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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Intra - oral swelling

The opinions within this web page are not ours.Authors have been credited
for the individual posts where they are - photographs courtesy: Mark Dreyer

From: Mark Dreyer 
Sent: Monday, February 19, 2007 10:23 AM
Subject: [roots] 2 step completed today Pt presented initially with intra-oral swelling. Between that finding and the large amount of bone loss evident on radiograph, Jerry Avillion's "force" advised me that this needed to be done in 2 visits. :-) Top right radigraph is with caoh in the tooth. Today, her swelling was gone and the tooth was comfortable, so we packed it. I hope it heals! - Mark Dreyer Intra oral swelling Too bad that's not Resilon. :-) - Guy W. Moorman, Jr. DDS Hey Mark, It's exciting to see the quality of your endodontic skills.?? A few of questions I'm sure you've addressed but the teacher in me makes me ask: 1. Can we agree that regardless of the obturation material, your treatment is probably doomed to failure if the coronal restoration isn't replaced with something that more adequately seals against leakage?? I've been fooled by treating the infection but not the source, only to have the lesion heal and then reappear or the crown fall off due to continuation of pre-existing caries. 2. Is the furcation involvement going to be addressed? 3. What do you suppose happened to the distal contact enamel on the bicuspid? 4. As the recipient of referrals, how do we promote the post-obturation procedures necessary to complete the whole treatment ? - Grant Grant, I think any restorative guy doing much endo will absolutely agree that failure to seal the coronal portion of the tooth and provide an excellent final restoration will lead to failure. I've seen it with my cases and I'm sure Mark has while he was a practicing GP. Good points, - Guy Grant, Those are some good questions, much better in fact than the answers I can give you. I do a lot of work on teeth like this with marginal perio and restorative situations. I certainly do my best to point out these "non-endo" issues, but at the end of the day (don't you hate that cliche?), the weakest link is in fact the general \dentist that quarterbacks the team. I don't know how to properly address these situations without actually taking over care from the referring dentists and in so doing jeopardizing the relationship. As Terry Pankkuk says, "I build the engine, and if the plane crashes because the mechanic that installs the engine is a clown what can I do? After all, my involvement in the patient's care has to stop somewhere and the referring dentist has to take over at some point. I can tell you that I think the only way to practice ideally is to restrict who I take referrals from, or just take the bull by the horns, and drill off crowns like that, do the endo and place the buildup like Joey D or John K do. This would have the indirect effect of limiting my referral base. I'm waiting just a couple years til my Porsche is paid off before I take that approach! :-)) In the meantime, when one of my cases fails and I suspect it is a restorative failure, I just re-tx it n/c as a cost of doing business. Fortunately these situations don't arise too often, but that's probably because some of the teeth are being removed without my knowledge &/or it just takes a lot longer for some of the failures to become evident. How do you handle these situations, Grant? And BTW, thanks for coming out and commenting on my case. You're one of my favorite Rooters! - Mark Mark, Thank you for being kind. It's easier for me to comment on how I handle situations like this now.? I am retired from practice.? However, I can be honest and tell you that both my philosophy and actions involved a long evolution.? Let me see if I can briefly describe it.? Nah, that won't happen. In the early 70's there were very few endodontists and few dentists for the population seeking dental care.? Even though my fees were $50.00 for an anterior, (cuspid to cuspid); $75.00 for a bicuspid; and $100.00 for a molar, it was, for me, the Golden Age of Dentistry.? It wasn't about the money--that was a given if I showed up.? Patients trusted dentists and referring dentists expressed gratitude that I would see their patients day or night, weekends and holidays.?? We told patients right up front that root canal treatment was essentially an esthetic procedure.? They had choices. For those who wanted to complain about the cost, I relayed that If they wanted something that was really effective at grinding up food, an Osterizer was more effective than teeth and less expensive.? If the referring dentist or my intuition told me the patient was sincere about taking care of their teeth but needed a break, they got it.? Rarely did I get burned.? But then, that was an age when people were more in tune with being deserving than being entitled. There were no regulatory agencies and my only contact with 3rd party payors was in filling out claim forms for patients to receive reimbursement for whatever portion of my fee the insurance company agreed to pay the patient.? We mailed patients letters at 6 months and then yearly intervals telling them it was time to check the status of their healing.? If they didn't call for an appointment, we tracked them down and twisted their arms to come in so we could make sure they were doing ok.??Like you, if the treatment failed and they had kept their followup appointments, I retreated or performed the surgical procedure at no charge; no questions asked. For years I used to treat infected roots through defective? restorations and tell the patients and the referring dentist that I was doing just that; recommending that the restoration be replaced as soon as we were done.? I was foolish.? Patients would return for 6 month checkups with a new crown somewhere else in their mouth and the same old leaky crown on the tooth I'd treated.? Sometimes the crown would come off a year later and guess who would get the call from the patient saying their dentist told them I must have loosened the crown while doing the root canal?? With time it became more frequent and these same dentist, (just a few of them), became bolder in deflecting responsibility. I felt lousy enabling sloppy dentistry and started really thinking about what I was doing.? Western-Kansas farmboy trust was not having the desired result. My conclusion was that I was putting my interest in the supposed benefit of having that referring dentist ahead of the patient's best interest.? As I learned later, I was trying to CONTROL the referral base by excusing bad behavior rather than having FAITH that taking the right action would serve everyone better.? Mind you, I had six children in elementary and junior high school, and a lovely wife who had sacrificed mightily so I could go to graduate school.? She had been a dental assistant before succumbing to my charms. We talked about it and decided being poor was not the worst fate we could receive. It was sort of like the first warm day of summer and you're hesitant to dive into the swimming pool for the first time.? You just know the water's going to be really cold and it'll be a real shock to the system.? It was both, but, after a couple of times you find you are still among the living and it feels really good. Having practiced general dentistry, I knew how to get crowns and bridges off.? I also knew some of them would be destroyed in the process.? It wasn't all that difficult describing for? the patient what the problem was and why it was in their best interest that the restoration be removed.? Shucks, I even found it comfortable to tell them that since most referring dentists had more experience than I at removing restorations, they would face less risk seeing them for that procedure and then coming back for the treatment.? It didn't take too long for an understanding to be reached with those dentists who respected my work to understand and appreciate the concern for their patient.? I'd be less than honest if I didn't tell you that I got yelled at, cussed at and generally told where to go by a few dentists.? Looking back, I wish I could have had the perseverance to bring them around to my way of thinking.? However, my main regret is that I came to know which of my friends they started referring to.? Hopefully, they handled it better than I.? The word got out on me in a big hurry...mostly to my advantage.? Dialogues opened up with my good referring dentists that helped educate all of us and build better and healthier relationships. You know what, it was a shock to my system for a while.? I lost some referrals....gained more and better.? I spent more time treating appreciative and informed patients.... less time covering up and putting out fires.? I slept a whole lot better and I have to admit, I started liking the guy in the mirror whose face I shaved every morning. We all learn from mistakes.? Mine was to value perceived CONTROL more than FAITH.? I suffered because in reality I had neither.? The good news is, I moved on and was able to apply the lessons learned to future dilemmas.? Keep up the good work - Grant Grant, Thanks for relating the details as to how you handled these situations. I am at a point in my career where I am doing some serious introspection as to which dentists I'll work with and which I'll not. I'm wanting to restrict things a bit based on issues we're discussing here, and my staff wants me to try to take patients from everyone. I don't have the situation resolved yet, but your post is helpful. Thanks again! - Mark
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