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Cervical hypersensitivity and acute sensitivity

From: Rob Kaufmann
Sent: Wednesday, May 26, 2010 1:45 PM
Subject: [roots] Nike ...or else

Some days I must admit that I really hate what I do for a living.

61 year old female sent to me by top 5 referral,  for consultation regarding
cervical hypersensitivity and acute sensitivity to cold in the right mandible.
More recently she has begun to have cracked tooth symptoms in the maxillary 
first molar. The patient has a relatively low dental IQ but has had one molar 
endo/crown in the left first mandibular molar. She was so senstive on the 
right sde that she asked me not to probe the area, even  before I examined her. 
She had been previously treated with RD applied topical cervical desensitizer.  
Oral hygiene was poor and poor plaque control has contributed to acute marginal 
gingivitis in the quad. (See photo) After examining the area I concluded that 
the amalgam crowns on the molars (and pinned amalgam in the premolar) were deep,  
had poor margins, exhibited creep and were leaking.  After several attempts,
I finally managed to isolate the hypersensitive area to the buccal cervical 
aspect of the second molar.  The patient was considering extraction of the 
offending tooth (whichever it was... she didn't care....she just wanted her 
problem solved.)  I excused myself and phoned the RD.

I said that managed to isolate the acute sensitivity to the mandibular second 
molar but that I could not guarantee that just treating the second molar would 
relieve all her symptoms because ALL teeth in the quadrant were acutely sensitive 
to cold. I explained to the RD that there were multiple teeth on that side that 
needed endo/crowns and I felt that a proper treatment plan for this side was 
needed. (We have had this discussion regarding other patients many times before 
...with him referring "A tooth" to me for treatment rather than having a treatment 
plan.. He's frankly tired of me calling and  telling him that the cases need a 
treatment plan - he claims his  patients won't let him do this and that his practice
(which is booked months in advance) seems to mostly work on the "single tooth/work 
to the Ins. max" principle. His patients have the reputation of being very tight 
with their money. (It's a cultural/regional thing....well known. Ironically, this 
town has has some of the highest growth in income of any place in the province.) 
Finally he said  he would deal with OH/Perio issues and implied   that if I wasn't
willing to " just do the endo on that tooth", he would find someone who would. 
That last remark got the message thru  to me and I said "Fine, I'll treat the 
second molar and that's it." and disgustedly put down the phone. I was furious.  
She scheduled to treat both the mandibular 2nd molar and cracked maxillary
first molar. The rest of it be damned.

Regular patient or patient who comes only when symptomatic, he seems to treat 
them all the same. I think he's just about reached the limit of tolerance for my 
" isn't a comprehensive care based treatment plan is what is best for your patient" 
sermon.  I must admit I am totally frustrated by his mode of practice. However, 
he IS a top 5 guy, a friend of almost 30 years and losing him
would not be very good for my practice.

Sometimes I REALLY hate referral practice.  - Rob Kaufmann DMD MS(Endo)

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