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View from the Chairside: Don’t Rush to Judgment, a Molar Falsely Accused

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Dr. Paul Belzycki is back with a case of a molar that was almost lost to rush judgment. In his presentations, Dr. Belzycki generously shares four decades of extensive clinical experience, striving to provide excellent quality oral care. In addition, you will find below a few pieces of valuable advice for new and young dentists on how to succeed professionally and practice to the best of their abilities. 

As usual we are very grateful and thankful for his valuable contribution and continued support.

I hope you enjoy watching the case. We always welcome your feedback, thoughts, suggestions, and questions. Email us at oasisdsicussions@cda-adc.ca or if you would like to call us, our toll-free number is 1-855-716-2747.

Until next time!

Chiraz Guessaier, CDA Oasis Manager

Dr. Belzycki’s Thoughts

A patient is deserving of an accurate diagnosis. In the absence of an accurate diagnosis, treatment is useless at best and dangerous at worst, if it is invasive. Consider if you had to undergo unnecessary surgery, how would you feel? 

There are several steps required to reach an accurate diagnosis. First and foremost, you need a thorough understanding of the clinical problem you are dealing with. When in doubt, do not act and consider that there is no shame in referring to colleagues who possess more clinical expertise, or in waiting for symptoms to become more site specific, if they are ill-defined on initial assessment.

Second, don’t rush and take your time. Sometimes, clinical problems are routine and quickly recognizable. Other times, they are obscure and they require lengthy appointments. So, use appropriate radiographs and conduct thorough clinical investigations to reach a closest-to-accurate diagnosis.

Third, give the patient the benefit of the doubt, if they describe sensations you deem not possible, mysterious, or trivial.

Finally, always consider that you may be mistaken!

Read/download the transcript of the full presentation (PDF)

Read/download the transcript of Here’s to Young Dentists (PDF)

Oasis Moment (2.41″)

Full Case Presentation (32.23″)

Here’s to New Dentists (8.01″)

 

6 Comments

  1. Anonymous November 14, 2018

    Young dentist chiming in here. Good work altogether. Just some questions that popped up while viewing the presentation:

    1) Why not raise a flap and evaluate to see the extent of the fracture prior to starting endo?

    2) I see that a periapical was used to assess CEJ decay? Should not a bitewing be used? I find it difficult to believe that a 70y/o female patient with seemingly good hygiene gets decay localized to just the mesial aspect of a second molar – but I guess it happens.

    Reply
    1. Dr. Paul Belzycki, DDS November 16, 2018

      Hello Young & Anonymous,

      Answer #1

      These presentations are organized with time constraints. Oasis wants them shorter, and I want them longer. It is difficult, if not impossible, to elucidate all the treatment nuances in these cases. I could spend half a day on this one.

      As I have stated, I provide Perio, Endo and Restorative dentistry in a comprehensive manner. There is no set order as to how treatment is sequenced. This is decided on the merits of each case. In this instance, I retrieved the broken fragment and quickly developed a mental image of the perio defect I would encounter. From experience, I knew the tooth was restorable with a crown.

      The more important question to answer in this case was: Is endodontic therapy possible, given the prior concerns of a calcified canal system and the need to investigate a possible root perforation at the mesial aspect? Hence, the endodontic therapy was provided first.

      There are other instances where endo is a sure thing but periodontal surgery may be provided first to investigate the extent of a bad fracture or gross decay to determine if a tooth is restorable.

      Add to this list, pain, swelling, infection, trauma, finances, patient’s social schedule… etc… and the permutations of treatment sequencing grows in complexity.

      Answer #2

      I did obtain a BW at a subsequent appointment.

      The decay is present on that film as well. The initial PA was taken at a flat angle similar to that of a BW because I wanted an image free of distortion to assess the pulp chamber and canals. I anticipated being short of the apex on that film. This did not concern me because I knew I would take additional films as endodontic therapy progressed.

      I find it difficult to believe that you find it difficult to believe that a 70-year-old could develop decay in the mesial of tooth 27. This is the very population of patients that suffers from this quite frequently. As patient’s age, the quality and quantity of saliva diminishes due to physiologic aging, often in conjunction with polypharmacy. In addition, there is a decrease in manual dexterity due to issues, such as arthritis, age-related tremors, Parkinson’s, and cognitive slowing. Often, they just forget to brush or lack the strength/motivation. Many of my patients have remained with me until their passing. Root decay can be challenging to control in the elderly. The literature substantiates what I have witnessed.

      And before some young whipper-snapper beats me to it, the images of this patient bear witness to good long life of heavy mastication. The grainy diet of India is tough on teeth. So, perhaps this lesion at the CEJ started as “abfraction” with decay as a secondary event due to its location between the teeth.

      For me, the point is moot. Amalgam saves the Day.

      Thank you Young & Anonymous for your contribution.

  2. Lisa November 14, 2018

    Thank you for sharing this. Always a good reminder to assess and diagnose accurately. And wonderful work. My question is: the X-ray did not show that palatal root of 26 fully, in case there is apical lesion? Being calcified and necrotic tooth and maybe apical lesion would you have considered doing that root canal as 2 appointments with diapex in between to kill all bacteria? Or in your experience doesn’t make a difference?

    Reply
    1. Dr. Paul Belzycki, DDS November 15, 2018

      Dear Lisa, thanks for taking the time to contribute.

      The initial PA shown was taken at a flat angle similar to that of a BW because I wanted a distortion-free image to assess the pulp chamber and canals. I anticipated being short of the apex on that film. This did not concern me because I knew I would take additional films as endodontic therapy progressed.

      Please note that given the time constraints of these presentations, I cannot present in great detail all the steps of the diagnosis and conversation with the patient. Suffice it to say that I knew that the tooth was not necrotic because there was no prior history of decay, trauma or past restorations. There was no history of symptoms related to thermal cycling or spontaneous pain nor swelling. Once the fracture segment was removed, the patient experienced no pain to pressure or percussion. The symptoms were solely related to the fractured segment. This diagnosis could not have been simpler.

      Unfortunately, I had to proceed with endo because the prior dentist had entered into the chamber. There was no foul odour or fluids indicative of infection. Merely tight canals with a little bit of blood due to live tissue. Hence, I felt comfortable doing the case in one appt. I did not state that this tooth was necrotic. Further, the degree of calcification was manageable. There are instances when calcification makes endo near impossible. Again, all cases have their unique clinical peculiarities.

      With regards to necrotic teeth, I have no set rules as to one or multiple appointments. Often it is a gut feeling. If dealing with no soft tissue swelling, a single wide canal where irrigation with Sodium Hypochlorite is feasible and where I can dry the canal easily, then I may elect to complete in one appointment.

      With swelling, pain, and multiple canals that remain wet due to drainage from the apex, I prefer to use Calcium Hydroxide paste between appointments and complete when symptoms subside in the presence of dry, clean canals. I do not rush these cases.

      In my experience, I find EVERYTHING MATTERS !!!!

      Thanks again for your participation.

  3. michael pollak November 18, 2018

    Thank you Dr. Belzycki for another excellent presentation. Your diagnostic and technical abilities and the philosophies you share, serve to inspire all of us to strive for excellence.

    Reply
  4. Paul Belzycki November 19, 2018

    Dearest Michael,

    Thanks for noticing. I realize fully that my efforts are for the few of us that care deeply for our patients and strive to provide treatment as we would hope to receive. I fear we are increasingly in the minority.

    My goal is to provide vindication to this small group, that we are still very much relevant.

    Equally as important is to demonstrate to younger dentists, that which constitute efficacious, long-lasting restorations and therapies. That achieving this goal must be rooted with knowledge in the self and to avoid the illusion that excellence is in the machinery we employ. No matter how expensive or sophisticated, these are only tools. Excellence is not found therein.

    Excellence is a concept only held in a human intellect.

    Appreciate your contribution.

    Reply

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