From: Jörg Schröder
To: ROOTS
Sent: Friday, February 16, 2007 2:51 AM
Subject: [roots] Catch of the day!

Referral called me and told me that during RCT there happened a little accident. Patient all of a sudden closed his
mouth (no rubberdam) while she was working with a more than 35mm long Hedström in a reciprocing handpiece. She was
not able to stop the handpiece and as the file worked its way through the apex, the patient felt a tremendous pain
(no anesthesia !) So he made a fast move and the file separeted. Pt. came in 2 hours later. Deep decay on the distal,
no rubberdam, cavit as a temp. The file (ISO 40) was screwed in the canal wall. 5mm through the apex. After about 12
mm I reached the head of the instrument. The diameter has been huge, so I had to remove a lot of substance. A lot of
irrigation, manged to partly bypass about the half of the instrument. I then tried in the smallest hollow tube that
just fit the coronal part of the fragment, dried the canal, filled the tube with dualcuring composite and placed it
on the fragment. After neverending 5 minutes I tried to pull with a Stieglitz. The only thing that happened, was that
the plastic part of the tube left the needle:((.

My assistant touched the tube with the US-device while I started to move the whole thing counterclockwise. And: It
came out in toto. Bad thing: referall was happy, but want to do the rest! (no rubberdam, deep decay and no clue, what
endo is about).

At the end I feel a little sad. What a waste of efforts. But a nice experience!

Best regards from Berlin, Germany  Took me 1,5 hours to finish - Jörg Schröder



Amazing! And after this, does the patient want and allow the referal to continue treating him????? Is he/she crazy???
In my opinion the referal is very irresponsible and negligent if she continues with the treatment, she has to realize
and admit her limitations Nice job, Jörg!! - Marcela

Hi Marcela, here in germany it is not very common to referr patients for RCT. " I can do that by myself". A lot of
patients are just not well informed what modern dentistry can do for them. And if you are starting to work on a
referral base, like I am doing since 2 years, it is walking on a thin line. If I would recommend treatment in my
office to the patient, the referral will 1. tell this to other dentists, who will refuse to referr pts. because of
their fear, that the pt. won't come back. There is no room for thinking about the patients advantage. It is all about
the money and the lack of selfcritism. 2. the dental chamber (if they get knowledge about my recommendation) will
write me a "nice" letter about being unfair to a collegue, who in fact is more a collegoid. If you don't stop acting
this way it will get really rough.:((  - Jörg

Great recovery!!! Could you tell me what kind of hollow tube you use for catching?
Best regards from Asunción, Paraguay -

Thank you Carlos, the hollow tube has been a blunt irrigation needle with a luer lock (which felt off, using the
stieglitz). I think ultradent does sell a lot of different sizes, but you should get them cheaper from a company
which sells medical equipment. - Jörg

Dear Jorg, You are no longer a endodontist you have become a " fisher of men " :-))
Keep those "miracles" coming. - Jan Skrybant

Jan, here in the States my kids would refer to Jorg's work as "sick" or "crazy good".  I will just say he's a
"freak". - Kendel

The patients and the dentists in your area are lucky to have you around to handle such mishaps. I remember one such
that happened with me with a pac mac and I had to extract the tooth due to lack of competence on my part and well as
not having someone like you around. The patient should be really thankful to you for managing this
case.....................The IAN was really close.- Sachin

Hi Sachin, when I saw the the PreOp Picture, I remembered that I have seen something like this on roots, but did not
remember, that it happened to you. - Jörg

Jörg, Nice save, but for godsake, don't let people abuse you with these kinds of ridiculous requests. You are way too
good for that. Don't be  modest, but pick up the phone, and say that you will only remove an instrument if you can
finish the case yourself. No rubber dam, deep decay, common, this colleague needs to be educated, and that is your
task.

Set the standards, make referrals clear what they can expect from you, and what you expect from them.
This can be done with a presentation, a newsletter, a personal letter, a phone call, you name it.
You will feel way better if you are not considered as aarbage bin to who people can refer their screw-ups - Marga

Great point, Marga. I will send a letter with cases, I finished. I will send this to any new referral, to set the
standard. Thanks for the idea. - Jörg

BOGUS!  Joerg,
You must be more assertive than this.
After such a save, you should simply do the endo and explain that for such an effort, you are not willing to turn the
patient back to finish.  You could say something like  ...stuff happened during removal that requires special
handling to complete the case.  ( such as dentin removal during retrieval, etc.)   Or   ...the majority of effort
went into the file removal, so they will not save any cost from you by turning it back to the refdoc.
In other words, your fee for simple file removal should equal the fee to do the endo yourself.

Now if the referring doc messes the case up he will blame you for your kindness.
You know the old saying: "No good deed shall go unpunished." You were too nice, my friend.- wes

Dear Wes, I agree with you -- and I think we should be honest and unashamed about it:

We make our living doing root canals, not removing instruments.

I once had a referral from a dentist who wanted me to rule out an extra canal -- and then send the case back.

We do not make our living by diagnosing, accepting the associated liability, and then sending the case back when
endodontic treatment is indicated.

I would ask the referral, "Do you believe in Win/Win relationships? Because I'm losing in this one!" (courtesy of the
very fabulous Ace Goerig). And removing instruments without completing the case simply would not be on my treatment
menu.

You don't get what you expect; you get what you accept. The referring dentist will in all likelihood wake up and
appreciate Jörg's awesome skills more after such a conversation.

I wish I had Jörg around and I would just show up and obturate when he says it's all ready to go!!

"Can you send it back to me after the instrument is out?"

"I'm so sorry I can't do that."  Period.  No reason given.

If pressed, respond honestly about what's on our menu, what's not, and why.

"Once I accept a case, I accept the whole case, and I complete and stand by the entire endodontic treatment."
In partnership, - Pat

Wes, you are absolutly right. Once again I learned something here on roots. I will send a letter to all my referrals,
where I tell them how cases will be handeled . I am not concered about the money, because here in germany there is no
fee for removing the file. I will charge the time I needed. Even if the pt. will not pay for it, I have had a nice
adrenalin flush and a good experience;)).  But again I agree with you, that there is the risk for being blamed for
the failure of the RCT - Jörg

Jorg, Excellent work. When a refferal tells me they want to send me a case just to remove a SI I tell them I either
do the whole treatment or nothing. I just don't have a FEE for removal of seperated instruments.

Great work as usual, I am sure the refferal can't appriciate it if he wants to continue and make $$$ on this case.
- Thomas

Jorg, I think this may be a function of there not being recognized endodontists in Germany.  I still think that
should be strongly addressed.  Maybe if it did become a recognized specialty there could be some education of general
practitioners that this kind of request/behavior is totally unprofessional and unacceptable.  A referral should be
just that.  It is a referral to repair an accident and in this case, it involved finishing the endo.  That is the
only way you can protect your hard work.  Lack of a rubber dam and all that other stuff is not the issue.  The issue
is that it is unprofessional to screw up, ask someone to share the risk and bail you out and then ask that the
patient be sent back to a lower level of care than can be provided to the patient.  It also is totally unfair to a
patient to have to go back through a procedure, no matter how skilled or unskilled the referrer might be, when you
could have finished the case.  On top of that the patient is charged two fees for one procedure.  Guy

Guy, I agree with you in all points. Yesterday I sent a letter to all referalls where I explained under what kind
of conditions I will do the job. - Jörg

Guy, you are absolutely right.

It is a heart matter, to do that (get endodontics a recognized specialty) and for that we have to establish high
standards to make clear what endodontics is about. This was part of our discussion before.

Specialist team approach, part of the soul of dental excellence, does not really exist in Germany.

Some recognized that long time ago, but not the mass of dentists. Actually it starts to develop in a greater number.

Jörg will establish himself as an endodontist in the near future, ‘cause he is doing real good stuff. Then he will
not need every referrer. Some referrers better refer to others, ‘cause they endanger a good outcome! - Carsten