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  A carrot, a stick and a gun

The opinions within this web page are not ours. Authors have been credited for the individual posts where they are. - www.rxroots.com photographs courtesy: John A. Khademi
From: John A. Khademi, DDS MS
Sent: Sunday, March 11, 2007 9:00 AM
Subject: [roots] A carrot, a stick, and a gun :-))

I had been working with this guy since starting here in 2001.  It was never a great relationship, but I thought, at time,
that it was a good relationship.  Some years back, he jumped on the mercury free bandwagon, and began procuring referrals
from one of the town Osteopaths who does heavy metal, chelation therapy etc...and tells his patients they should see this
guy to have their rat poison removed.  Of course, it's good business and he is happy to comply.  Unfortunately since he
doesn't know what he is doing, he rips out all these amalgams w/o a rubber dam, places leaking resins, and the patients
end up in my office.  Becky had a client that had this done to remove all the rat poison and her Hg titre went up by a
factor of 1000.

So we are chugging along, and I am trying to accomodate him by placing resin cores when it is reasonable to do so, like in
this girl that I saw in 2002

I am always inclined to give him the benefit of the doubt...i.e. he just doesn't know and is not consciously malignant until I discover otherwise. These are not rhetorical questions, but serious questions. Where do we go with him? Who are his teachers? Who is enabling this behavoir? - Glenn First off John........thanks for the interesting read and I read it all. Next off, I don't envy you at all trying to deal with these issues. I would surround myself with clinicians of substance. Those that are in the 46% of dentists who do care. I would tell them that I want their referrals and will make sure that I do everything possible to make sure that the patient is treated promptly, professionally and that those dentists that YOU want to work with will send the bulk of their endo to YOU. If there are practitioners who dont use loupes (does this guy), dont care , dont do good work, are too busy, have problems going on at home, are hurting emotionally, physically or financially. I dont deal with them. A few years ago I heard my specialist friend in this area complaining about some of these cases. I mentioned to him the old saying......."if its meant to be, its up to me" I told him to make his practice the office that others wanted to refer to. However he could do that. Great service , great endo, getting patients in promptly, great office, great staff. Whatever it took to get the guys who do get it. He did that. He has 6-8 guys that he wants to work with. He knows that they will make the odd mistake but it isnt from lack of effort - Glenn

I decide that it is time for an intervention, so I keep tract of the next few cases he sends over. He is not sending that much anymore - John A Khademy

Then this young girl comes in Feb 2006. Recent resin placed by him, continued pain, not referred, not managed. Referred by her orthodontist. By the time I get her, the pulp is necrotic. I figure these cases should be enough, so I call him and say "I know you want to have a mercury free practice, but these large, deep posterior resins are really difficult to place. I have taken pictures of the last few and I'd like to go over them with you." He says "OK" We never meet. He has not sent a patient since. I have not missed "patch and cover." This is "The Stick" as he obviously has not been inspired, and noticed the four canaled upper second, the three mesials on the lower first, the five canaled upper second...cases he has never, ever seen or done.... - John A Khademy

Here are the lowers - John A Khademy

Fast forward to 2007. I recall her tooth #14 in as part of the study. We take a radiograph on #14, which is fine, but notice #13 is...an implant. Tooth #14, the bashed-to-hell, perfed, missed canal, brutalized molar is fine. The broken amalgam bicuspid is now an implant. As it turns out, in less than 4 years. Hmmmm..... So I do some more homework and get the pre-extraction radiograph - John A Khademy

So we chug along, a few years go by, I'm trying to accomodate him restoratively. He's starting cases he shouldn't be, some screwups, we patch and cover. Then in Sept of 2005 the girl above comes in again. She had two amalgams removed from #18 and #19, resins placed, then she has pain. He starts endo on #18, and she has continued pain, then I get her. Patch and cover. Patch and cover. We take some pre-op radiographs of #18 and #19, and take a recall radiograph of tooth #3 that we had treated three years before. The crown margin is at the contact level on restorative, not down below the resin core, and is decaying. You can see what the resin replacements of the (I'm sure servicable) amalgams look like. I'm done. It is now my way or the highway. No more resin cores for this guy. So we treat both #18 and #19, and place amalgams - John A Khademy

It gets worse. While this tooth was not part of the study, we take a recall radiograph of it when we recall #19. I don't see him (the RD) sending her back to me to cut off the crown and do a bonded amalgam buildup and crown prep on this tooth like we did on #14. I see him trying to do a crappy leaking resin core with a new crown that will not even be down below that leaking resin core, and a two year recurrent decay failure. I recommended an implant - John A Khademy

So here is the take-home. It is not pleasant: "It is difficult to get a man to see something when his salary depends on him not seeing it." This guy took a simple broken amalgam bicuspid, did a crappy resin on it that became symptomatic, then did a crappy endo on it, followed by a crappy crown, followed by an implant done by a specialist, which will probably be there the rest of her life. As bad as he is, he is nowhere near the bottom of the heap. None of this has anything to do with any bonding agent or set of instruments. This guy refused to be educated, and refused to allow me to "stack the deck." I sent him several pretty nicely done cases after that initial failing upper molar with recurrent decay and he either didn't know, or didn't care...i.e. the carrot didn't work. Then, in concrete terms, I said "I understand what you want to do, and I want to help. We have a couple of problems that we need to go over." I never saw another patient from him. So the stick didn't work either. So Glenn my friend, she lost #13, and will loose #'19 next. He has many, many other patients as well, including the first girl that has recurrent decay underneath the crown on #3. I am always inclined to give him the benefit of the doubt...i.e. he just doesn't know and is not consciously malignant until I discover otherwise. These are not rhetorical questions, but serious questions. Where do we go with him? Who are his teachers? Who is enabling this behavoir? - John A Khademy

So in preparation for District II of the AAE lecture, I do this retrospective review of 108 cases I had treated in 2001, my first year here, and identify this lady with this screwed up tooth that I treated a month after starting practice that want to recall. I don't realize it at the time I'm picking it out to recall, but guess who did the work? Yep. Dr. PatchandCover. So we cleanup the brutalized chamber treat the missed anatomy as best as I could (which stinks) repaired the perf with MTA, then Geristore over that, then bonded amalgam and crown prep the tooth. Send it back to Dr. Patch. We also take a picture of the broken amalgam on the bicuspid. This is all in March of 2001 - John A Khademy

The plot thickens a little. I have a little trouble getting the radiograph....for obvious reasons - John A Khademy

She comes in late that year, and we treat her lower molar thru the crown. We do a recall on #14 at that time, and then again in May of 2002. Not so great, but not getting worse either. The broken amalgam has been replaced with a resin, and now has endo and a temp crown. We follow up again in early 2003 to recall #19, but also recall #14 and she is fine. We should have recalled #13, but missed it. Now in hindsight, I can just barely see there is a PFM on the bicuspid. Hmmmmm.... - John A Khademy

So Glenn, The last guy is at the stick stage, and I am stuck there for now. Recalling that in the States, we are obligated, by the ADA Princiles of Ethics and Code of Professional Conduct, to report "gross and continual" faulty treatements of colleagues. This is not optional. It is required by the ADA. So here we are. This is a different guy at the "gun" stage. This letter, with the supporting documents, went with the OS who had lunch with him to discuss the same types of problems. The OS's precipitating event was several extractions on a compromised patient that did not get managed, and did not get referred. You will see this pattern continued. That patient now has a bicycle chain for a mandible - John A Khademy

Dr. XXX, 10/11/2005 I recognize that we have not had a referral relationship for some time, however I continue to see patients that have been previously seen and/or treated by you. The management of your cases has been a cause of concern for me, and is becoming a concern for other specialists as well. The following cases just span the past couple of months. · LD reports that you evaluated her and recommended extraction of tooth #18, which we have treated endodontically to her satisfaction. It would have been a tragedy, and violation of her informed consent for this tooth to be extracted without at least recommending a referral to a specialist qualified to evaluate the extent of her problem. · RD reports that you treated her upper first molar and she had continued problems. These problems were not managed, and she was not referred. She had heat sensitivity when evaluated in my office. The endodontic treatment performed was well below the standard of care, and two canals were missed. We re-treated the tooth to her satisfaction. · EG reports that she presented in pain and you started two root canals on her. She had continued problems, in addition to the most severe case of ASA burns I have seen. These problems were not managed, and she was not referred. We had a difficult time with diagnosis due to the prior case management and her ASA burns. We were finally able to diagnose the ultimate source of her pain which was tooth #31. She is still under my care. ·DR reports multiple procedures done in your office, most recently an implant "extraction" the likes of which I can only imagine. She is still under my care, but probably has a vertical root fracture on the distal root of #19. I have referred her to Dr. Periodontist for further evaluation for implants. She is understandably unenthusiastic about this. Dr. XXX, there is no general dentist standard of care. You are required legally, ethically and morally to treat patients within your training and skill level, and to the standard of care. Weekend courses do not make you an endodontist, implantologist, or oral surgeon. These four cases are not hand picked. They are just the last four I have been dealing with. I do not generally keep track of these things, but in conversations with other specialists, it came to my attention that there are problems in other specialty areas as well. This is a small community…and a very small dental community. Up to this point I have quietly managed these cases and defused threats of litigation. I had made myself available to you in the past, and offered counsel regarding difficult cases, which went unheeded. Unfortunately, if this pattern persists, I may be unwilling to continue defusing these threats. People are being harmed. I have listed four of them

So Glenn, I plod along for the next year and a half, "quitely managing these cases and defusing threats of litigation." But my patience is wearing thin. Then this young girl comes in referred by one of my best and favorite guys. She sees him complaining of pain LLQ. His testing indicates a necrotic #18, yet he starts #19, which is vital. She doesn't get better, so he gives her Clindamycin/Metronidazole, a combination I have never heard of, especially for a vital tooth. She continues to get worse and figures out that he is a clownician and sees one of my best and favorite. We open #18, which is necrotic, and she is better the next day - John A Khademy

Then, not even a week later, this girl comes in. She's having problems, and her step-mom now works for another best and favorite guy and refers her in. We request records, and like the last case, he drags his feet. I still don't have complete records on this case, or...worse...I do have complete records. There was never any workup, pulp and periapical testing, or diagnosis on #30 or #14. #30 had been previously treated, and you can see his retreatment result. #14 got an endo and a crown, when at most, it needed a filling. So Glenn, This is the kind of carnage that Terry and I see on a daily basis. You don't see it, because you can't fit it in your brain that there is a bottom 50% that do this kind of stuff...on a daily basis . You also don't see it because of: 1) numbers. There are a lot of you, and there are only a few of us. We see all of them that.... 2) ...leave the practice. Most don't leave the practice, and the teeth are extracted, or the patient moves or there is a latency in the problem and no-one connects the dots. That guy from above with the broken amalgam bicuspid that is now an implant....I have not seen a case from him in over a year...where are those teeth going.... So again Glenn, Who is teaching these people? Does this guy sound like someone who would come to AMED and be inspired to be better? Does he sound like a guy that would spend $2,500, plus airfare and lodging to spend two days with Buchanan? Or is he the kind of guy that would show up at a free course by some travelling endodontist given on a Saturday AM promising "Fearless Endo" with cheap unbreakable instruments? It is a compliment to your temperment to believe that people will do what is right and good but it is not true. Not everybody is motivated by the carrot. Some require the stick. Others require a gun, and it is our ethical obligation dictated by the ADA Priciples of Ethics and Code of Professional Conduct, and our obligation as professionals holding the public trust to police ourselves. If we breach this trust, which we are doing, in our lifetimes we will have Uncle Sam doing the policing for us. It has already started - John A Khademy

Hey John: this is an interesting discussion that has several factors to look at including. 1. I am a GP 2. I live in Canada I don't think that this guy will change at all. I make mistakes too, will continue to make them but want to improve in every area I can. I know that I cant be everyones dentist. Just like you cant be everyones endodontist. You might have to report this fellow to the right people as is you ethical obligation or just stop accepting referrals from him so a gun, carrot or prod isnt around. My choice always has been to leave those who I dont want to be around and move on. You as a specialist may be have to abide by different rules. Maybe thats why I dont want to be an endodontist. In any event, its been a great discussion. I have learned alot about what you face. I told a guy today who told me he was trying to go back to endo school that your discipline is faced with large challenges coming (implants) and retreatment costs vs implant costs. GPs who figure that they dont need to worry about excellence. Mediocrity failures lead to implants........... Its the tincture of titanium. My family still eats if we dont have an endo tomorrow.........others may not be so lucky. I feel for the specialist crowd and also know that you can make a difference. Not sure if polite discourse is always the most effective way to create change, maybe as a Canadian its the only way I know how. PS I do believe that the inlay has a significant crack. I can post lots of cases demonstrating that crack on the marginal ridge to be decay (interproximal) and that many of these are vertical from Mesial to Distal and precursors of the Vertical cracks (not Oblique) that David fears so much. Cracked teeth are a story for another day (especially when I am not so tired ) but honestly John, the best part of all these threads is the way you told me of your plight ( I feel for you) without resorting to ranting or verbal attacks.........for me its the only way. Civility is for me the only way....its just the way I am. Great thread...one I will keep - Glenn

Glenn, Part of the point is that neither of these guys refer to me. They also do not refer to the other endodontist. I have not only elimiated the turkeys from my practice, but have even eliminated the "dark meat" as well. :-))) Yet I continue to see their screwups that are referred in by my guys, in horror. So...I don't deal with them, yet the tragedies continue to occur. I only see a small percentage of those because of: 1) These guys bury their mistakes and 2) There is a latency to these kinds of problems So the central question remains. What next? I accomodated the "bicuspid" guy, then talked with him on the phone, then talked with him on the phone some more, then talked with him on the phone suggesting that we review the last few cases that I had taken pictures of with the voids, leaking resins all etc... It never happened. What next? Do we blindly stand by and allow this kind of assault and battery to occur? As specialists, by continuing to accept referrals from this kind of clincian we place our own immediate financial needs in front of patients' needs, and the good name and good will our forfathers established for dentists and dentistry. It cannot be seen any other way. Further, do we look the other way when people proclaim themselves "Masters" and preach this kind of care? Grant Merrit, With the utmost respect, do you really think you can stop this kind of behavoir, and the people that teach it with a gentlemanly, civil, polite discussion? Glenn, I screw up too. I just posted one that I spent 5+ hrs on, and still did not get down the MB2. I also think this is different than "being a screwup" like the guy who spent 75 minutes on a greet 'n treat on two teeth... Lastly, You are a GP and live Canada. How 'bout this guy from just down the block from you? This is the kind of work he did on his chairside. He was voted #1 dentist in Vancouver for three years in a row. Obviously Glenn, that would make you the #2 guy...at best. :-))))) - John A Khademy

John, the best part is that you get me to think. I think because the issues you raise are not the ones that I have to face. I will leave the issue of the Vancouver dentist alone for a variety of reasons but will tell you that I am thankful that as a GP I dont have to deal with these issues that you face. I live in a sheltered world and I try my very best each and every day. I still think that sometimes I need to know when to refer and when to say no to a case. I also know that I am human. Yours is a tough job John....I definitely dont have the answer but will say that when you discuss tough issues in a civil fashion you will get more replies then if you dont discuss it at all or if you attack someone . I know that we have different ways of dealing with things..........you and I are inherently different in many respects and you as a specialist deal with issues I cant appreciate or understand fully. In closing, I just enjoy the dialogue and I like to read of these issues without worrying about the personal attacks or confrontational styles that some will use. Its just not my way........doesnt mean I am wrong or right.....its just not me - Glenn

Removing amalgam for this reason in Georgia could cost you your license - Guy

you mean if amalgam is removed for this reason under the dentist's recommendation? what if it is the patient who wants it removed for that reason? - Marcos

If the dentist removes alloy for physiological therapeutic reasons it is viewed as care outside the scope of dentistry and fraud in MANY states. If the patient comes in and tells us that they don't like those black fillings and want them to be white then it is fine. I know it is a thin line but there are many dentists in this country curing MS, fibromyalgia, chronic fatigue, bipolar disorder, autism, etc by removing alloy and claiming that this will cure the disorder. Most have lost their licenses but many get around it by saying it was done at the request of a physician. That is now crashing and burning in Georgia. There is no science to support any of this and it is still viewed as fraud. Guy

JL, It is a fine line. Patients who want their amalgams removed for whatever reason tend to find clincians willing to do it for whatever reason. Often they are rated #1 in their community, and have large and extensive adertising campaigns claiming such things, along with being "mercury free" ;-)) As professionals, it is our obligation to give informed consent, which includes an explaination of the risks, benefits and alternatives. None of these pulpitic or nectoric cases ever come in and say "Yeah, he told me this might happen." What they do come in and say is "It didn't hurt until he took out my silver filling and replaced it." It is a violation of their informed consent to not tell them about these complications, which are well known, and well documented, and have been the subject of scores of lectures and papers over the past two+ decades. Further, do you tell them about all the carcinogenic aromatic hydrocarbons in these resins? ;-)) Lastly, see if you can fit this in your head. :-)))) These case types, like that maxillary first molar that should have had a filling and got an endo and a crown instead, or the lower first and second molar that had symptom free amalgams and ended up with root canals and crowns after the amalgams were replaced, were basically minimally diseased, or disease free. Treatment should be a slam dunk. I mean, how good of a cancer surgeon do you need to be to "treat" someone with no cancer. But that is not what happens. The cancer surgeon "treats" the disease free patient, who then actually ends up with cancer. Or a pulpitis or pulp necrosis. Fit that into your head. :-))) I am always willing to give the benefit of the doubt to the individual clinician. However, I want his teachers shot - John

John, Like you, I resent the teachers who teach students to become clowns. There is no focus on ethics whatsoever. You constantly see practice management articles and seminars focused on improving “patient acceptance” of dental procedures. No one gives a rat’s ass about informed consent because “treatment acceptance” is the focus. Amazingly the ADA, AAE, and other “official” organizations sanction this horseshit. 40% of my endodontic consultations are examinations of patients that will not be treated. I’m proud of this because I know a higher patient acceptance level would mean incomplete communication, inappropriate treatment, and unprofessional ethics. Health Care isn’t about soliciting patients to agree to unnecessary treatment or tricking them into accepting procedures they don’t fully understand. The majority of dentists don’t understand that their role and professional obligation is to accurately diagnose and appropriately treat dental disease. There is truly an ethical crisis and dentist entrepreneurs are to blame for “tooth rape” and the race to titanium tooth replacement - Terry

John, The majority of dentists don’t understand that their role and professional obligation is to accurately diagnose and appropriately treat dental disease. There is truly an ethical crisis and dentist entrepreneurs are to blame for “tooth rape” and the race to titanium tooth replacement - Terry

Terry, the majority of dentists don't want to even view themselves as healthcare providers. I mentioned the Hippocratic oath I took on graduation and got the crap kicked out of me. Most claim they took no damn oath. If you move over to other forums you'll see the big deal in dentistry is marketing. They are having a huge gathering out in Austin next week just on marketing. CE is rapidly moving away from patient care into most marketing. For an old wore out sack of crap this is very disheartening. It is one of the good things about being in the twilight of my career. Maybe I won't have to see dentists return to being barbers and traveling medicine shows. I cringe at ex-employees of another practice telling me about "huddles" every morning to see where the practice stands on "goals for production" and how they are going to find the ten crowns and five endos they are short for the week. They are found. Large spaces are left open for big cases so you can get the patient into treatment before they have a chance to think about it and change their minds. Perfect mouths are assaulted simply to make production goals. Terry, it is a sorry ass world in dentistry and if leadership doesn't take this bull by the horns and kick the crap out of shysterism we WILL crash and burn under the "quit and easy and profitable" banter of the "gurus" of financial success. As Bill Dickerson told me once. Everyone does not deserved dental care. Dental care is optional and if they can't afford care then screw them. That's a growing philosophy in our profession. State boards are stalling at attacking patient care issues because they don't seem to know what is right and ethical any longer. The woman who did the assault and battery on the patient I posted on here continues to assault patients down the street because the board does not want to deal with patient care issues. This is in spite of a state senator pressing the board to take up patient care issues. Guy

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