Limitations: Know When to Fold 'Em

I got my pilot's license 42 years ago. I learned to fly in an airplane that had only five basic instruments and no electrical system. It was one of the safest planes ever built because it could just barely kill you. Now I'm an instrument rated commercial pilot, and a flight instructor with multiple ratings. There were A LOT of steps in between and I'm alive today because as I expanded my knowledge base; I understood my current limitations and explored my boundaries with caution. After all this time and additional training, I know I am a highly skilled pilot flying excellent equipment, but I still have limitations and I know that too. I have planned trips where my ultimate decision was to stay on the ground.

I think that knowing one's limitations is equally important in dentistry, providing that one's intention is to provide the best care for one's patients. We all make mistakes, like having a bad day perhaps with eye-hand coordination, for example. But if we are honest with ourselves, taking on cases for which we know we are qualified, judgment errors should be infrequent.

Knowing your Limitations

Rachel, all of 4 feet 11 inches and 89 years old, accompanied by her husband of 70 years, presented to her general dentist earlier this month with a problem that was easily identified as being of endodontic origin associated with tooth #24. This presentation had Warning, Danger Ahead written all over it. (Fig. 1)

One, Rachel is old and frail, and because of this, has less stamina for prolonged treatment time. Two, she, as well as her caring dentist, want desperately to maintain the status quo, as any change is likely to mean a major commitment in time, money, energy and inconvenience. Three, not only is this tooth is in her esthetic zone, it is perceived by Rachel and her dentist as being a key tooth. Four, it's not only splinted to adjacent teeth, it's part of a composite resin bridge, a delicate and tenuous situation at best. (Fig. 2-3)

Five, the composite splinting has obscured the anatomy, meaning the precise location, shape and size of the crown as well as the tooth's inclination. Six, it's a lower incisor, one out of five have two canals and even in ideal situations there isn't much room for error. Seven, it's an old tooth and no matter what, it's going to be somewhat calcified. And eight – did I mention she is swollen and in pain?

Now, if you practice dentistry alone, say, in Barrow, Alaska, and you have developed some skills in endodontic access and treatment, then I say go ahead; what does your patient have to lose? In Scottsdale, AZ, this general dentist could drive a golf ball in any direction and hit an endodontist.

After a valiant (and to my way of thinking, excessive) effort to treat Rachel, the general dentist, to his credit, quit just before perforating to the facial, and referred her to me. All I did was move the access coronally and facially, where it should have been started in the first place. (Fig. 4) This allowed me to place a file directly into the canal, with absolutely no additional removal of radicular tooth structure. After three weeks in calcium hydroxide, Rachel returned symptom-free and I completed the case. Since the tooth structure was already removed, I placed a post in the empirical belief that I might make the tooth less weak. (Fig. 5)

If, after seeing it, you still want to tackle this tooth, the takeaway lesson is to start your access in the right location. And remember, there are old pilots and bold pilots, but no old bold pilots.

Glen E. Doyon, DMD, Spear Contributing Author [ www.CMSEndo.com ]


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