Intra - oral swelling
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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
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
4. As the recipient of referrals, how do we promote the post-obturation
procedures necessary to complete the whole treatment ?
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,
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
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
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
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
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