There are certain referring dentists with whom I work well and there are others who have tried me out in the past, but for various reasons send elsewhere now. No hard feelings, no worries.

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.

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The first picture is how this premolar arrived (with the patient) to my office. Discharge was present through the gums from a chronic abscess. Looks like a radiolucent post was placed practically to the apex. There’s some remnant gutta-percha or cement mid-root and probably an apical perforation at the base of the post.

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.

Everyone likes to show off their best work, but when can you remember being at a continuing education presentation and the presenter shows off work that they have produced that is less than ideal?

Here is a case that was fraught with issues from the beginning:

The patient will be on a recall schedule with me for the next year or two while I keep tabs on healing within the jaw bone. Hopefully the problem of chronic infection from this tooth is solved. Options are very limited now if the infection persists.

Written on the referral slip that arrived with this patient was a note from their dentist, “Please perform apical surgery.”

I suppose the dentist was concerned about the post being irretrievable. My concerns were the probable coronal leakage that was causing the apical lesion and the fact that apical resection of the root would put me up against the end of the post — leaving me in a difficult position for a retrofilling. Apical surgery will not hold up against coronal leakage in a predictable fashion.

Assuming that the dentist could do a crown with a decent coronal seal, why not take the post out and retreat the root canal work? Retreatment would offer a more predictable solution for the tooth.

Ah, but a deep screw post like this is quite daunting to remove. We worry about the risk of fracturing or perforating the root.

Here’s what your average neighborhood endodontist should be able to do for you:

Microscopes, ultrasonic instruments, and training allow us to deal with cases like this in a conservative, predictable fashion. Orthograde retreatment of cases like these are viable options and should be presented to patients. Jumping straight to the surgical option is a disservice to your patient.

Update (August 14th, 2008): Here’s the post-op film:

I was watching this video, thinking that the dentist was doing an ok job. The only things that made me a little worried were the lack of eye protection on the patient and the extremely long hair the assistant was tossing around.I was about to give a passing grade until he said that he’s putting a titanium post into the tooth to strengthen it. That’s completely false. He should know better and if he does, he’s doing an unnecessary value-added service (that will increase the fracture potential of the tooth)…from what I can see of the tooth the post is unnecessary from even a restorative-retentive perspective.

So why does it matter to me what the restorative dentist does in the tooth? The answer is ethics for one, and the second reason is more selfish. Often the first thing to fail in a tooth that is having trouble is the endo. In today’s society where people take no responsibility for their actions and find it much easier to assign blame to others, the patient shows back at my office with the impression that their tooth is having trouble because of inadequacies with my work:

March 2006, consultation appointment. A long discussion about why this 1.5 year old endo is episodically symptomatic. Her dentist did the work. I recommended retreatment, another discussion ensued about the post and the reason it was placed. She was not optimistic about root canals in general because of the history of this tooth.

December 2006. Because of the patient’s trepidation about endo, I decided to medicate the tooth and only complete the retreatment once signs of osseous healing were evident. I babysat the tooth while it was medicated for a few months and saw some obvious signs of healing. Symptoms had also disappeared. Retreatment was completed. A discussion about posts ensued again because the patient was wondering whether one was necessary or not. I told her I didn’t see a need for it because of the amount and strength of internal structure.

Last week. The patient’s dentist sent her back to see me because the tooth has been episodically symptomatic (demonstrating recurring parulis formation) since the retreatment was done. Upon further questioning, the patient said the tooth started acting up after the permanent restoration in the crown was done. She said she told her dentist she didn’t want any posts and he said he wouldn’t do the filling unless he put posts in. He insisted, so she felt she had no choice.

From the film it’s obvious that a non-metal post was placed in the P canal, gutta percha has been removed from the coronal 1/3′s of the buccal canals and material consistent with the core resin was placed into those areas. Apical bone appears good still, a lesion has developed in the furcation. The lesion in the furcation is associated with all of the work that was done in the coronal canal areas. There’s likely been a strip perforation in one or more of the roots. My guess is the MB root.

As much as I tried to diffuse a potential situation with this patient, I know that she’s going to have a few unpleasant words with her dentist.