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Another molar
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From: Randy Hedrick
To: ROOTS
Sent: Friday, October 28, 2005 7:16 PM
Subject: [roots] Another Molar
Another Molar finished Yesterday
Diagnosis: Necrotic pulp, Normal periapical tissues
Upon access coronal pulp was necrotic in Mesial canals but vital in distal
MB & ML #50 LightSpeed
D #70 LightSpeed
Obturation is Resilon Simplifil apical plugs with Epiphany sealer. I知 not happy
about the small void in the MB. The literature indicates it may not stand up very
well to silver nitrate leakage but will stand up to bacterial
leakage better than gutta-percha. I am confident it will be successful. - Randy
How is a void that far up the canal going to cause a problem? The second molar is
not far away from endo. - Guy
Looks nice to me. A Pac Mac might have 'dismissed' that void for you,
but it is nice anyway. - Alan Cady
Randy, Why the post space? Are you able to do build ups for your referring docs?
This would be perfect for a Nayyar core - Bill
I agree that it doesn't need a post but all of my referrals except one wants to
do their own BU. A little more than half do BU without posts but some prefer posts.
I prefer not to use a post unless absolutely necessary but I have to respect my
referring dentist's request unless they are significantly outside acceptable
restorative parameters - Randy
That痴 the advantage I have over all of you endodudes, randy. Since I refer the
case to myself, and I think I知 a really great knowledgeable referral, I give myself
permission to treat the tooth optimally, which means the core goes in before the
patient heads out J. I have 100 % compliance with this. - Gary
Do you ever call yourself just to make sure you won't be upset by you putting
in the core? If so, does your staff ever find it curious that you talk to
yourself in this manner? :-)))) - Mark Dreyer DMD
Gary your a hoot! Yes it's easier for some people to get along with themselves
than to make the effort to get along with others. Now if you start arguing
with yourself over who will do the BU, Gary endo or Gary restorative, then
you're in trouble. If it gets bad enough you can quit referring to yourself!
- Randy
Yep, if I tick off my limited referring base I知 screwed. I値l see you and
the guys on Thursday. I got to go pack as I知 working in the a.m. tomorrow and
flying in the p.m. and I have nothing ready. Poor glenn has to try to show me
how to use this scope on something other than the maxilla - Gary
The molar case presented does not need a post and most particularly it does not need
it in the D root. The post will be adjacent to tooth structure and will not become
sufficiently incased to add stability. The M roots should have the post if one is placed.
This type of outcome is why I place post and core buildups.
You have a nice outcome which is now at risk of contamination and possibly canal damage
caused by post placement. Completed at the time of treatment the post core is a time
saver for all involved. Remember the patient does not enjoy an additional trip to have
the buildup done, nor do they particularly enjoy the discomfort of a temporary when a
permanent core could be made.
I have taught for thirty years and have become convinced that core buildups are one of
the most misunderstood procedures in dentistry. Perhaps you can enlighten your referrals
that your placing the core saves them time and protects the patient who forgets to return
to the referring dentist before the temporary fails - Jim Roane
But, Jim, you misunderstand. It is not about what is good for the patient.
It's about the MONEY!!!
If you guys do the post, look who gets the cash. I've beat my endo guys
over the head for YEARS trying to get them to just put a dang permanent
restoration in the endo prep. They will not do it because a majority of
there referring docs call filling an endo access a "core build up" which is
manure.
The largest problem is not with the post. Those things are good only help
retain a core. They fail miserably if you expect them to retain a
restoration. It is about sealing the coronal portion of the tooth
immediately following endo. The endodontist does the endo, places a temp
material, and tells the patient to get back to their GP ASAP. This is three
years later to many and by that time you have a blown out furcation. A
simple occlusal alloy would have prevented that.
The problem is a function of referring docs. I don't charge to fill an endo
access whether I do the endo or an endodontist does it. That is part of the
treatment. If a sound final restoration was placed at the time of endo a
huge number of teeth would be saved that are lost due to patient negligence.
- Guy
Actually, what I read was Jim felt NO post was needed and the one in there
distal was more show and a fee for the GP than any help retaining the core.
He then typed, if one were to be placed, the mesial would actually give more
retention. It should of course be small, maybe to thin ones converging, but
again, neither needed. ? BUT YOU have to do what the referring docs wishes
and hope that meat ball doesn't hog out the prep anymore.
Alan just an GP Cady
Jim, Thank you for your comments and I agree with all of them except posting a
mesial root on a mandibular molar. I believe there are studies that show
the mesial root is much more susceptible to vertical fracture but I can't
name the studies. We are oversupplied with endodontists in St. Petersburg
and if we don't respect the referring dentists requests were done. I have
sent articles including the 2004 JOE review article on posts ( Schwartz RS,
Robbins JW. Post placement and restoration of endodontically treated teeth.
JOE 2004;30:289-301). I have sent newsletters, I've talked to them on the
phone and over lunch and lost referrals over that issue. Most felt like I
was trying to take over their treatment, take away income or not respecting
their judgment. There came a point when I had to recognize the things I can
change, the things I cannot change and have the wisdom to know the
difference. Restorative dentists who have an engineering background are the
most difficult to work with on this issue. You are right, core buildups are
very misunderstood. - Randy Hedrick
Randy, Do you think it's any different here in Phoenix?
There is an oversupply of endodontists. There were something like 58 in the
metro area....and GP's do alot of molars out here....they jumped on the
Rotary band wagon early.
That doesn't mean you should cave on the issue of restoring at completion of
endodontics...we implemented it by doing them all on referers that were at
the bottom of the referal totem pole and worked our way up. It took 3
years....and now it's funny, I go places and they say "I love your
cores...they are so crown ready..I don't have to spend much time prepping
them".....
The key is offer the value. When I first started it was like hitting my
head up against the wall....but now I'm almost 5 years out, can't tell ya
how many recalls I still see the build up in place....and how often I get
compliments from the refering docs letting me know how much easier I made
their life.
Sure, some guys don't want it...They fired me by refering elsewhere...and
surprisingly, most have returned....
Your right about the initial excuses too...trying to take over Tx (Not the
case, just trying to increase the chances for success), decreasing their
revenue stream (absolutely wrong on this issue...even my brother finally
came around and realized he can do a crown prep faster and better when he
doesn't have to deal with the core...now he's happy and was one of the
biggest complainers out of the bunch), nor respecting their judgement
(false, we can be valuble to the Tx planning process)
IF your refering docs don't appreciate ya, what you do, and what you stand
for, then you otta fire'm and not work with them. IT sounds harsh, but any
other way and you'll trap yourself to the medicore folks.....JOey D
Don't you think your referring docs would prefer a tooth already built
up and virtually prepped? Mine love it, but then there is no history
over here of charging for build ups. Our NHS system, typically pays
around $10, yes ten, dollars for this, and many of the docs I deal
with are still working in the NHS. Docs who control their fees are much
happier to have an easier time doing the prep, as again they don't bill
for build ups separately.
Very simple crown prep for them, and a better service for the patient.
If not, then maybe they are the wrong referring dentists. I would find
it very hard to work with someone who's only motivation for themselves
placing a core went kerching.
Several US based Endodontists will testify that since they started
placing their own build ups the referring docs have been happier, would
it be possible for you to send some back with build ups and see the
reaction? - Bill
Bill,
I think the dentists in your area are different than mine which would
not be unusual. I have a "technique questionnaire" that I have every
referring dentist complete so I know what their preferences are. It has a
lot of questions about post space and build-up. All of these dentists know
I was a general dentist for 8 years before I specialized so they know I know
how to do build-ups yet they insist on doing it themselves. I think they
feel they are the restorative dentist and want that responsibility and I
have had dentists say exactly that. Here is the questionnaire:
-Which teeth do you want post space? Anterior teeth: Yes
No, Bicuspids: Yes No, Molars: Yes No
-Do you want a "roughed out" a post space with a Peeso or a finished post
space with a Para Post drill or other type of post drill? (circle one)
-Do you have a particular post system that you prefer?
-Would you prefer to leave the decision to make a post space to our
discretion?_____Yes No, please call me.
-Would you like to have the build-up completed before the patient returns to
your office? Yes No I will advise you for each
case
If yes, do you have a core preference?: Resin Amalgam
___Other
-In cases where only an access filling is required to complete treatment, do
you want us insert the filling? Yes No
-Do you wish to be called following: diagnosis, only for
complications, at completion of treatment, don't call
-Would you welcome restorative suggestions? Yes No.
-Do you want us to reinforce the importance of a build-up and crown to your
patient when it seems appropriate? Yes No
-Upon completion of endodontic therapy, do you want our office to:
_____contact your office while the patient is still in our office to make
the next appointment?
_____dismiss the patient, notify your office of completion and let your
receptionist contact the patient at her convenience?
-Types of cases most likely to refer: Retreatments,
Molars,_____Bicuspids, Anteriors, Surgeries
-Positive past experiences with endodontists:
-Negative past experiences with endodontists:
The questionnaire is scanned into my server so I can refer to it on rare
occasions when the patient forgets the referral slip and we cannot get in
contact on the phone to the referring dentist about how to finish the case.
Feel free to use it and modify it or add to it.
Only one dentist was wanted me to do the build-up, everyone else wanted
to do it themselves. Makes much more sense for me to do it since I already
have the tooth isolated but it's not what they want and I'm not going to do
it for nothing. I don't have any insurance contracts to limit my options
either. It's frustrating trying to get the business of dentistry to line up
with the ideal standards but it comes with the territory. I have a friend
who has an endo practice in Salt Lake City he is much happier than he was in
St. George 30 miles south of Salt Lake. In St. George there were dentists
who wanted him to find the canals so they could do the endo instead of him.
He packed up and left after a year or two. My family is deeply rooted in
St. Petersburg so I'm not going anywhere, just have to deal with it.
Randy Hedrick
Several US based Endodontists will testify that since they started
> placing their own build ups the referring docs have been happier, would
> it be possible for you to send some back with build ups and see the
> reaction?
Absolutely positively true.
I would find
> it very hard to work with someone who's only motivation for themselves
> placing a core went kerching.
Yep....me too. Joey D
doesnt it make sense the person doing the endo makes the post space (that doesnt
mean they are placing the post) am sure no referring gp would have issue with
having the post space present to make their placing the post easier and less
chance of a perf - Gregori Kurtzman,
Absolutely, in fact I often will make the post myself, the referring gp's here
appreciate it, but do you think a post is needed here? Can't remember the last
post I placed in a molar.
There certainly looked to be lots of tooth available from the rads, but I wasn't
there clinically, some pictures would be nice. - Bill
I never say never or always, but I have to agree bill. I almost never put a post
in a molar, and I also can稚 remember the last one. For that matter, the post
manufacturers are going broke on me in general - gary
I would be more inclined to place a narrow fiber post in the MB and ML canals as
that's where the tooth is missing. the distal even after prep for a crown will
have sufficient tooth on the distal and I dont think a post there will be of a
lot of benefit - Gregori M. Kurtzman
Randy, You appear to be a bit short, which could be a future problem with a
necrotic case. Of course, if you did this in 2 visits with interem caoh, then
hopefully it will heal. Nice looking case overall though - Mark Dreyer
Mark, to you and me, anything without a puff is short. :-) Guy
Or the poe and apex are not one and the same. - Gary
Well, some of you guys should move to the boonies. It is a crying shame
when a bunch of GP's who are not practicing quality dentistry are dictating
to good endodontists how to care for patients. It's simply about the money - Guy
