The Periapex » Retreatment

Is Your Dentist a Spoiled Brat?

Periapex — Sat, 24 Apr 2010 11:44:57 +0000

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.

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.

How Not To Use A Carbon Fiber Post.

Periapex — Wed, 22 Oct 2008 13:00:28 +0000

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.

An Example of Imperfection.

Periapex — Tue, 09 Sep 2008 21:44:40 +0000

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.

Would You Refuse to Retreat This?

Periapex — Thu, 03 Jul 2008 21:53:25 +0000

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:

Huh?

Ameloblast — Mon, 29 Oct 2007 16:35:00 +0000

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.

Hurray For Calcium Hydroxide!

Periapex — Fri, 03 Aug 2007 11:08:00 +0000

Unlike many of my peers here in North America, I use lots of calcium hydroxide paste in my cases for reasons like these. The medication gives less-than ideal work a more-than fighting chance to be successful.

Here’s how I first saw these teeth. There is a blurry history of trauma (kickboxing injuries) and when I first saw the patient there was discharge associated with 22.

This first xray is from August 2nd, 2006.

At this point, 22 looked like it had suffered from incomplete root formation, some external resorption, possibly dens-in-dente, and of course infection. I thought I’d have a rough time locating the canal.

Not so. During treatment, I found a massively large canal that was much, much shorter than where I expected it to end. I cleaned things up as best I could and then loaded the canal up with calcium hydroxide for a couple of weeks (or a month…I can’t remember off hand).

The next xray is from October 11th, 2006. Obturation is obviously short of where the root ends, but electronic apex readings were consistent to this point. This angle also shows that what I thought was a root with a canal was actually just one side of the actual root. I started to worry about some sort of vertical root fracture having split the root up the middle. There was no internal visual evidence of this however, and the medicated phase had cleared up the sinus tract.

Later films will show that that left part of root might actually be a root tip that’s floating around from a horizontal root fracture. I reasoned that the short apex readings were either from a resorptive perforative defect through the root at that level, or because of the blunderbuss apex.

When there’s doubt, I use the apex locator as my diviner of length. Once I can get consistent readings with it, I tend to trust it beyond what my eyes see.

One more thing: I informed that patient that a lesion was now becoming apparent apical to 21.

The next film is from November 8th, 2006. Tooth 22 was doing fine, but another sinus tract had appeared. A sinugram traced it to the apex of 21.

A retreatment with a medicated phase was initiated for the tooth.

The canal was cleared, medicated with calcium hydroxide for a month, and then obturated. The apical canal area was irregularly calcified because of the incomplete root formation and the previous work. That’s still no excuse for the voids in the obturation…But proof of success is always in the pudding.

This xray is from February 26th, 2007. It’s post-obturation of 21.

And this next one is from July 30th, 2007. The lesions are shrinking and trabeculation is becoming apparent within them. I’m still not sure what happened with 22 and I’m not sure at this point what is happening. There’s either some external resorption going on as the bone heals and remodels, or that one thing that looks like a root is a root and it’s moving around…

I’ve been temped to go back into 21 and try to improve the appearance of the apical obturation so that the case is more presentable. That, however, won’t necessarily be serving the patient’s best interest. Healing is occurring, so we know there are no bacteria up there. The remaining obturation is good. Any corrective work would be for my benefit rather than the patient’s.

My Finger is Hurting.

Periapex — Tue, 19 Jun 2007 21:10:00 +0000

I was moving wood last weekend to try to clear the backyard up a bit more before the landscaping started. I had just climbed on top of the pile of wood that I was creating when one of the pieces rolled down and landed on my left hand. It then bounced off and landed on my right index finger tip squishing it so much that it broke skin just under the front of the nail. Blood copiously dripped out.

I was so deeply under the influence of Advil Cold and Sinus pills for my allergies that I hardly felt anything. I did notice that my knuckles were scraped quite nicely on my left hand and did think that my right index finger should be hurting more than it was.

Anyway, being right-handed, and having a sore finger there, it’s a given that this week all of my cases would involve picking my way down calcified canals or around curves. The finger is definitely hurting now.

Here’s a retreatment that I finished today. It was completed by an endodontist late last year and remained bite sensitive. He recommended apical surgery to address the symptoms. The patient came to me for a second opinion.

Because I thought that I could improve on the endo, I recommended a retreatment with consideration for an adjunctive surgery if necessary. Long story short, the post op film shows some decent improvement on the technical quality, but what’s more interesting is the up-bend at the tip of the mesial root. WTF? No wonder my finger is sore today.

At least the patient is comfortable with the tooth now.

A Surprise Inside.

Ameloblast — Thu, 03 May 2007 17:30:00 +0000

I’m almost finished posting all of my interesting archived cases. Just one more to go after this one:

This one is from about 6 years ago, which explains the multiple backfill voids in the obturation. Anyway, I don’t know how many of my peers would attempt a retreat on this tooth. That post which looks like it would tack down drywall appears menacing to remove. It actually came out extremely easily. That was a pleasant surprise. The other surprise was the fifth canal.

That’s one mutant tooth.

Gutta-Percha Blowout.

Ameloblast — Fri, 30 Mar 2007 02:30:00 +0000

The first xray is a duplicate which accounts for the poor quality. The case was referred to me by the patient’s new dentist. When I saw the patient, a parulis existed in the buccal furcation area. Apparently the endo was done in the 80′s and retreated by the previous dentist 1-2 years ago. That was when obturation material was pushed out the apex and the carbon fibre posts were placed and the bridge with the open distal margin was glued on.

I’m posting this case to show that extruded gutta-percha generally doesn’t cause problems.

The canals were cleared and medicated with calcium hydroxide paste for 6 weeks. The parulis disappeared. I obturated the canals.

Carbon fibre posts are a real pain to get out because I have to pretty much drill or ultrasonically destroy them to get them out; unlike metal posts which I can usually get out in one piece.

The extruded material had no impact on healing. The open margin on the distal will have an affect on healing if it isn’t addressed.

Silver Points.

Periapex — Mon, 05 Feb 2007 22:17:00 +0000

I just saw this case for a recall. The first xray is preop from May 2005, the second is a recall film from Jan 2007.

I wasn’t able to get the silver point out in toto from the MB1 canal because it ended up fragmenting on me around the curve. I was able to bypass it though. The tooth was medicated with calcium hydroxide paste for a couple of weeks then obturated.

Looks like healing is progressing well. However I wouldn’t be surprised if, once healing is complete, we see a residual lucent area around the extruded part of the silver point. Chances are a persistent foreign body reaction will go on there.