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Case Conference Prosthodontics Restorative Dentistry Supporting Your Practice

View from the Chairside: Holy “Bleep” or the Anatomy of a Misadventure

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Look for the password to watch the presentation in the Dec 20th CDA Oasis Bulletin or email us at oasisdiscussions@cda-adc.ca to receive the password.

 

I was approached by Chiraz from CDA Oasis to present a case requiring extensive treatment to correct dental problems that resulted from clinical mismanagement by a previous clinician.

In this post, it is not my intention to disparage any one individual, but to emphasize a Philosophy of Treatment that should not be obscured by the new technical wizardry and materials that are nowadays available to dentists.

The main messages of this case presentation evolve around the following points. First, good dentistry will always remain an arduous task where grand success is the result of expertly managing many small details. Secondly, patients have a right to an accurate diagnosis. Thirdly, patients deserve treatment provided to a high standard. And finally, patients deserve the truth. By this philosophy, trust is earned and our profession as a whole will be elevated in the eyes of the public.

Thoughts, comments, feedback, email me at oasisdiscussions@cda-adc.ca

Enjoy the presentation!

Dr. Paul Belzycki, DDS

Full Case Presentation (36.20″)

 

10 Comments

  1. Mark Antosz December 19, 2017

    The comment about the cost of dental education is very appropriate. Personally, I lay part of the blame for the focus on money squarely at the feet of the universities. The cost of a dental education is absolutely prohibitive, and graduating students are FORCED to think about money. I’ve talked to deans about this, and they have justified the cost by stating that in no other profession can you graduate and be guaranteed to make $200k/year. I’m not sure what plane of existence they live on, but that doesn’t reflect the the real world. The cost scares away good candidates who don’t have the resources to take what amount to a huge risk. That’s fundamentally wrong, and IMHO the Ivory Tower types need to recognize that the cost of this education needs to be subsidized or risk having those with the wrong motivations populate the profession.

    The speaker took a jab at “large corporations”. That was a cheap shot, made based on emotion and not fact. I’m part of one, and I operate freely with no interference on production or referrals, and lots of support if I want it. I’m actually more concerned about “practitioner-controlled corporations”, where individuals or groups buy practices, stock them with associates and prohibit their freedom to practice by insisting that they keep referrals “in house” to their own pseudo-specialists, rather than referring to whomever can provide the best care. Which is worse? I leave that to you to decide.

    It would have been interesting to see that patient’s occlusion, anterior wear, etc. Sadly in my experience this is an area that gets ignored far too often. Patients get restored, and restored, and restored – but things still fail. The reality is that with a poor occlusion the best dentistry in the world will ultimately fail.

    Reply
    1. Anonymous December 19, 2017

      To Mark Antosz.

      I will start with your last point. Not addressing the occlusion while providing restorations is by definition NOT GOOD DENTISTRY… Hence, I illustrated that one must mate occlusal demands with techniques and materials. See slide showing the 2 gold crowns in one of my patients. With the limited time available to do these posts, it is challenging to address all the details.

      My referral to large corporations was not a “cheap shot”. It is my opinion, based on stories told to me by many of my retiring colleagues (we are of that demographic) that have experienced this process. This is an emerging reality in our profession that will have consequences, both planned and unforeseen. By your own admission, you are on “that side” of the fence. Therefore, you too can be swayed by an “emotional bias”. I do not wish to debate it in this forum. My intention is to point out to other viewers that you too harbour biases. We all do.

      It is my wish that you flourish and provide excellence wherever you find yourself. By this method, mutual honour and respect between yourself, staff, patients and colleagues is fostered. It will also pay dividends when you look in the mirror.

      Dr. Paul Belzycki, DDS

  2. Robert M. Kaufmann December 20, 2017

    Regarding the Endodontic aspects of the case:

    One must wonder why surgical Endodontic treatment was performed over inadequate Endodontics and leaky coronal dentistry. That was a poor decision and directly contributed to eventual loss of these teeth, regardless of how well the teeth may have been subsequently restored.

    No competent, contemporary and ethical Endodontist would consider performing apical surgery on these teeth without disassembly retreatment first. That’s a given. It is a recipe for long term failure, as you have clearly illustrated.

    The placement of multiple deep posts (especially in the M roots of mandibular molars) shows a gross disregard and ignorance of root anatomy, potential for perforation and complete lack of understanding rationale for post placement. It does (sadly however), generate a higher fee for post and core placement.

    I suggest that had you brought this case to any of the Endodontic faculty at the U of T, they would have insisted that these teeth be conventionally retreated first, before any surgical procedures were considered and certainly before the patient committed to re-restoration.

    Putting a nice lid on a trash can does not make it stink any less.

    Reply
    1. Paul Belzycki December 22, 2017

      Hello again Dr Kaufmann.

      The treatment provided by the endodontist in this case is ill-conceived, but no mysterious wonderment.

      Please note that I am guessing here and not making accusations.

      The original dentist my be a good source of referrals to the endodontist. The endodontist probably considered the “clinical limitations” of the restorative work. He may even have discussed it with the referring dentist. I do not know. But, I am guessing he wanted to help everyone. He wanted to get the patient out of discomfort. And, he may have wanted to help the referring dentist out of a jam. I sincerely hope and imagine, he did not do this solely for financial gain. I would bet you he hated every minute of it. Then again, he may have thought that the New Super Duper Retro-grade Apex Sealer, mentioned in their newsletter to referring offices, may prove impenetrable to micro-organisms.

      We all are human. We are subject to the stresses and strains of practice; and sometimes we render questionable judgement with the best of intentions. The late Dr. Simon Weinberg said it best: “Good judgement comes from meaningful experience…Meaningful experience comes from bad judgement.”

      An endodontic colleague here in Toronto confined to me many times that he would love to fire some of his referring dentists, because in their cases, the endodontic treatment he provides is compromised with bad restorations.

      And there is a flip side. Being treated by a specialist, by no means guarantees excellence.

      C’est la ‘Dental’ guerre…

      Dr. Paul Belzycki, DDS

  3. Cliff Leachman December 21, 2017

    Paul you slay me, I’m an old poop as well and one of the few prividing amalgam in Victoria. Some tell their patients no one is placing them now, almost fell off my chair watching that was the treatment.

    I agree with most of what you say except that the top people in our field are teaching these principles.

    A few years ago, I was listening to the great Pascal Magne teaching to place porcelain(Cerec) onto Endo cores. Couldn’t believe it, I guess if you margins is on composite it doesn’t matter what crown you use.

    Also with Trios we have entered the future and it’s finally performing at the highest of level, but give me a cast gold crown, lost wax by an expert, EVERYTIME they let me! Thanx for the effort!

    Reply
  4. Paul Belzycki December 21, 2017

    Dearest Cliff,

    Thank you for your kind words.
    Sitting in my private office, all alone at the end of the day, staring into a computer and recording these posts is a difficult task.
    With no live audience, you have no feedback as to how you’re doing.

    Hard to know what to stare at. I have to keep reminding myself to look at the little camera on the top of the screen to try to provide some sense of eye contact with an imagined viewer.

    I figure most of them are just young dentists figuring I’m an Old Goat.
    I’m beginning to feel like Andy Rooney.
    I would like to say that on one of the posts but I figure that reference is lost on them.

    I gave a lecture at the BC dental convention a few years ago. The older dentists in the crowd came up to me and thanked me, stating it’s reassuring to know that they’re still practicing solid dentistry.

    A young female dentist stated that she is part of the practice where they attend a Gold Foil club. I was shocked to know that one was still in existence, somewhere in BC.

    So all is not lost yet.

    I know I appear stiff and sound artificial on these posts. But I’m learning. Your words have given me encouragement to get better.

    Keep fighting the good fight, we’re still relevant.

    Dr. Paul Belzycki, DDS

    Reply
  5. David Kennedy December 22, 2017

    Congratulations Dr Belzycki on a great presentation. As an Orthodontist and Pediatric dentist, I will not comment on the quality of the restorative work. However, anyone who takes the time to take beautiful photographs and radiographs and to document their treatment so impeccably is probably pretty darn good on that side. It certainly looked excellent. This patient’s needs were well served in your hands and poorly prior to that. As you said, we need to ensure that the patient’s needs are put ahead of ours; something that is often lacking in this era. I agree with you that the lack of public trust is something that we have unfortunately earned.

    Too often, we are too quick to embrace new technology when the old tried and true still works very well. Regrettably, the new technology is sometimes advertised without the evidence to support the claims.

    Also glad that the prior dentist was reprimanded. I hope that the patient had some financial recourse for the re-treatment that was needed.

    I admire the courage you had to give this presentation and thank you for your leadership.

    Reply
    1. Paul Belzycki December 22, 2017

      Dear Dave,

      My first reaction to your comment is simply “Wow”. I am honoured.

      Yes, some courage was required as I do not want to be perceived as a “snitch” or “Holier than Thou”. I endeavored to let the facts speak for themselves.

      It was not my idea…it was a CDA Oasis request.

      I do document all my cases extensively, because that is the best way to explain treatment to patients and now to my fellow dentists.
      Furthermore, sometimes I start on one tooth and discover decay in a tooth next to it. I take a photo to explain why additional treatment was required. I am very sensitive to patients wondering, if I was “undertaking a make-work project”.

      Secondly, it keeps me, and more importantly, it keeps the lab honest. I photograph and store every impression going to a lab as proof that it is defect free. I supply perfect impressions, I expect back perfect restorations. We have a love/hate relationship.

      I have cases going back to 1988. Don’t ask what it costs to store them. It all started out of a need to prove to patients that I am trying my best. Only now has it become a source of material for these posts.

      Thankfully, you work in an area I avoid; Ortho and Pedo. Someone has to do it, mercifully, it is you. Ortho is a killer. So much beyond your control; patient compliance and growth. And now, Invisalign.

      One of my patients, who is now 30, has been with me since birth. One day he comes across a Groupon for bargain Invisalign with a GP office. He starts treatment with an unknown entity and one I did not recommend. Man I was upset and I did let him know. That is a New World Order.

      I have been told by my Ortho colleague that the true intention is to cut out dentists totally. Have free standing booths in a malls. Sit down and have your mouth scanned. In a few days, the stents arrive via Uber. Easy-Peasy.

      Let us continue to glory in the struggle.

      Dr. Paul Belzycki, DDS

  6. Don Allen December 28, 2017

    Paul that is a fantastic job you have done . I am in my 5th decade of practice, and have seen the more expensive composite restorations placed. I am in a group and continually see the younger Dentists place garbage in their patients mouths. Their standby answer is that the patient wanted it!! I get requests all the time as well but usually can convince the patient that the compoosite( Spelling intended)is not as good. Also one of the dentists was using a scanner and the crowns were placed in a cement lake. What about coding of treatments that occur. easy extractions that are coded as 71201, the list goes on why?? We can earn a really good living being honest. DON ALLEN

    Reply
    1. Paul Belzycki January 15, 2018

      Dear Don,

      This past Friday, I gave a one-hour presentation on The Delivery of Long-Lasting Restorations, to dental students at their first National conference. It was geared towards fillings, core-build-ups and single crowns that a new grad would likely encounter early on in their career. One hour leaves little time for all the technical skills required.

      I tried to convince them that amalgam was the best all-around restorative material. I showed several cases of amalgam restorations that were over 30 years old as compared to what “composite” fillings look like after 2 years. I seemed to have struck a cord. Some claimed this was a revelation when presented with photographic evidence. Perhaps the profs are getting younger and not presenting the facts strongly enough. Perhaps they too are succumbing to market pressures of the big dental suppliers and manufacturers that fund the schools. Hence lasers, that you and I know are worthless expensive tools in the dental office, are finding their way into the schools.

      All the schools across the country were represented.

      I will consider tailoring that material for an Oasis post.

      If you are in your fifth decade, I am a rookie still in 38 years of practice. Could I buy your practice and have you mentor me?

      Still learning.

      I am deeply honoured that an Old foggy took the time to leave a meaningful comment. Equally impressed that you use a computer. Go figure.

      Us Old Farts need to stand united against stupidity.
      Dr. Paul Belzycki, DDS

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