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  • #76
    Originally posted by VagabondMD View Post
    Purely anecdotal - several years ago, my wife and I both were experiencing similar tooth pain and sensitivity for which our dentist recommended a root canal and referred us both to the endodontist. I called to make an appointment and was told about the series of appointments which would be required and decided to put it off until I had more time on my schedule to get all of the work done in a timely fashion.

    My wife went to the endodontist, had two or three visits which were very painful, the tooth pain subsided, she had a crown made, the tooth pain returned, the tooth was deemed dead/dying/unsalvageable and was extracted, and she got an implant (which was improperly made and had to be replaced - apparently the fault of the lab). Probably a total of 10 visits for one tooth over the period of 2+ years and a cost of thousands of dollars out of pocket.

    Over 6-12 months, my tooth pain went away and has not returned.

    No doubt, similar things happen in medicine all the time. I did ask my father (retired orthodontist who had second career in dental public health) at the time why I could not just skip to the extraction/implant, and I remember him not being able to give me a good answer.
    My endo was very upfront about my weird tooth thing. Said it may be salvageable, but that may not end up being right move and extraction/implant would be more appropriate. It was kind of an edge case. I told her to get in there and if it was gone, it was gone, if not give it a go (we all have been surprised by preop imaging ofc). She told me during the thing it was worse than expected but still thought tooth could be saved, at least 5y, more if lucky, less if not. Worked for me to have good thorough discussion and let me be a part of it. She seems very on top of decision making.

    Otoh, I have been in practices that were totally about milking you, and given we all read the implant thread, quoted me 10k, tried to get all unnecessary exams and stuffs, and I never went back there.

    Comment


    • #77
      Originally posted by Lordosis View Post

      No they just document that they did.
      Lol, so so true, and drives me crazy.

      Comment


      • #78
        Originally posted by Molar Mechanic View Post
        For those worried about radiation...

        For those who only want radiographs based after subjective complaint. Thank you. My endodontic practice is built on others neglecting their care...

        Dentist malpractice suits are fortunately small in dollars, but can be large in time....

        .... I suspect the uproar would be deafening if the tables were turned and the dentists on the forum started a thread accusing the MD community of malfeasance and greed.


        .
        thank you for the thoughtful response, a few responses

        1) I wasn't so much worried about radiation as I was annoyed that I had a CT scan performed on me w/o even perfunctory consent and w/ no one even asking if I had complaints. For all the tech knew I could have had a CBCT the week before at a prior dentist. I think this is ethically shaky. Things change when a patient is presenting acutely for something in my mind.

        2) I hear you on the neglect thing, I think we some of us non-dentists are having a hard time grasping is how direct the corollary is between an asx pt not wanting what they perceive to be unnecessary tests and severe endodontic dz down the road. Again, my last dentist has been "following" a cavity on one of my molars for a few years and it never came up after my CBCT. Doesn't that seem weird? Sometimes the cry goes up "well not every dentists knows what they are doing" but the reality is that i think many people have similar experiences and it causes us to be a little skeptical.

        3) The initial malpractice issue was the suggestion that missed cavities were leading to large judgements, I think we are still waiting for evidence on that. No one is doubting that dentists get sued, I just don't think they get sued for missing cavities very often and thus far no one has been able to produce evidence to refute that.

        4) I really don't think there's been a suggestion of malfeasance and greed on this thread, just a fairly cordial discussion of EBM or lack thereof.

        Comment


        • #79
          Originally posted by MPMD View Post

          thank you for the thoughtful response, a few responses

          1) I wasn't so much worried about radiation as I was annoyed that I had a CT scan performed on me w/o even perfunctory consent and w/ no one even asking if I had complaints. For all the tech knew I could have had a CBCT the week before at a prior dentist. I think this is ethically shaky. Things change when a patient is presenting acutely for something in my mind.

          If you had a CBCT taken as part of a routine NP exam, that is indeed strange. CBCTs are a great tool but they are not very diagnostic for 90% of things we do or look for. Most CBCTs do throw off a reconstructed panoramic image, but it's not terribly diagnostic for most things either.

          2) I hear you on the neglect thing, I think we some of us non-dentists are having a hard time grasping is how direct the corollary is between an asx pt not wanting what they perceive to be unnecessary tests and severe endodontic dz down the road. Again, my last dentist has been "following" a cavity on one of my molars for a few years and it never came up after my CBCT. Doesn't that seem weird? Sometimes the cry goes up "well not every dentists knows what they are doing" but the reality is that i think many people have similar experiences and it causes us to be a little skeptical.

          I've never tried to diagnose decay off a CBCT, and I'm not even sure it's possible. Out of curiosity, I'll look through a bunch of images tomorrow and see if I can pick any. Somehow it never entered my mind to do so in the past. I think it would be very difficult and totally inconclusive, as they are a completely wrong tool for that.

          3) The initial malpractice issue was the suggestion that missed cavities were leading to large judgements, I think we are still waiting for evidence on that. No one is doubting that dentists get sued, I just don't think they get sued for missing cavities very often and thus far no one has been able to produce evidence to refute that.

          I just went on NYS OPD site (http://www.op.nysed.gov/opd/jan19.html#denti) and clicked on a random date.

          Russell George Edman; Pine Plains, NY
          Profession: Dentist; Lic. No. 042542; Cal. No. 30251
          Regents Action Date: January 15, 2019
          Action: Application for consent order granted; Penalty agreed upon: 2 years stayed suspension, 2 years probation, $4,000 fine.
          Summary: Licensee did not contest the charge of failing to diagnose and treat multiple teeth with carious lesions, on one patient.


          I did not look for any more, or court records, but I am sure they exist. If you are looking for evidence, there it is.


          4) I really don't think there's been a suggestion of malfeasance and greed on this thread, just a fairly cordial discussion of EBM or lack thereof.
          This thread has been fairly cordial so far. Some others in past... not so much. Perhaps that's why we dentists expect the worst

          Comment


          • #80
            Originally posted by molar roller View Post

            This thread has been fairly cordial so far. Some others in past... not so much. Perhaps that's why we dentists expect the worst
            Actions by a medical or licensing board are different then a malpractice lawsuit.

            Comment


            • #81
              Originally posted by MPMD View Post

              thank you for the thoughtful response, a few responses

              1) I wasn't so much worried about radiation as I was annoyed that I had a CT scan performed on me w/o even perfunctory consent and w/ no one even asking if I had complaints. For all the tech knew I could have had a CBCT the week before at a prior dentist. I think this is ethically shaky. Things change when a patient is presenting acutely for something in my mind.

              2) I hear you on the neglect thing, I think we some of us non-dentists are having a hard time grasping is how direct the corollary is between an asx pt not wanting what they perceive to be unnecessary tests and severe endodontic dz down the road. Again, my last dentist has been "following" a cavity on one of my molars for a few years and it never came up after my CBCT. Doesn't that seem weird? Sometimes the cry goes up "well not every dentists knows what they are doing" but the reality is that i think many people have similar experiences and it causes us to be a little skeptical.

              3) The initial malpractice issue was the suggestion that missed cavities were leading to large judgements, I think we are still waiting for evidence on that. No one is doubting that dentists get sued, I just don't think they get sued for missing cavities very often and thus far no one has been able to produce evidence to refute that.

              4) I really don't think there's been a suggestion of malfeasance and greed on this thread, just a fairly cordial discussion of EBM or lack thereof.
              MPMD Pretty reasonable comments. I agree with molar roller that CBCT is a terrible tool for decay, and absolutely useless in the vicinity of any metal and most composite restoration. It is absolutely invaluable for reading roots, canals, and bone, as well as determining the sinus / IA nerve proximity in relation to root ends and surgical access. I also agree that it would be hard to get a judgement against a dentist for failure to diagnose decay. Decay grows slowly enough that with routine radiographs, it should be detectable at the next exam if not found initially, and if radiographs were declined, then what case is there to sue on? All the sizable judgements I've ever heard of are either medical complications of sedation (aka killing somebody) or wrong site exodontia.

              Comment


              • #82
                General dentist here

                A couple of reasons for frequent X-rays:

                - Children and teens have a much higher risk of cavities. Baby teeth have much thinner enamel. Teens usually don't have proper oral hygiene and more unstable and poorer diets dental wise. Soda, candy, drinking with their friends and forgetting to brush.

                - As you get older, you probably have more fillings. The ones in between your teeth are easier to get recurrent decay underneath them. Think every 5-7 years sometimes without proper hygiene AKA 95% of the population because not many people floss daily. Americans also drink a lot of soda, wine, sparking water, and sugar overall.

                - You're also taking more medications as you grow older. Polypharmacy and a lot of drugs in general cause xerostomia, or dry mouth. Dry mouth is one of the #1 causes of cavities because our saliva is the #1 line of defense against bacteria in our mouth. Many medications, such as anti-hypertensive drugs, have these effects.

                - We are held liable for doing examinations without all the proper diagnostic info. This includes X-rays.

                - They are one of the easiest revenue generators in our offices because they don't require the doctor in the room, they're quick, and generally easy for what they pay.

                - A lot of things are actually left undiagnosed in dentistry. This is partially because of how hard it is for insurances to pay and so the older dentists gave up trying to convince patients to pay out of pocket. Part of it is also laziness from the dentist or hygienist in explaining to the patient what they actually need versus what they'll pay for. It's our job to diagnose and present the diagnoses. If they decline then so be it, but we cannot decide for them what they would pay for. This is similar to trying to sell nice cars to the people who come in wearing nice suits. A lot of the time it's the techie wearing Target clothes who'll come in and buy the nicer car without many problems.

                - Just because insurance covers it or doesn't cover it doesn't mean that's what's best for the patient (obviously). This includes dental treatment, X-rays, and cleanings.

                - We need X-rays to see cavities in between the teeth, to see how old fillings and crowns are being kept up, bone and gum health, amongst other things.

                - CBCTs should not be routinely used in examinations. As noted previously, they're very valuable in root canal and implant procedures and finding abscesses and cracks.

                THIS YEAR WE'VE BEEN SEEING A RECORD AMOUNT IN THE NUMBER OF DENTAL EMERGENCIES FROM:
                - dental, and probably medical, neglect
                - stress which leads to clenching --> breaking teeth and fillings
                - fear of going to the dentist, or out in general, when a problem arises because of COVID and waiting months before it turns to a medical emergency (have seen a couple this year)

                I'm sure most of you already know this, but just because a tooth isn't hurting doesn't mean there's no cavity. When it's hurting then it means it needs a root canal and you never want to get to that point. You'd much rather have fillings done when they're small. Like in medicine, the less invasive the better. Believe me, we'd love all teeth to have root canals and crowns, or fall out and we place implants because that's $$$$$.

                Also some nerves may already be dead but be asymptomatic. These infections can fester for a long time before presenting with pain and when it does, it comes all at once and keeps you up at night.
                Last edited by Pileos; 11-16-2020, 11:22 PM.

                Comment


                • #83
                  Summary: Licensee did not contest the charge of failing to diagnose and treat multiple teeth with carious lesions, on one patient.”

                  Does an uncontested case count as “evidence”?
                  Just a question, no idea about the facts in the case. It was already pointed out licensing and malpractice are two issues.

                  My point, if there is any licensing requirements/standards all would have zero problem. There is a perception or lack of definition, so the “I could lose my license” or “I could be sued” rings hollow.
                  What law and what standard? It doesn’t seem to exist other than a case by case basis, judgement.
                  That is not a criticism of dentists, simply an observation of the administrative environment.

                  Comment


                  • #84
                    Get your dental x-rays people. Physicians, quit playing dentist. Radiation is negligible. Cost is modest. Clearly they help the dentist with his job. Maintain regular screenings. Brush. Floss. Mouthwash. Cut carbs. Avoid grinding.

                    An ounce of prevention.

                    Comment


                    • #85
                      Originally posted by Molar Mechanic View Post

                      MPMD Pretty reasonable comments. I agree with molar roller that CBCT is a terrible tool for decay, and absolutely useless in the vicinity of any metal and most composite restoration. It is absolutely invaluable for reading roots, canals, and bone, as well as determining the sinus / IA nerve proximity in relation to root ends and surgical access. I also agree that it would be hard to get a judgement against a dentist for failure to diagnose decay. Decay grows slowly enough that with routine radiographs, it should be detectable at the next exam if not found initially, and if radiographs were declined, then what case is there to sue on? All the sizable judgements I've ever heard of are either medical complications of sedation (aka killing somebody) or wrong site exodontia.
                      Looked at a few CBCTs yesterday as I was working up surgical cases. Couldn't see decay where I knew there was some. Thought I saw decay where there wasn't any.
                      Finally found some slices where it was half-way diagnostic. Probably took me 10x as much time as an xray and gave me 10x less info

                      Comment


                      • #86
                        Originally posted by molar roller View Post

                        Looked at a few CBCTs yesterday as I was working up surgical cases. Couldn't see decay where I knew there was some. Thought I saw decay where there wasn't any.
                        Finally found some slices where it was half-way diagnostic. Probably took me 10x as much time as an xray and gave me 10x less info
                        i think we've arrived at a tenuous consensus that asx pt at the dentist for cleaning shouldn't get a CBCT.

                        fwiw i've never refused xrays at a dentist. i've mostly had good experiences w/ dentists. my one horror story was a DDS who wanted to drill out an old filling (needed to come out it was like 25 years old) and couldn't get my inf alv nn blocked after 4 tries. i asked her how much lido she'd given me (she'd used 4 cartridges) and she said "oh, i don't know." i actually stood up and walked out. practice owner saw me next day and blocked me w/ a single shot.

                        Comment


                        • #87
                          Originally posted by MPMD View Post

                          i think we've arrived at a tenuous consensus that asx pt at the dentist for cleaning shouldn't get a CBCT.

                          fwiw i've never refused xrays at a dentist. i've mostly had good experiences w/ dentists. my one horror story was a DDS who wanted to drill out an old filling (needed to come out it was like 25 years old) and couldn't get my inf alv nn blocked after 4 tries. i asked her how much lido she'd given me (she'd used 4 cartridges) and she said "oh, i don't know." i actually stood up and walked out. practice owner saw me next day and blocked me w/ a single shot.
                          I would agree with that - and I think the consensus is better than tenuous. I do know people that recommend CBCT as part of new patient exam. Usually they are heavily involved in treating sleep apnea, and look for airway issues. Most dentists do not consider it standard of care.

                          I've been doing this gig for 20 years. As much I'd love to tell you this never happens to us experienced docs, in the last 4 months I've had 4 patients I've had difficulty numbing... which is 4 more than I've had in at least 4 years. One of them was my wife, on whom I've done tons of work since my residency days, and whose anatomy I am very familiar with. Or a patient I saw last week, whom I couldn't fully numb 2 weeks ago no matter what trick I tried (and I have many in my bag). Last week - yup, single shot.
                          BTW, if that patient were to ask me how many mg of lido I'd given him, I'd stumble for an answer too.

                          Comment


                          • #88
                            My cardiologist wanted an EKG because I am in my late 50s, obese, sedentary, have high cholesterol, a family history of CAD, and some other stuff he mumbled about. I refused since I had no chest pain and we all know he was just trying to collect the insurance money. He should be able to do his job and know everything he needs to know about my heart with that stethoscope hanging around his neck.

                            I love it when physicians act like they know something about dentistry.

                            Comment


                            • #89
                              Originally posted by molar roller View Post

                              I would agree with that - and I think the consensus is better than tenuous. I do know people that recommend CBCT as part of new patient exam. Usually they are heavily involved in treating sleep apnea, and look for airway issues. Most dentists do not consider it standard of care.

                              I've been doing this gig for 20 years. As much I'd love to tell you this never happens to us experienced docs, in the last 4 months I've had 4 patients I've had difficulty numbing... which is 4 more than I've had in at least 4 years. One of them was my wife, on whom I've done tons of work since my residency days, and whose anatomy I am very familiar with. Or a patient I saw last week, whom I couldn't fully numb 2 weeks ago no matter what trick I tried (and I have many in my bag). Last week - yup, single shot.
                              BTW, if that patient were to ask me how many mg of lido I'd given him, I'd stumble for an answer too.
                              1%-10mg/ml, its easy.

                              Though I generally never keep too much track of it either, because its super rare to even come close to a serious dose. All the lido stuff many came up with is just dead wrong and based on procaine, not lidocaine. Eg, never with epi in fingers/toes/ears/nose/genitalia, lol, those places are the worst and need it the most. Always cracked me up to see ED residents freak out when I'd do a digital block with epi. The amount we've found to be tolerable to pts on dose is 50mg/kg, though folks like to say 35mg/kg because it sounds safer.

                              I never use marcaine, in real life use (we did a study on this) it has the same efficacy and duration as lidocaine, less of the cardiac worries.

                              I also have had the rare difficulty numbing people, they are usually anxious or have inflammation, or sometimes a scar that is not allowing simple diffusion around the area. There is definitely an art to it.

                              Comment


                              • #90
                                Originally posted by Zaphod View Post

                                1%-10mg/ml, its easy.

                                Though I generally never keep too much track of it either, because its super rare to even come close to a serious dose. All the lido stuff many came up with is just dead wrong and based on procaine, not lidocaine. Eg, never with epi in fingers/toes/ears/nose/genitalia, lol, those places are the worst and need it the most. Always cracked me up to see ED residents freak out when I'd do a digital block with epi. The amount we've found to be tolerable to pts on dose is 50mg/kg, though folks like to say 35mg/kg because it sounds safer.

                                I never use marcaine, in real life use (we did a study on this) it has the same efficacy and duration as lidocaine, less of the cardiac worries.

                                I also have had the rare difficulty numbing people, they are usually anxious or have inflammation, or sometimes a scar that is not allowing simple diffusion around the area. There is definitely an art to it.
                                We use lido in 1.8 ml carpules, and it's 2%, so it's 3.6 mg per carp. And while it's easy to the math, chances are the last time any dentist calculated it was on his or her board exam
                                Our lido comes pre-mixed with 1:100,000 Epi. If we want to use non-epi stuff, it's 3% Mepivocaine. The only other anesthetic used commonly is 4% Articaine with 1:100,000 Epi.

                                I hadn't used Marcaine in years, until 2 months ago I had a patient who'd lose all numbness within 30 min. And I was doing a full mouth rehab (every tooth getting a crown). So fun when when you're in the middle of a major procedure. I got some Marcaine just for her, can't say it made a big difference.

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