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.

Just finished closing this case up. It was a lower left first molar with a persistent abscess (I retreated it a month or two ago). I decided to flap it to see what was going on and to do an apical resection if necessary. I didn’t get past this part once I saw the split mesial root.

I finally got around to checking the parfocus on the microscope and resetting the white balance on the Nikon. Hopefully pictures will turn out nicer.

Here’s a lower molar that had a large amalgam buildup with a sagittal crack through the amalgam. I suspected that this would translate into deeper radicular cracks but couldn’t find any of these cracks until late into the retreatment.

Here’s one crack running into the ML canal:

And here’s one running into the D canal:

I’ve sent the patient back to his dentist for extraction.

I see a significant number of teeth needing endodontic treatment because of intracanal infection or periodontal involvement caused by radicular cracks like this. The prognosis of any of these cases is poor because bonded restorations or obturants and subsequent crowns will not eliminate the periodontal long-term issues, or predictably hold the crack together.

Unfortunately, I know that in too many offices these cracks are seen and conveniently ignored or seen and the patient is told, “we’ll finish the root canal, put a crown on, and hope for the best.”

The only hope, there, is that the patient will make it to the Visa machine before the tooth becomes re-infected…

On another note about the lack of ethics in dentistry: I saw a patient this week for a consult about a molar. He had just moved into the area that I work. After we discussed the tooth in question, he pointed at his two upper centrals and showed me how they were whiter than his adjacent teeth. They are crowns that were cemented within the last 6 months. He doesn’t like to smile because he feels that the colour discrepency is embarrasing. He wanted to know what could be done.

Apparently his previous “cosmetic” dentist (whom I know and who has published a few articles in Oral Health about cosmetic dentistry) got these crowns back from the lab for cementation. At the appointment, the patient indicated that he didn’t like the colour match. The dentist agreed, but said, that he would cement the crowns and they could deal with the colour problems after. Don’t ask me how this was supposed to be done. The patient’s Visa went through though.

Anyway the patient continued to complain at subsequent appointments. The proposed solution was to veneer the adjacent teeth back to the 5’s or 6’s. Needless to say, the patient hasn’t done anything. The adjacent teeth do not need any veneers and the problem should be addressed simply by remaking the crowns. I can totally understand why the patient is pissed.

I’m telling you, one day, I’ll pack my things and take the Boy and Girl, Hector, Sundance, and Polly, and go and work somewhere that people don’t fuck others around for money. Don’t know where in the world you’d find a place like that though.

You had something to hide
Should have hidden it, shouldn’t you
Now you’re not satisfied
With what you’re being put through
It’s just time to pay the price
For not listening to advice
And deciding in your youth
On the policy of truth
Things could be so different now
It used to be so civilised
You will always wonder how
It could have been if you’d only lied

It’s too late to change events
It’s time to face the consequence
For delivering the proof
In the policy of truth

– Policy of Truth, Depeche Mode.

This patient reported a history of endodontic treatment in the Far East, then retreatment a few years ago. He ended up in my office because of a persistent parulis buccal to the tooth. I decided to retreat again, but had no real success in resolving the infection. It’s a rare two-rooted lower premolar.

We decided to do some exploratory/apical surgery. After mucosal reflection, I was able to confirm a vertical root fracture that started apically. This is probably partially because weakening of the roots from the amount of intracanal instrumentation this tooth has gone through over the years.

I was not able to apically resect the root to eliminate the fracture because of the complete loss of buccal bone and the short root that would have remained. The prognosis for this tooth is hopeless.

Yes, I do work on other teeth besides upper anteriors…We’ve just had a few neat recalls this week.

This a case of a horizontal root fracture. The endo was done 1.5 years after the accident because no vitality had returned to the tooth and a grey caste was developing. Endo for prevention of infection was advised. Teeth with horizontal root fractures are tough teeth to endodontically treat and once infection sets in, the prognosis becomes even more guarded.

Once I started the endo, I got through necrotic tissue coronally, but as I approached the fracture line, I found vital tissue (was able to tell because of hyperemia). In order to try to preserve as much of this tissue as possible (to help with potential reduction and stabilization of the fracture and also for possible biologic closure of the end of the coronal root fragment–ie. apexification) I minimally instrumented to the fracture and then filled the canal to that point with white MTA (mineral trioxide aggregate).

Two years later, osseous healing is complete and the root segments appear to be stabilized. Mobility has reduced. There’s a cosmetic issue now though. Although I used white MTA and the pt’s dentist bleached the tooth prior to placing the final resin, it’s turning more and more grey. Oh well, at least he still has the tooth.

And speaking of horizontal root fractures, here is a case that I did years ago. I wouldn’t necessarily do the same thing today but the post op film looks cool.