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Endo tips    Better Endo    Endo abstracts    Endo discussions

Accident during RCT - Courtesy ROOTS

From: Jörg Schröder
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 

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

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 
handled . 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
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