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 Another molar
The opinions within this web page are not ours.Authors have been credited for the individual posts where they are. - www.rxroots.com photographs courtesy: Randy Hedrick
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
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