I'm an Endodontist....any Questions?

I've been an endodontist for 18 years. I teach as a volunteer some, and am writing a textbook right now. I have a thread over at the pre-dental forum. Any questions?

dc,

Most endo programs require that you have a few years of general practice, service, or GPR. Check out a thread in the pre-dental forum that's:" I'm an Endodontist..." check out what I told croco on 10-2-2003. He had the same question.

Come back here if I can help you any further.

Rob,

Sure. I think, like most endodontists, the way to go is to use a combination. I think we all start with hand files, find canals, get a working length, get to maybe a 15 file. Then try to open the body of the canal first in your instrumentation. I use a 2 and 3 Peeso. You might use a 3 and 4 Gates. The NiTis come in handy to flair and taper the canal. I use the Tulsa NiTis, then it's easy to use hand files to finish the apical prep without changing the curve or breaking something.
When you get used to hand files, you can get a real good feel for what you are doing. I don't usually take working length xrays and I don't use apex locators. I can feel the apical constriction with a file, usually a 15. I've been doing this for about 15 years. Most times I just take a final. I started doing this when I did OR cases where there wasn't an xray machine. One of my Mentors showed me how to do it. Was a few years until I could figure out what he meant. It's one of those things I'd have to show you. Can't explain a feel like this one.
NiTis break for no reason. You have to use the correct handpiece and get real good at it. But still, they break when they please.

SeaBass,

I guess you are worried about getting profound anesthesia, right? First of all, I can't see relying on a premedication to help you at all. IV sedation, yea, but that's a one in a hundred or more for an endodontist, and we get cases for no other reason than the patient can't get numb. You should rest assured that you have about a 99% chance that your patient will feel no discomfort and leave laughing at how easy it was.
I have to give interpulpal injections sometimes. I hate to have to do it, but I can't do my job right if my patient is feeling it. Concentrate on giving your local properly and test the anethesia with your cold sensitivity testing material (on a tooth with a vital pulp) before you start.
Just do it.

SeaBass,

Guess I misunderstood you at first, there. Anyway, I cannot think of any situation where you would delay treatment in the case of an acute infection. Most of the time, you can use a nerve block anethesia technique, as you know. Most agree that due to the pKa of your anesthetic, not enough of it will dissociate in the relatively lower pH of infected/inflammed tissue. Carbocaine has a slight edge here. In all cases of a swelling and acute infection, you have to get rid of the cause physically and establish drainage. If you can't get drainage through the tooth, clean out the canal, fill it with calcium hydroxide, and do the I&D. You don't need much of an anesthetic to do either one of these. It helps to make the rubber dam clamp more comfortable. You can have vital tissue in the canal in the case of an acute infection, but it is rare. Some feel that it is not wise to inject in the area of swelling because of a possibility of spreading it. You don't need much because you really only need some soft tissue anesthesia anyway.
Use the antibiotic, get your patient numb enough to handle the rubber dam, clean the canal, fill the empty space with USP calcium hydroxide, temporize with no cotton pellet, and I&D if you need to. The antibiotic is no substitute for getting out the necrotic pulp. There's no drug in contact with the microorganisms.

Secondedition,

Check you pm.

DC-10,

I got into my endo program right out of of Pitt. As far as I know, I'm the only one who ever did this at UCONN. I did a bunch of things in dental school that kind of set me apart. I got accepted to four endo programs then. I think the mind set was that since endo is so closely related to the restorability of a tooth by a general dentist, they wanted you to see what it's like in thier shoes for a while. Kind of like the reason you had to make your own dentures and crowns to see what the problems a lab guy would have with your impressions and transfers and the like. I still felt comfortable going into practice without this. I was done with my requirements after my third year in dental school and I spent my last year in a program I designed doing a lot of more complicated restorative and fix-ups for unhappy patients. That helped.

Originally posted by freedyx3
Endotom,

After all your years being a dentist do you view back and neck pains as problems for dentists?.

Click to expand...

I can tell you from experience that the neck and back problems are real. Of course it is an occupational hazzard and it is more noticable with age. I'm an endodontist and I have found that there are some situations that just don't lend themselves to indirect vision. I'm paying for it now. The first thing that I did was to visit a patient/friend of mine that is a chiropractor. He did his thing and I felt better. The next day he went to Staples and bought me a chair that is commonly used by people who work at computer terminals. With this chair, you sit "in" it by resting your knees on a crossmember and leaning back onto a stool. It's a Scandinavian design meant to prevent you from sitting incorrectly. Your wieght is distributed down your spine in a straight line, then onto your knees. You cannot sit wrong. It's very comfortable, you can get yourself under the patient's head where you belong, and have no trouble reaching the gass pedal with your toes behind you. Got one fo my assistant too.

Fred,

I can't see where this would be practical. I don't think the problem is tilting your neck to look in someone's mouth or indirectly into a mirror. It's more with your back and poor posture. I was terrible at it and it took me 25 years before it started to bother me.

Now, there are intraoral cameras that a lot of dentists use. These are mostly for before and after shots you can show your patients and dazzle them with your new toy. They can look at a TV on the wall and see how they look inside.

no2thdk99:

I've used a dental microscope. In fact, have one in my office I haven't used for quite a while. They are nice toys. Mind you, I'm an endodontist and most of the work I do, you can either do it or see it but not at the same time. Most everything is by feel. They give an amazing view of the floor of the pulp chamber until you have to stick your fingers in there. They surely have thier place though.

jred378:

In general, I think that endodontics has the lowest overhead. I had it figured out how to keep it at 18% for quite a few years. I didn't have my own building, equipement, or employees. I payed a flat rent that included all of these. Materials are very inexpensive, but I made sure that my "employees" got payed well. This just raised my rent some. Although this makes you cash happy up front, you are deduction and depreciation poor. You pay a lot of taxes. I personally paid for the first Gulf War. I didn't own anything. When I left that, I had nothing to sell. There is no practice to sell as an endodontist anyway. You have no patients of your own. I got referals because of ME so I couldn't sell that as goodwill. And then I had no old equipement to get rid of.
I think that other dentists vary from about 40-60%.

LestatZinnie

You can find a chair like I described ealier in this thread at Staples. Try www.staples.com and go to office chairs. Find the Office Star Ergonomically designed knee chair. I think it's about $80 now. They work. Don't trip the first time you try and stand up. I tried sending you the url for the page it was on, but it wouldn't work. Let me know if you can't find it.

Bump!

blankguy,

You know, the way that I got to be a very successful endodontist is a secret that I will share with you. I have to get referals from other doctors, you know. Nobody walks off the street into my office. I sit back and do consistently good work. I do the very best I can with what walks in the door. Everyone is different and has different needs and expectations so I try to recognise that in each person. Then I treat everyone just like I would want them to treat me. And I will assure you that what goes around comes around. And honesty. Your reputation is something that no one can add to or take away from you. You keep it in your back pocket all your life. (Heck, if I wasn't such a nice guy, I wouldn't be here, right?)

I don't join country clubs and send cases of Jack Daniels sippin' whiskey to all the doctors. I don't pretend to like to play golf with someone while I'm trying to schmuze them into likeing me so they will send me some patients. The patients leave my office and sometimes it gets back to me that they wished all the doctors treated them like this. They want to know if I would be thier real dentist and do all the work. It's embarassing sometimes. When they tell thier dentist how they were treated at my office and how it was a piece of cake compared to what they thought it was like, that goes around too.

If you are asking about the skills, foriegn dentists have to take the same boards doing the same proceedures that you do. Most all of them are doing the same kind of dentistry that you are if they are practicing here. If you are talking about people skills and different cultures, I think we are all alike no matter where we are from, and all have different talents that way. All of my doctors are foriegn but one and he went to med school in South America.

endotom

blankguy,

I got into endo because it was my favorite thing to do in dental school. There are other reasons, but that's mainly it.

No, my job is not routine at all. You may think I do the same old thing every day, but I don't. All the patients are different. It's like playing golf. You play the same course every day. You play all day long. You get really really good at it. You are the best even in the rian and the wintertime. And you get to play with somebody different and interesting on every hole.

Here's an example of a case I did a long time ago. It's an example of what I get to do. This story is from DentalTown where we were talking about the tricks of the trade and stuff:


Seems a kid age 9 years was riding his four wheeler one night on his nieghbor's farm. We'll call him JR, because that's his name. While crossing fields he ran into a wire fence that caught him in the chest, rode up his neck, hooked onto his two central incisors and flipped them out whole. He rode back home with his problem, told his Dad who went back to where he had the accident and found the two teeth. Dad takes the teeth home in a wet Kleenex and then after calming JR down and checking him out, puts the teeth in a cup of milk and goes to the emergency room to a hospital where I'm on staff. He waits there until an oral surgeon buddy and I reimplant the teeth. So far so good with what happenened, right? However, teeth out of the alveolus about 1.5 hours.
Well, how are you going to stabilize two teeth, the only two secondary teeth he owns in this area. His primary teeth are missing back to the canines which as you know are too tiny to be of use. You really can't put arch bars on because there's nothing to use 'till you get to the first molars.
I took JR and Dad up to my office from the ER late that night. He got the regular Tetanus booster and everything at the ER first, including two silk 050 sutures inside his upper lip. I share a waiting room with a general dentist, so I go over and steal stuff from him when he's not looking all the time. The only way I could figure out to splint these teeth was to first take an impression of the maxillary arch with alginate, pour up a model, and make a vacuum stent like you use to make a temporary bridge. Now JR, mind you is a real trooper through all this. He even thinks it's the coolest thing he ever did. By the way, he's numb-er than a doorknob from the ER and also thinks that's cool. Dad is OK and a pretty good dental assistant by now. I cut out the stent from molar to molar and for lack of anything else available, I cemented the whole thing on with a stiff mix of zinc phosphate cement. Worked great. That's the moral of the story.
Couple of days later, JR gets out of school, which is great by him, and I put a rubber dam over the stent using two premolar clamps on either side of the two centrals. The stent is clear plastic and I do access openings in 8 and 9, the pulps are removed very easily, as there are tears at the apex right next to the root sheath on these immature teeth. The canals are wide as you know, so I use an amalgam carrier to fill the canals with CaOH2 tamping it down with #12 pluggers and fill the canal to the pulp chamber and place Provit also smoothing the openings made through the stent.
I finished this case a year later doing what you would expect to get apexification and fill the open apex. Got a call from JR recently. He called from Camp Legune (sp). He's in the Marines and wanted to know if I remembered him

blankdude,

I don't get your question.



endodude

blankguy,

The vast majority of endodontic treatment is done by general dentists. Most all of the emergencies in the cases of acute abcess and traumatic injuries are seen by general dentists first. The only cases that endodontists see are the cases that general dentists have seen and decide not to treat themselves.

They refer these cases for various reasons. The number one reason is that they have found that by examining a patient and looking at the radiograph they can predict that it will be a difficult case. It would be better for both them and the patient that an endodontist have a try at it because it would take too much time and might be so difficult that it could be ruined by an unsuccessful attempt. They get good at predicting this situation by looking at the curvature of the canal, the amount of calcification in the canals, the access problem to the tooth and the canals, and the cooperation of the patient. It's true, some general dentists have decided not to do any endodontic treatment at all and send every case to the endodontist. I like that situation, because then I get to treat some easy cases once in a while. That is extemely rare. Of all the refering dentists that I have had, I can only recall three over the years that did that.


endotom