Every so often I think about the idiot dentist that we wrote about in this post a while back. For some reason he is one of the few things that aggravates the hell out of me. It is probably because when you mix ignorance and arrogance you get a bully, and when you have a bully working on patients, trouble usually isn’t too far behind.

He has some fairly popular ideas about dentistry and the various subspecialties. He believes that endodontics in particular is merely a technical skill that can be improved upon practice. Continuing to improve your endodontic skills over time will put you at the same level of training as an endodontist.

Basically, as a general dentist, you would take a few hours of continuing education courses. These sometimes consist of weekend courses that involve both a didactic and hands-on component. They are usually taught by endodontists, and are often sponsored by an equipment manufacturer (the one whose equipment the specialist will be teaching about). These courses are meant for general dentists who are interested in how to do good root canal work.

Continuing education courses that specialists take are also given by specialists, but the goal of these courses isn’t usually about how to do good root canal work (since we already know that), but about more academic ideas. The controversies and thoughts that these lectures bring about are responsible for ongoing research in our field. The findings from this research evenutally trickles down to GP dentists through their courses as improvements in patient management and technique.

As much as administering the Canadian Endodontic licensing exam is a real pain in the ass (takes up a lot of time, and I don’t get compensated for it) it is rewarding.

My partner during the oral exams last weekend is the new chief examiner. I am confident that with his leadership we will see some very positive and constructive changes to the examination. The examination brings some of the brightest minds in Canadian Endodontics together — both examiners and candidates. I always find this refreshing because I work alone.

Working alone means that I only have myself to critique my work, I only have myself to toss ideas off of, and I only have myself to decide what journals and articles I should read that are most relevant to what I do. When specialists meet as part of a conference or an examination, we bond through the sharing of each other’s ideas.

But what about that asshole that I mentioned earlier? What does all of this have to do with him? Here is a summary of what it takes to be an Endodontist in Canada.

Now think of yourself as a patient in need of a root canal. Even if the procedure is merely a technical skill (which it isn’t) and your family dentist might have done hundreds to this point, would you not feel more comfortable having it done by an endodontist?

The answer is fairly obvious. The less obvious fact is that millions of root canal procedures are done annually by GP dentists and endodontists. GP dentists are trained to be competent at the procedure but annually as well there are thousands of cases that lie outside of a GP’s competency level. It is for those cases that we specialists exist. Any general practitioner dentist who states that he or she never refers patients to an endodontist leaves me wondering about the standard of care in that office.

It’s that time of the year when storms in Workland can knock power out for seconds to hours. It’s an annual ritual for us to have at least 1 patient per year experience a power failure during a procedure.

I only work during the day and we have lots of windows in the treatment rooms at the office but storm clouds are quite dark and so we usually have to break out the flashlights in order to finish things up. I haven’t needed a power generator…yet. That’s unlike the periodontists next door.

A patient that I saw back in 2005 during a power failure returned yesterday for me to check out an unrelated tooth. Here’s my treatment note from back then:

Here’s my post-op xray of the tooth I worked on (I did the 5 and the 7):

And here’s the tooth as it stands today:

There’s a massive screw post that her dentist has placed almost to the apex. I don’t know how long this tooth will survive before it either splits along the root or bacterial leakage happens alongside the post.

Morale of story? Not really sure, but it has something to do with power failures affecting root canal treatment prognosis less than irresponsible dentistry does.

…If this was my excitement for the day of work that I put in:

It’s an upper second premolar (an uncommon morphologic phenomenon) with 3 canals that I retreated the root canal work on. The first 2 pictures are the before ones, the second 2 are the afters.

Patients ask me that sometimes as they sit in the chair. Depending on my mood I’ll joke with them and ask them how long they’ve got.

Remember that convict that I saw for consultation a while back? His first of two treatment (retreatment) appointments was today.

Him: So how long am I gonna be here today?

Me chuckling: How much time do you…have?

I realized the context of that statement after I said it. He looked at me sadly.

Him with a shrug: My whole life.

Me: Oh. Well you’ll be done here before that.

The Guards: *chuckle*

I didn’t ask any more silly questions for the rest of the appointment.

Although I’m perfect, not everything that I do is. And if you believe that, well…well you’re welcome as a guest in my house anytime!

Here is a case that is about 12 months old. The right central incisor had a history of trauma and at the consultation appointment there were clinical signs of infection (chronic apical abscess).

By the time I saw the child for treatment, the apical lesion had enlarged. The plan for treatment was endodontic therapy, of course, but I was unsure if apexification would be necessary. I assumed it would be, but decided to play things by eye.

Once I got into the tooth I found pus in the coronal third of the canal but as I worked my way further up the canal, hyperemia developed. The apically vital pulp was likely the reason that I found an apical stop.

The apical vitality and stop allowed me to complete the case, rather than medicate it therapeutically against infection or for apexification purposes. I was a little overzealous with my obturation (warm lateral condensation for this case) and squished out a heavy amount of sealer.

To show you that presence of infection is really the only factor that affects apical healing, I took the third film as a recall this year. The left central incisor has completed apical maturation. The sealer outside the right central is still there but the periapical radiolucent area has practically disappeared. Clinical examination found no signs of infection and our patient reports no issues with the tooth.

This is a healed case.

The goal of my therapy is not to squish sealer out the apex, but to create a favorable environment for osseous healing. I did both of those things here. Extra-radicular material will increase post operative inflammation and will cause a foreign body reaction which can result in a fibrous connective tissue scar. The scar can look like a persistent lesion over time and complicate future diagnosis.

Histology of the periapex (yes, that’s my name) of this tooth would probably show fibrous encapsulation of the sealer, but in this case the capsule is thin enough that it does not show radiographically.

Hey, I’m not perfect and not everything I do works out the way it is supposed to. Fortunately for our patient this case did. Seeing how a substantial Ellis II fracture line is now obvious on the left central, I might see this guy again at some point in the future for work on that tooth.

And lest I forget, one more thing: When you get your cases back from an endodontist and they say that the tooth has been temporized with a cotton pellet and Cavit, please remove the cotton pellet from under the Cavit before you place your permanent filling.