosomatic disorders⁵.

So yeah, dentistry being a profession that deals with pain and suffering to some degree is prone to professional burnout. Endodontics, my specialty, is where people with pain and suffering that can’t be helped by their regular dentist get shipped to. I’m probably more prone to burnout than a general dentist.

Most people are helped by what I do, some aren’t — that’s the nature of medicine. It’s very unrewarding, and often stressful, when patients return with relapsed treatment after having spent hundreds of dollars on a tooth.

There are some jobs that, although you may love, emotionally tire you out. There are others that emotionally energize you. The practice of Endodontics, in my opinion, is not an emotionally uplifting job. It is rewarding in many other ways — intellectually, financially, altruistically — of course, but not emotionally.

To maintain a healthy personal life, then, what mechanisms have I developed over the years to deal with burnout? Here’s a list. Each point can be a post in itself, so I’ll keep the points short:

• Leave work at work. Very rarely do I bring “my patients” home with me.
• Bring home to work as often as I can. This grounds me.
• Yoga and dancing.
• Strict policies at work that pertain to management of our patients and referring offices.
• Pay a little more, hire motivated, intelligent staff who don’t mind sharing my burnout.
• An understanding and supportive wife.
• Ignore a certain man who has for years said that I should work more hours, “Do it now while you’re young”. He looks like me, only a little older.
• Maintain a cost of living that still allows me the choice to work more or less hours without feeling imprisoned in a tiring, demanding work schedule.
• Vacations.
• Pets.
• This blog.

Lastly, remember way back up at the top of this post, I spoke of energy?

Burnout is all about energy. Needy patients suck positive energy out of me. I give freely of the energy because it is my job. Other people in creative fields may find that their work involves manipulation of energy to create something larger and greater than the individual. Not so in my field.

Some people arrive in such a negative psychologic or emotional state that my energy is just barely able to get them to a neutral level — just enough that the job can get done. By the end of the day I’m pretty drained and need to recharge for the next day.

How we recharge our batteries is an individual process. For me, the first step is to eliminate as much negativity from my life as possible — lead a positive life, eliminate negative people. And then I just let life swallow me up. I take the time to stop and observe the goodness around me. I see the world for the beauty it holds.

Our dying Maple, 40 years old, lets go of its last leaf. This leaf is a vestige of the spirit this tree once knew. I watch as the wind takes hold of it and the leaf zigs away then zags towards me. I do not move. I am part of this drama.

The leaf rolls through the currents as fate inexorably pulls it down. Then it lands on the surface of our pool. It produces no ripples across the water’s face, yet it is a jagged red blemish upon the reflected sky. It floats heedless of its destiny.

The wind blows. A frog croaks. I hear. I see. I smile.

1. A painful swelling of the soft tissue of the mouth and face resulting from a diffuse spreading of purulent exudate along the fascial planes that separate the muscle bundles.
2. Maslach, C. (2003). Job burnout: New directions in research and intervention. Current Directions, 12, 189-192
3. Van YPeren, N. W., Buunk, B. P., & Schaufelli, W. B. (1992). Communal orientation and the burnout syndrome among nurses. Journal of Applied Social Psychology, 22, 173-189.
4. Mallett, K., Price, J. H., Jurs, S. G., & Slenker, S. (1991). Relationships among burnout, death anxiety, and social support in hospice and critical care nurses. Psychological Reports, 68, 1347-1359.
5. Parker, P. A., & Kulik, J. A. (1995). Burnout, self- and supervisor-rated job performance, and absenteeism among nurses. Journal of Behavioral Medicine, 18, 581-600

© Periapex for Life's Context, 2008. | Permalink | 11 comments |

Me: Uh huh?

She: Yeah, maybe dentists should look into something like that.

Me: Uh huh?

She: It’s like the thing that mechanics use. You know, where they lie on it and then it slides under the car.

Me: Uh huh?

She: So the eye doctor rotates the patient so that they are lying upside down and the eyes fall forward and the doctor works on them from underneath.

Me: Hmm. Uh huh?

She: So wouldn’t that be easier for dentists and their patients too?

Me: Working from underneath you like you’re a car?

She: Yeah…like that…

Me: Except you’d drool all over me. No thank you.

She: Oh, you’re right. Hmm.

Me: Uh huh.

© Periapex for Life's Context, 2008. | Permalink | 3 comments |

The tooth was retreated over a couple of appointments. Sure enough there was a perforation at the apex of the root, but laterally. I was never able to regain the true canal beyond the perf. A carbon fiber post was removed, Calcium Hydroxide was used as an interappointment intracanal dressing, and then MTA (Mineral Trioxide Aggregate) was used to fully obturate the canal.

There is a 21 month interval between the two films. Osseous healing is progressing well, and no mucosal lesions were evident at the time of the second film.

This case also serves as an example of the fact that a 1-year recall on endodontic cases does not provide enough time to properly evaluate healing. From a strict radiographic interpretation, this case has not healed and is therefore not currently a success. One strike against the relevance or clinical significance of that Cochrane Review.

By the way, I did address the molar’s obvious periodontal issue verbally. The patient is aware of a guarded long-term prognosis there.

© Periapex for Life's Context, 2008. | Permalink | 8 comments |