Using the assistants side on their scopes
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Endodontics |
From: "Dr. Glenn A. van As" To: "ROOTS" Sent: Tuesday, September 20, 2005 1:40 AM Subject: [roots] A public apology to those using the assistants side on their scopes To my fellow rooters: It has come to my attention through private emails that perhaps I may have offended some on here in ROOTS and also members of AMED, with some of my comments about the assistants side of the microscope and the relative role of it in microscopic dentistry. As outgoing president of AMED, and a long term member of Roots, I felt it might be wise for me to clarify some of the issues surrounding this. First and foremost, I respect Gary Carr , the founder of microscopic dentistry , for his pioneering efforts to bring microscopes into our profession. His passion, enthusiasm, ambition and clinical excellence is something I do miss here on Roots and not being on TDO I miss him there as well. Although over the 8 years I have practiced using the microscope in my practice for all aspects of dentistry I have not developed into using the assistants side of the microscope, I have had experience with it in the office and found it easier for me to practice with a live video stream to a monitor instead of using the system that Gary Carr and his lovely assistant Joy have been able to perfect in their office and train many others at PERF to use. Perhaps if I had been one of those trained at PERF I may be using this system now. I was not trained at PERF and for that reason and a few others I have learned to use the scope in the fashion that I use it. I want to emphatically state that Gary, Carlos and John who all practice with the assistants side to the scope are wonderful endodontists, great teachers and passionate clinicians. I am in no way, shape or form thinking that because they practice in a different fashion than myself that it is not a viable option. Particularly for endodontics, and surgery I think it is a wonderful alternative to how I practice. If you buy a microscope, this is a viable option. I am not someone who can train you to use the scope in this fashion and perhaps John, Carlos or Gary can suggest someone who can train you and your assitant to become proficient in this manner. In closing, I will never stray from my ideas that a useful alternative to practicing with an assistant also in the scope is to use a monitor and a video feed from the microscope to the monitor. This is something I covered in my DVD, which I still stand by as being one method of practicing with the scope. It is but one alternative, and although I don't always agree with everything said by John, Carlos and Gary, I still value their expertise in microscopic endodontics and have learned a tremendous amount from each and every one of them. I look at it this way, I dont necessarily agree with everything my dad did as a dentist even though we shared a practice for the last 18 years til his recent retirement, but I darn well respected his opinion. I feel the same way about those that I have mentioned above........I really respect and eagerly read their opinions, I don't always follow them blindly, but I value their insights and respect their opinions into what they have to say particularly about microscope positioning, and the ergonomics of the operatory and the role of the scope in it. Finally, if I have offended anyone with comments I have made, that if my comments created angst or offended you , then I pass on my sincerest apologies both as a member of Roots and as the soon to be former President of AMED. It was not my intent to do so and I will refrain from making suggestive comments on the issue from now on.- Glenn Glenn, I can't see why it is necessary to appologize for having a different view of operations at the dental chair. Your method is valid, Gary Carr's method is valid, and endo without a microscope is also valid. Before we allow the people who are trying to lead us down a path that dictates that everyone who does endo shall have a microscope and their assistant shall be on the scope, it is up to those people to provide some answers to some questions. 1. Is it reasonable, practical and affordible to teach all dental students good microscope technique? If the money could be found to pay for the scopes and instruments in all (50?) dental schools, will the educational track have to be expanded to 5 years to accomodate the extra time necessary to teach microscope technique? 2. We all know endodontic anatomy is so complicated that in spite of our best efforts it is impossible to routinely clean and obturate all of the canal system in every tooth, every time. If we feel we must routinely use amicroscope and spend 2-4 hours/molar to exhaust all avenues of instrumentation and debridement to feel satisfied we have done our best, how high will the fee be? Will it be so high that it would just be better to get an implant? The people who are pushing these, "high ideals" better think about just where they are leading the specialty. Are they leading it to a place that is unatainable for the vast majority of general dentists and many endodontists? If so a humble approach to teaching these highly specialized skills would be much more attractive than berating others (not you Glenn) who do not have the ability or the means to achieve such a high level of performance. In the end it will be less frustrating to those leaders if they quit pushing everyone to do it their way and be accepting of other dedicated clinicians who help save millions more teeth every year than all of the frustrated microscope advocates combined. Am I in favor af raising the standard of care in endodontics? You bet I am! I think we need to recognize that there are many paths to improvement. All of us need to be involved and no one who is interested in improving needs to be excluded. Certainly the president of AMED who has donated his time to such a worthy cause doesn't need to be reprimanded because his model isn't identical to other microscope advocates.- Randy Hedrick Randy, what a kind reply.......life is a constant learning process. I have also learned that many others do things similarly and also different in using the scope. I have seen many different ways of practicing and I realize there is no one path to nirvana (ie clinical excellence) but the passion to succeed must be present. I dont want to alienate people, I cant do that in my position and wont do it as its not my nature. We all make mistakes and we learn from them. I hope that the other parties involved in this matter also see their errors and commit themselves to improving as I am doing and always trying to do. In closing, I have been rewarded by the fact that my local university here in Vancouver has a brand new dental school set to open soon. In it they are installing up to 40 scopes with the hope of educating even the undergraduate dental students to the power of magnification. In some small way I know that I have at least contributed to the thought of this being possible......like our them for AMED this year " The Art of Possible"........training undergrad dental students as to the possibities with enhanced visual acuity through the scope is rewarding to see. As I say......its a big big world, we are looking at a small piece of it daily under the scope, and theres lots of room for all of us.......... Thanks for you note Randy, it means more than you know to read it.- Glenn Randy,I don't think you have to worry. Those of us that are pushing the high ideals that you are criticizing seem to be in the minority. I think the philosophy you've outlined in your post is pretty mainstream in your specialty, so you don't have to worry about those of us that are pushing "high ideals" too much.....unfortunately.- Mark Dreyer DMD Mark, I don't mind the high ideals at all, it's the frustrated, dominating, arrogant attitude behind the ideals that creates problems for everyone including the advocates. It's not life and death, it's not worth ruining friendships over. It's about helping to raise the standard of care for everyone in a constructive friendly way. If the advocates are burnt out and feel the need to be caustic or sarcastic in a malicious way then they have crossed the line and have little value as a teacher. Time to take a break, recharge the batteries, and try a fresh new approach to life. - Randy Hedrick For what it's worth, I agree that high ideals, the pursuit of excellence, raising the bar etc etc are what we need in dentistry (as in most things) to maintain and raise standards. Surely this is beyond dispute.- Simon Bender Simon, I agree with elevating standards of excellence in endodontics. Can we not expect excellence in attitude also? We all remember the instructors in dental school who were arrogant, dismissive, impatient and we probably stayed away from them even though there was a lot we could learn from them. It was the instructors who met us at our level encouraged us and raised our understanding who made the most difference in our educations. They too were unwilling to accept mediocrity but found a better way to teach us and to motivate us. Yesterday morning I was at an AEGD program teaching diagnosis and then covering the clinic after that. All of the residents have huge gaps in their understanding of endodontics. Some are very good at endo and others don't have a clue and probably won't do endo when they leave. I show them some of my cases to demonstrate what is possible but not to demonstrate how superior I am to them. All of them find me to be approachable, I answer them, I encourage them and guide them so they can improve. Somehow I don't think I could help them as much if I used a stick instead of a carrot. - Randy Hedrick Well said randy. Sometimes this is tough for us type anal retentive obsessive compulsive dental types to understand, myself included. My staff is a whole lot nicer than I am, and that’s why they are here. They excel at the people skills, the small talk, the you had a baby,how’s the family stuff. I don’t. I want to fix stuff. But, as a friend of mine is very fond of saying, YOU CATCH A WHOLE LOT MORE FLIES WITH HONEY THAN YOU DO WITH VINEGAR.- gary Randy , You’re talking about making everyone feel comfortable and free to be a schlock like the current leaders who don’t enforce standards. Self denial, resistance to logic, inability to understand ones limitations and intellectual dishonesty are all the systematic machinations performed by those who want to keep things at a crap level because it protects their self esteem. Those who aspire to greatness shouldn’t be weighted down with the bricks of mediocrity piled on their backs by the professionally insecure.- Terry Terry , I don't think that's what Randy is saying at all, and putting words in other people's mouths at the same time time as you make value judgements about their professionalism is exactly what we're bloody well complaing about! Can you only feel great by making other people feel small? Isn't that kinda like winning the high jump against the pygmies? - Simon On 9/21/05, Tim Silbert wrote: Randy without these "high ideals" and "dominating and arrogant attitudes" we wouldnt have scopes in dentistry at all - I am eternally grateful that Gary has high ideals and is dominating and arrogant - he must have been very strong to push the point in the early days rather than succumb to peer pressure. Accepting less because they dont want to offend or be read as arrogant doesnt raise the standard - look at HS - he was right back in the 60's and it took us all (with the possible exception of BU grads) a long time to accept this. I personally dont have problems with people who can produce the 'goods' knowing they are good, I strive to produce results as good as Mark and Terry et al and am happy to have them tell me how they do things - to be a believer and have passion is what achieves a high standard. It all depends on how you take things, I dont use an observer tube but am open to revisiting it again, I have admitted it on here but have never felt that I was hounded down for it - perhaps I just didint realise they were having a go at me or perhaps they were just passionate about what they do. - Tim Silbert, Australia Tim......I just tend to lose the meaning of the message when its rammed down my throat by an arrogant individual. Its just me. The opportunity is lost because someone spends their time trying to tell me how good they are instead of show me. The pictures tell me the story, not their words in the lectures........... For me its like the Charles Schultz cartoons (Peanuts) where the teacher is talking and all you see are ......"Blah blah blah".......... Its just the way I learn best I guess. The arrogant ones may be brilliant, they just dont get enough time with my "closed mind" to show me. I see your point, just dont think at 44 that I will change now.- Glenn Hello Randy, I have some questions and comments below in blue ----- Original Message ----- From: Randy Hedrick To: ROOTS Glenn, I can't see why it is necessary to appologize for having a different view of operations at the dental chair. Your method is valid, Gary Carr's method is valid, and endo without a microscope is also valid. Before we allow the people who are trying to lead us down a path that dictates that everyone who does endo shall have a microscope and their assistant shall be on the scope, it is up to those people to provide some answers to some questions.1. Is it reasonable, practical and affordible to teach all dental students good microscope technique? If the money could be found to pay for the scopes and instruments in all (50?) dental schools, will the educational track have to be expanded to 5 years to accomodate the extra time necessary to teach microscope technique? 2. We all know endodontic anatomy is so complicated that in spite of our best efforts it is impossible to routinely clean and obturate all of the canal system in every tooth, every time. If we feel we must routinely use a microscope Randy, do you routinely use a microscope? I'm asking to see where you are coming from. and spend 2-4 hours/molar to exhaust all avenues of instrumentation and debridement to feel satisfied we have done our best, How long do you spend for a molar endodontic treatment? A lot of endodontists schedule for 45 minutes to one hour. how high will the fee be? There are many endodontists who spend 2-4 hours per treatment and their fees are comparable to the area. They probably howevr are willing to sacrafice some income for increased quality to thier patients, and choose to make less than half a million dollars a year. (but are not going broke ! : ) Will it be so high that it would just be better to get an implant? The people who are pushing these, "high ideals" better think about just where they are leading the specialty. Are they leading it to a place that is unatainable for the vast majority of general dentists and many endodontists? Randy, please think about this statement. Why would a speacialty be concerned if non-specialists cannot do the same things? Why should those with the best clinical ability (and desire to actually use it) worry about those that won't use it? Most children get "C's" and "B's" in school. If the parent accpets this, the child has no chance to get "A's". If the parent want's the child to shoot for "A's", then the child may or may not actually be an "A" student. If so a humble approach to teaching these highly specialized skills would be much more attractive than berating others (not you Glenn) who do not have the ability or the means to achieve such a high level of performance. I agree with you on this one. my thoughts - Jeffrey H. Janian, DDS Jeff, At last someone has reviewed my original questions. I was about repost the questions again. I will answer all of your questions precisely and directly. I would like to have others review the original questions I have posed and answer my questions in a precise and direct manner also. Jeff, I also ask you to review and answer the questions please, I'm interested in your opinion. This is very much about the future direction of endodontics and how well the microscope endodontists will regard and interact with the non-microscope clinicians. Our specialty is small and cannot afford to be divided based on scope or no scope in my opinion. 1.No, I don't use a scope. I use 2.5 and 3.5 mag loops. I am very interested in moving into the scope in both operatories but all of the rigid dogma from certain schools of thought are unappealing to me. I have a digital office with 2 monitors in each op and am interested in photographic documentation through the scope to update my presentations for the AEGD students. 2.I schedule an hour and 10 min for a molar. If I need more time I either run continue into the next appointment time or medicate with Calcium hydroxide and schedule to finish at another appointment. So the answer is somewhere between 1 & 2 hrs depending on the degree of difficulty. Rarely I have to go to 3 appointments if the canals are still wet. I do not charge extra if 2 or 3 appointments become necessary. Molars with apical lesions are done in 2 appointments with CH medication. 3.Statement not a question. I am one of those who make significantly less than $500K/year and spend extra time to maintain quality of my work and teach University of Florida AEGD residents. 4.Statement not a question. Most of the endo is done by non-specialists. I gathered from Glenn's apology that he is a long time experienced user of a scope but has been attacked because he doesn't have his assistant on a co- observational tube even though he has a video feed for his assistant. My word, if even he is subject to attack because of a difference in preference, how low do the attackers regard the clinicians that do most of the endo in this country? Is that low regard going to elevate our specialty in the eyes of the non-microscope specialists? Will that attitude not drive the non-specialists to get their CE from more understanding, friendlier, approachable non-specialists? Should a cardiac transplant surgeon feel that a cardiologist, who doesn't do surgery, is unworthy because he is not performing at the same level as the surgeon? Certainly not! They should work together for the good of their patients and continue an open dialogue about cardiology that is not limited by rigid dogma. 5.Terrific! Can't we all get along for the good of the specialty? I hate the arrogant superstar mentality of the players in the NBA and I have lost all interest in the sport. I don't want our referral base to lose interest in our specialty for the same reasons! Marc Balson has been called a visionary for the future of endodontics and is an occasional contributor to ROOTS. I would be very interested in his view on the original questions I asked in my statement to Glenn. These are the original questions that still have not been answered: 1. Is it reasonable, practical and affordable to teach all dental students good microscope technique? If the money could be found to pay for the scopes and instruments in all (50?) dental schools, will the educational track have to be expanded to 5 years to accommodate the extra time necessary to teach microscope technique? 2.We all know endodontic anatomy is so complicated that in spite of our best efforts it is impossible to routinely clean and obturate all of the canal system in every tooth, every time. If we feel we must routinely use a microscope and spend 2-4 hours/molar to exhaust all avenues of instrumentation and debridement to feel satisfied we have done our best, how high will the fee be? Will it be so high that it would just be better to get an implant? Sincerely concerned, - Randy Hedrick Randy, this has become an interesting thread to a post I made. As one grows in any field, be it dentistry or a hobby like photography, you gain knowledge about that topic. Some will only surround themselves with people who are of a similar level in that area, wanting to continue to learn more and not wanting to deal with those who are at an entry level or starting the pathway that they themselves have taken Perhaps with time, insight into the other persons situation and some humility, you can help educate (not denigrate) the other individual into following your pathway. If not, you shouldnt think anything less of the person. Its funny how we all want to surround ourselves with people of similar nature and ability but its how we treat those not so similar to ourselves that in my opinion distinquishes you. So with that in mind, I look at what you are doing and ask a couple of questions to you. How long have you been in endodontic practice. Did you learn to use the scope in your training and if not , are you now looking at turning to microscopy due to pressure, or other reasons. THe photography part is fun, and has a steep learning curve but it can help with your teaching passion immensely. I dont see that much difference in what you schedule than some who use a scope except to say that initially the scope will slow you down. You have to be prepared for that and to accept that in preparing for a practice using a scope routinely and for most if not all of the appointment will initially reak some havoc on your schedule. I think that a prime example of this is Rob Kauffman. He was very anti scope initially, had a long article on his fine website discussing the economic issues of endo as they related to slowing down with the scope. I really am proud of Rob as he has made a complete U turn with respect to the microscope, the proclaimed pygmy has become one of the biggest proponents of the scope. How often do you see someone who has an open enough mind to turn 180 degrees on an issue as Rob has done. It has caused me this week to consider dusting of the assistant side scope and put in on in my second room to see if ergonomically it can be used by me. I dont want to be berated into using it, just led down the garden path. I recognize that not everyone will become a scope user, and I dont think anything less of them. I always am there for them if they change their mind and want to know more about either scopes or lasers then I try to help them out. So......if you are interested in scopes look at AMED (www.microscopedentistry.com) and the meeting in Tucson is coming up Nov3-5th and there are hands on courses, lectures (about a third of them involve endo) and some master break out classes. This might offer you the opportunity to get a first hand view of the scope and how to get started in it. Who knows maybe by then I will be saying that I am using the assistants side scope more in my practice.....Glenn Glenn, In endo practice since 1993, no scope training but I did seat an onlay under a microscope at Emory Dental School in 1983. It wasn't difficult at all. Yes, I will pursue microscopy. No, I'm not against scopes at all but I am against the attitude that it is the only way to do endodontics. That attitude is not realistic when we look at real world dentistry today. Fact: 1. General dentists must do endodontics, 2. the vast majority will not have a scope, 3. They will save many, many more teeth by doing endo than will be lost and should be appreciated by their peers with a higher level of expertise.- Randy If we feel we must routinely use a microscope and spend 2-4 hours/molar to exhaust all avenues of instrumentation and debridement to feel satisfied we have done our best, how high will the fee be? Will it be so high that it would just be better to get an implant? Are implants the answer to this? Think about this for a minute....do implants work 100%? You bring up the reason why many endodontists don't do a proper diagnosis...and the primary reason is cost...but other reasons include the refering docs don't like it and the patient doesn't want to bothered with it...it slows down the process of getting the procedure done...they don't like the testing...what exactly does this have to do with the Cost?....every endoodontist is morally, legally and ethically obligated to do a proper endodontic diagnosis. End of story. Not a day in my practice goes by that I know for a fact the microscope made an impact on my treatment....that doesn't mean all Tx's will be successful...I've had cases that I found 6 canals and the tooth failed due to VRF....but this type of case is impossible to do without it. I'm one of the folks that spends 3-4 hours on every molar tooth we do....and because of my committment to quality...I take it financially in the shorts...reason? because of the time, energy, equipment, and skill level to do that quality of work costs more then I can get reasonably reimbursed.....does that stop me from doing it...heck no! Money is NOT a primary motivator in my life...excellence is....I want to do the very best I can on every case....and this should be the bar of excellence AAE and endodontics strives for....Medicracy is NOT the path to specialtiy When you start the slippery slope of where do cut the corners to keep the costs reasonable...it only goes down hill from there - Joey D Randy, thanks for the detailed reply. My responses are in blue. -Jeff. ----- Original Message ----- From: Randy Hedrick To: ROOTS Sent: Friday, September 23, 2005 8:52 AM Subject: Re: [roots] A public apology to those using the assistants side on their scopes Jeff, At last someone has reviewed my original questions. I was about repost the questions again. I will answer all of your questions precisely and directly. I would like to have others review the original questions I have posed and answer my questions in a precise and direct manner also. Jeff, I also ask you to review and answer the questions please, I'm interested in your opinion. This is very much about the future direction of endodontics and how well the microscope endodontists will regard and interact with the non-microscope clinicians. Our specialty is small and cannot afford to be divided based on scope or no scope in my opinion. 1.No, I don't use a scope. I use 2.5 and 3.5 mag loops. I am very interested in moving into the scope in both operatories but all of the rigid dogma from certain schools of thought are unappealing to me. I have a digital office with 2 monitors in each op and am interested in photographic documentation through the scope to update my presentations for the AEGD students. I encourage you to get microscopes. You will be even better than you currently are. You will be frustrated less often searching for things, and you will find things more often. You will be less likely to inadvertently gouge deep into the pulp chamber. You will need to do less surgery. (I'm not saying you do these things a lot, I'm just saying you'll do better than you are now.) I was very fortunate to be trained from 1999-2001 and used the scope for all cases during my training. I have read many posts from dentists and endodontists that switched to using a scope and they say it revitalized their interest in endodontics. There are many on ROOTS who can attest to this. When you do it, don't try to save too much money. I think inclinable binoculars are critical, especially when new to a scope. Also, get a good light source that is bright. Get an objective lens that gives you enough room to fit your hands and handpieces under (250mm +) Be committed and understanding to yourself that you will be learning new skills and it will take some time. If you can, go to a hands on course. The AMED has some hands on beginning scope courses I think. 2.I schedule an hour and 10 min for a molar. If I need more time I either run continue into the next appointment time or medicate with Calcium hydroxide and schedule to finish at another appointment. So the answer is somewhere between 1 & 2 hrs depending on the degree of difficulty. Rarely I have to go to 3 appointments if the canals are still wet. I do not charge extra if 2 or 3 appointments become necessary. Molars with apical lesions are done in 2 appointments with CH medication. I suspect you will find you need more time on some cases. This is because you will likely find unusual (or usual) anatomy more often. Actually, many times you will find things faster, thus saving you time. But your patients will benefit, and of course indirectly so will you. (more satisfaction, less missed anatomy causing problems, less surgery) 3.Statement not a question. I am one of those who make significantly less than $500K/year and spend extra time to maintain quality of my work and teach University of Florida AEGD residents. Don't let me scare you into thinking you'll go broke if you start using scopes, and also my hat is off to you for teaching. There are not enough teachers. (I'm speaking to myself here too.) 4. Statement not a question. Most of the endo is done by non-specialists. I gathered from Glenn's apology that he is a long time experienced user of a scope but has been attacked because he doesn't have his assistant on a co- observational tube even though he has a video feed for his assistant. My word, if even he is subject to attack because of a difference in preference, how low do the attackers regard the clinicians that do most of the endo in this country? Is that low regard going to elevate our specialty in the eyes of the non-microscope specialists? Will that attitude not drive the non-specialists to get their CE from more understanding, friendlier, approachable non-specialists? Should a cardiac transplant surgeon feel that a cardiologist, who doesn't do surgery, is unworthy because he is not performing at the same level as the surgeon? Certainly not! They should work together for the good of their patients and continue an open dialogue about cardiology that is not limited by rigid dogma. I agree this style of delivery of the message alienates many readers. I personally like several of the guys that have this abrasive style, not for the abrasive style, but they are very giving, knowledgeable and instructive in their own curmudgeony ways. : ) But I'll let them speak for themselves.... 5.Terrific! Can't we all get along for the good of the specialty? I hate the arrogant superstar mentality of the players in the NBA and I have lost all interest in the sport. I don't want our referral base to lose interest in our specialty for the same reasons! Marc Balson has been called a visionary for the future of endodontics and is an occasional contributor to ROOTS. I would be very interested in his view on the original questions I asked in my statement to Glenn. Yes, my impression of Marc is consistent with your statement. Maybe he can correct the pathetic watering down of residency requirements that went from microscope use to magnification as a requirement. The AAE lied to many very concerned endodontists on this issue. (somebody correct me if I'm wrong.) I could go on and on about this but I don't need to pop a vessel today. These are the original questions that still have not been answered: 1.Is it reasonable, practical and affordable to teach all dental students good microscope technique? If the money could be found to pay for the scopes and instruments in all (50?) dental schools, will the educational track have to be expanded to 5 years to accommodate the extra time necessary to teach microscope technique? I think the dental schools can at a minimum expose the students to microscope use. Endodontic residencies absolutely should have a microscope for every resident. But with the new AAE requirements for residencies, if you get some dinosaur program director running the program that wants to use 2x loupes for training the newest wave of endodontists, they can be an accredited endodontic specialty program. Sure the AAE will tell you, "this is not the intention", but why the hell put the wording in the accreditation requirements then? It seems underhanded and regressive to me, especially when you consider an email exchange that several endodontists had with the AAE president last year. My understanding is she said what happened was a great error, and it wood be promptly corrected, but it was all hot air. (but I digress and I'm getting more negative than I want to be today. Again, somebody please correct me if I'm wrong, I'll be glad if I am, but I fear that I am not.) 2. We all know endodontic anatomy is so complicated that in spite of our best efforts it is impossible to routinely clean and obturate all of the canal system in every tooth, every time. If we feel we must routinely use a microscope and spend 2-4 hours/molar to exhaust all avenues of instrumentation and debridement to feel satisfied we have done our best, how high will the fee be? Will it be so high that it would just be better to get an implant? With this line of reasoning, you could say, "well, the canal morphology is so complicated, I'm not going to even use loupes and I'm not going to spend more than 29 minutes to treat a case because I'd have to charge too much". Yes the example is extreme, but I'm trying to prove a point. Do you see what I'm driving at? The fee won't be too high. I can prove it because I routinely use a microscope and I routinely take 2 hours per appointment and my patients would pay even more if they got implants instead - Jeffrey H. Janian, DDS Joey D, I'm not promoting mediocrity, I never have. Don't really like that implication that keeps surfacing. I'm talking about raising the standards at all levels of competence. It's important that we recognize that routine non- microscopic endodontics saves millions of teeth every year. There are several studies that report 90% success rates and higher with vital teeth that were done with routine non-microscopic procedures. (That should provide a little cognitive dissonance to those who feel the procedure is worthless with out a microscope.) Those clinicians should be appreciated (by the microscope endodontists) for the service they provide the public and the microscope endodontists should continue to draw clinicians to learn their techniques without the brash, alienating, arrogance. We need to help others doing endo to raise the quality of their treatment and not make them feel as if their treatment is useless because they didn't use a scope. There is no way I can teach the AEGD residents how to use a microscope because there aren't any scopes available, but they need to learn how to do the best endo they can because, in the course of their careers, they will save many more teeth than they will lose because they know how to do a good, basic endo procedure. In my book that is a valuable skill! Joey D, I appreciate your dedication to quality! In the month or two I've been a member of ROOTS I've never seen you put down a lesser clinician. That's commendable and that's the approach that will keep the channels of communication and education open and endear our specialty to our referrals. Everybody needs to remember that we're on the same team. - Randy Hedrick It's important that we recognize that routine non-microscopic endodontics saves millions of teeth every year. Hey...I'm the first one to tell ya....that I personally believe that more important then a microscope is the amount/type and time of irrigants used during tx...that's why 15 minute root canals are a specialtiy killer and why those who bought into the "faster is better" mentaility have completely screwed our professiona and success rate.....next up...missing anatomy and that's where the scope comes in.....Incidently, if these folks doing 15 minute root canals could see the crud they were missing with the scope...this argument wouldn't exist! Do you really know the literature on success and they way they are measured? Can you find problems with studies that have been done.....heck....some say that we have ONLY 7% success when measured histologically back in the 60's....I think the idea "Hey we get 90% success anyway" is showing me you don't have a handle on this concept of success..... In addition, when looking at % success...you have to look at success 10, 15, 20, and 25 years out....and then tell me which has a higher chance of success....again, this is my personal belief...but I think most endodontic therapy is successful in the first 2 years...but then start seeing failures at longer terms based on how the initial endodontic therapy was completed.....Success to me is measured by lifetime...but it's not easily achieved....and certainly can't be measured right now. We need to help others doing endo to raise the quality of their treatment and not make them feel as if their treatment is useless because they didn't use a scope Now this totaly incorrect in my opinion....alot of folks are only motivated when either legally they are pushed or because they feel useless....I believe the scope should be used during the entire endodontic procedure and it should be standard of care in the US....I don't throw stones or put folks down here because everyone here is commited to excellence, but not everyone here has access to the resources that we do in the US...so I bend my ideals for them....as bad as I've got it...the dentist working in a country where they paid 100 bucks for a root canal unquestionably has it worse then I....and I look at their cases differently...they have a different environment to work in...and when endodontics is valued more in the location...the reimbursement rate will go up in those countries and these folks here are leading the way.... It's funny, we aren't the first speciality to be rocked by this quesiton...years ago, they did brain surgery without a microscope.....now I wouldn't even dare to have a person do brain surgery without one on me and I'm certain the legal liabilities would probably prevent it....to keep costs down, should we go back to doing naked eye brain surgery? That's what you are adovcating....Joey D I used to be an avowed scope skeptic. Hard core. I had all the excuses down pat. 1. Didn’t fit my practice “style” - emergencies etc. 2. Need to train assistants to work ENTIRELY differently (Staff resistance) 3. Lousy rear delivery ergonomics – my ops not set up to do this optimally – I’m not willing to redesign my office 4. Scope costs 5. Reduction in speed 6. Nothing but a scam perpetrated by scope manufacturers to generate sales 7. Some Scope Dogmatists turned me off initially And probably half a dozen others that I was foolish enough to publish in an article on my website. And I’m telling ya – as a BU trained guy with almost 15 years of specialty experience…I had no lack of confidence in my technique. (Comes with the training!) That was until I sat down, stuck my face in one and really looked at what I could see and what I was missing, (Loupes just don’t cut it – the Coaxial nature of the scope lightsource is one of the keys.) Being able to see down into canals, isthmuses, fractures – it’s just not the same. OK, maybe Gary C was a bit of a jerk for calling me a “pygmy” publicly on here, but I will always be extremely grateful to him for kicking me in the ass. Now, I can’t ever imagine doing molar endo without one…EVER. My 3rd op is scope- less and I LOATHE going in there to do recalls, and the occasional emergency exam etc. Just hate it. I’ll get one in there eventually but I’ll tell you straight away, I can’t see as well as I like in that op. Not enough light, magnification …my comfort zone is lost. If I have to treat…as soon as the other op is open, they’re moved. I think what David Clarke said is absolutely true. There are always going to be those who will resist and that’s OK. Those that want to use one will move over to the scope at their own pace and in their own time, Some faster, some slower. For some, it is simply not wishing to change, and that’s unfortunate…for them and their patients. For others, it’s simply a matter of not WANTING to see that well. (One of the most profound experiences you will have is looking at your own previous work under the scope – it’s about as humbling an experience as you could ever have as a dentist.) As for most surgical treatment – well, lets just say that I now consider it essential. You cannot easily see perpendicularly resected root ends without one and a micro mirror. That means increased bevels which translates directly to greater leakage – of that there is ample proof in the literature. No one’s twisting your arm. The great thing about it is that no matter how long it takes, there will always be people like Glenn, Joey, John S, and John K, Terry P., Clarke, Gary C. and all the others who are ready to share every nuance and trick with you to help make you better - Rob Kaufmann Lol, yep it does rhyme…..self-esteem~revenue stream clearly goes together in the flow of profitable self denial just like the ridiculous view that non-microscopes users can achieve the results of scoper’s. It’s one thing to utilize the best resources you have available to perform treatment but it’s another thing for some dweeb to want to protect his profitability by performing inferior treatment and BS’ing their patients and colleagues. These people have no business performing molar endo and should be referring everything out to specialists. Utter horsecrap - Terry Joey D, Brain surgery is not root canal therapy. The former can be essential for life, the latter is not. When endo gets as complicated and as expensive as brain surgery people will extract teeth and place implants instead. If, in an ideal world, all of the endodontists had microscopes and all of the general practitioners referred all molars to endodontists, the endodontists would be overwhelmed with patients. What about the patients who couldn't get in to see an endodontist? Should they have their tooth extracted or should a non-microscope dentist do a root canal and help them save their tooth? Isn't that what dentistry is all about, saving teeth? Is a non-microscope root canal so worthless it should not even be attempted? If that patient gets to keep their tooth after a non microscopic endo it certainly is a valuable service to the patient. When you have a patient with limited opening or is too fidgety to work with a microscope do you recommend extraction or do you find a way to do the endo without the microscope? Is that root canal worthless too? Then why did you charge for it? I'm not against the scope. Unquestionably it improves the quality of the procedure and we are in a transitional phase as the microscope becomes more prevalent. While we are in the transitional phase I have to say I'm against the dismissive attitude of the microscope endodontists against anyone who does not have a scope and dares to do endo. There are a lot of patients being helped by endo without a scope and we should appreciate the work of our committed colleagues who perform this service for the public. I think the propagation of this dismissive attitude will alienate endo from our referral base. If the microscope endodontists are so into promoting excellence then why not excellence in attitude and approach to others? It's a fundamental issue of manners. That is my point!!!!!! It is valid for today's neurosurgeons to have a dismissive attitude to anyone who would attempt neurosurgery in the USA today without a microscope because of the life and death issues and the money that was poured into the advancement of medicine over the last 50years. There are also substantial resources to pay for not only the procedure but also the training and education required to use it. Endodontics is not neurosurgery. It's not life and death (although some clinicians act like it is). I think it is inappropriate to foster and propagate this dismissive attitude while we are in this transitional phase of increasing microscope popularity. It's not necessary and may very well hurt the cause more than it helps.- Randy Hedrick Randy, ............If, in an ideal world, all of the endodontists had microscopes and all of the general practitioners referred all molars to endodontists, the endodontists would be overwhelmed with patients. What about the patients who couldn't get in to see an endodontist? Should they have their tooth extracted or should a non-microscope dentist do a root canal and help them save their tooth? Isn't that what dentistry is all about, saving teeth? Is a non-microscope root canal so worthless it should not even be attempted? If that patient gets to keep their tooth after a non microscopic endo it certainly is a valuable service to the patient. When you have a patient with limited opening or is too fidgety to work with a microscope do you recommend extraction or do you find a way to do the endo without the microscope? Is that root canal worthless too? ............... No, a root canal done without a scope is not necessarily worthless. I think though if that's your philosophy, you should add that the patient should be informed that "possibly" a better job could be done on their particular tooth if they were treated by a scope using dentist. Then the patient can make their decision on who will treat them. - Mark Dreyer DMD Randy, OK then...let's throw out the brain surgery thingy....how about occular surgery...think of all the eye surgeries that are done under the scope...I had one of the very first eye surgeons that used the scope starting in the late 40's in the use as a patient he was considered a terrible for the profession that he had crappy eyes and couldn't see anything...you should hear his peers demean him!.....you don't need eyes to live! Sure, they are convient to have to see...but's what's an eye? What about the patients who couldn't get in to see an endodontist? Arg.....I don't want endodontists Tx all Endodontics....far from it...I just want the bar raised BY ALL who Tx endodontics. I think it is inappropriate to foster and propagate this dismissive attitude while we are in this transitional phase of increasing microscope popularity. It's not necessary and may very well hurt the cause more than it helps. Can I sign you up for eye surgery without a scope? You don't need an eye to live do you? - Joey D Joey D, No, because they don't have eye implants and we only have 2 eyes. The same arguments apply.- Randy interesting since we only have two eyes (which by the way are exactly the same one and the other) I can't underdtand why the eye doctor specialty should last 4 years we deal with 32 teeth, but still 16 different anatomies; hence, our studies should last longer, or they should be transforming the eye doc specialty into a weekend course; two weekends if you wanna do it under the scope - JL, the great digressor Your compromising doesn't make any $ents or cents. Let's see....2 microscopes...Let's just say 25,000 apiece for 50,000 dollars ...and work 200 days per year (gotta have time off)...I've had my scope for 10 years...let's say I practice for another 15 years with it.....that's 10 bucks per day...and if I see 5 patients a day...that's 2 bucks a patient! I use my rotary Niti on a single patient only (one time use) because I want to minimize breakage....let's say 7 bucks each...and I use about 6 per patient treatment....so your talking less then then cost of the rotary files.....OK...let's look at Stainless steel, these instruments cost 1.25 each...so if I throw 2 SS instruments away (I usually go through about 25).....it's 2.50....still more then the scopes Your arguement does NOT hold water here........even from a cost perspective.... Randy...your thought process is completely and totally riddled with holes....even the most ardent scope haters like Rob K can tell you he was wrong....if you want to go put your head in the sand over this issue and make up all the nonsense surronding it...OK.....but your compromising....Joey D Joey D, By focusing entirely on the technical procedure and economics I feel you are overlooking the larger issue of how we deal with our referring dentists in this transitional move towards the scope. I think it's foolish to alienate specialists in endo and the dentists who refer to us. It's not about the microscope being good ar bad. I have not questioned that it is good. I never have been a "scope hater " and never will be. However some cannot see the forest because they only see the trees. Time to move on. - Randy
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