From: Rob Kaufmann
To: ROOTS
Sent: Saturday, August 19, 2006 4:20 AM
Subject: [roots] Ag Posts and new referral

A new name just showed up in my appointment book recently and we're always quite pleased when that happens. The cases
were booked while I was on vacation. He's a rural practitioner and his patients have to drive about an hour one way
to see me.  The first case was an elective endo on a mandibular right first molar that had lost a restoration
Things went uneventfully and I completed the endo on the 4 canal first molar and then bonded the orifices with
PermaFlow Purple as usual. There still was lots of coronal tooth structure, room for undercuts and tons of room for ferrule.

A few days later I get a call from the guy and he sounds unhappy. He's booked the patient in for a core prep
( Don't get me started on why I didn't do the core- Endos just don't do that where I live- if they want to keep a referral).
He says he's got the patient in the chair and the Perma Flo is preventing him from restoring the tooth the way he wants.
I say - fine,just remove some of it on the DB or DL until you get tio GP and then carefully prepare a post space.
He's afraid to. I tell him its purple - for a reason!  No go - he wants me to take it out and make him 4 retention areas..

I ask him if that is his restoration in the 2nd molar and why he placed 3 ( count em!) posts. He said that they weren't posts,
they were amalgam. Now wants to place amalgam down the canals I prepare and/or have me prepare the canal for him to do this on
the first molar.  He says he does things "old style" a la Terry Donovan,, uses bonded amalgam in the canals and also said
"I've been doing it like this for 3 decades with a lot of success."

Looking at the 2nd molar again, I see some developing pathology apically and I know that the distal GP is less than ideal.
I'm also not thrilled about anyone going in there with a Peeso or GG or whatever and then placing amalgam to that depth.
Frankly, what he is doing scares the crap out of me and I don't know if I want this kind of thing done over MY endo.
I want to safeguard my endo treatment but at the same time, I'm looking to preserve the referral relationship.

How would you approach this? Any suggestions? - Rob Kaufmann




Oh boy. He should be more open minded about your recommendations. Explain how you really want to be able to get back into
the canals in the future and it makes you feel uncomfortable to seal the apexes any other way.  If youre getting good endo
results for him, then he probably would want to keep the relationship going. - R Carter

Either live with it or talk to him on the 1:100 chance he might listen to what you have to say....
but gonna bet your gonna lose him....

He want's you to roll over and be like all the other endodontists....keep their mouth shut..and just do the endo.

I personally would have a conversation....Joey D

Hell, Joey, I agreed to talk to him.  I'm betting he doesn't own a computer so it would be by phone.
Rob, ask his permission to post this radiograph. :-)  Then I can call him.  Guy

Hi Joe and Rob, this happens in india to and most of the old folks  do this , they ask me to prepare the root space for a
similar kind of amalgam restoration , so i tell them  that since strength of silver is  good  u dont need to "screw" the
tooth that deep  maybe only 3 mm is enough and cite them "arun nayyar's" amalgam core technique,  but talk to them when u
invite them over for drinks and hit  him with this  when he is 3 drinks down , hope and i am sure this will help , works for me
- Gurpreet Singh

Hi Rob..................I too try and condense amalgam into countersunk orifices but just into the coronal part but these
Amalgam cores are way too deep and I wonder whether this increases the chances of root fracture during amalgam condensation
into the canals? - Sachin

I'm not Rob but I see too many lower third molars that I have restored with amalgam that have NEVER had opposing occlusion
cracked.  In my uneducated opinion those cracks can only come from expanding amalgam.  Point of fact, I've got an endodontically
treated lower left third that had and occlusal alloy placed in the military that cracked...no opposing...EVER.  Amalgam swells
and in my, again, uneducated opinion amalgam cracks teeth by expanding.  Maybe we have no absolute proof but I have tons of
anecdotal evidence.  I do not think it should be placed down canals or in endodontically treated teeth in face of the fact
that we have so many new means of restoring these teeth.  Composite may leak but I can do a decent job of sealing that with
full coverage of a bonded crown - Guy

Rob and all, I would tell the referral - that there is certainly literature to support the use of amalgam, and if one intends
to bond the amalgam so much the better, but one of the  advantages of amalgam is also its disadvantage - that of high compressive
strength, but low sheer strength. So posts that extend that far into the root will not add any significant resistance to the core.
Further the contraction shrinkage of the bonding agent could compromise his result. If he wants to achieve synergism, then you
would be willing to leave 5mm retention pits on top of your rct, which will be bonded with permoflow. The result will be -
when he has finished - just as retentive core, but with less danger to his patients, and leaving your seal intact.
An added advantage is that he will not be out of step with current opinion of people who use amalgam.

The problem is that we will have to make ture the patient returns to you post haste - as I will have to leave a temp on the tooth
so you can access it easily.

Rob this is a great referral - if he has been in general practice for 30years - then he is most likely to have tried bonded systems,
burnt his fingers several times frequently over the years, and unless he has kept current (which does not seem to be the case)
-  John Ctseee
Well, Rob, for starts, if he says that those aren't posts in the second molar and are amalgam, he's a lying piece of...
well we won't go there.  #2 Tell him just because he's been doing things this way for three decades doesn't make a rat's
arse bit of difference.  He's wrong.  I see pathology on the mesial root apex.  How does he expect you to treat that?
You are going to need an air hammer and a pair of vice grip pliers to get the damn posts out.

That being said, I know you are not going to do that but I'd be absolutely OVERJOYED to do it for you.  In my opinion,
nothing should be packed down canals other than an occasional post which can be removed, such as fiber or a passive
FlexiFlange that I can unscrew out of the cement.  This sort of thing irritates the hell out of me and damn
I HATE it for you guys.  It is embarrassing so see such crap.  I can remember the day when I might place two posts but
those are long gone.  I remember when you charged for pins by the pin.  I've seen as many as twelve pins in a tooth.
Idiocy.  The care on the second molar sucks so we can suspect the restorative on the first will suck also.
I'd get the patient back and fix them so that he can screw this tooth up also because you need to keep the referral.

I'm one of those strange people who does not charge for a build up when I replace the restoration I took out to do the endo.
Often it is mine so where do I get off charging them again.  They get charged only if they are someone else's patient,
which I doing a fair number of, or I have to do a post...rare.  Working the codes is unethical.  That's just my opinion
and this guy/woman is working the codes and the patients wallet.   Guy