Friday, July 20, 2012

Endo Failure

I am finishing up The Girl Who Played with Fire. It is a shame this author died because he is a really good writer. There are A LOT of characters in his books. I mean, there are more than 25 that he keeps alluding to, and I can't remember who they are. I have started doing this new thing now. I make a list of the characters on a sheet of paper and use that as my bookmark. It takes me so much longer to read a book nowadays because I am so crazy busy. And if he mentions a character and doesn't return to him for about 200 pages, I have no idea who this character is. My list helps on books like this. But it is very good.

I watched a couple of movies since the last time we talked. I watched a Christian film called Courageous. It has the same actors as Facing the Giants and Fireproof, but I think this time everything was much better. I thought the acting was decent to good and the plot was good. I really did like this movie. I didn’t want to bawl because I was watching it with another family, so I had to cry quietly.

I also saw Acts of Valor (done by real Navy Seals, not actors), and it was pretty good. I watched Couples Retreat with Vince Vaughn; I didn't like this one. The previews were funnier than the movie. I also watched Tower Heist. I had very low expectations, but I really liked this one too. And last night I finished Safe House. This movie was really good, definitely worth the rent.

Okay, on to today’s topic. I had a one-minute window while I was sitting at my desk and I sighed heavily. I looked around and there were 12 magazines in my inbox. Throw out, throw out, throw out, look at the cover, throw out. You know the drill. I usually page through AGD Impact and General Dentistry and occasionally I will look at JADA.

But something on the cover of JADA caught my eye. The catch line is “Restorative outcomes for endodontically treated teeth.” There are a couple reasons why I went to this. Obviously, when something says "restorative," I want to see what they are talking about. But I started to think maybe they might touch on the posterior composite after a root canal.

The article does not talk about anything I do most of the time, but it was a bit shocking to me. They had an exhaustive study on restorations after a primary root canal. They looked at 1,298 teeth and found that after 3.9 years (Did you hear that? 3.9 years), the average failure rate for the full coverage restoration was 13.9%.

But this was not all. I will quote this paragraph, "However, the 13.9% restorative failure rate reported here, when combined with the 19.1% failure rate of primary endodontic therapy we reported earlier, underscore the need for the practitioner to give careful consideration to all treatment options when planning treatment for teeth with IP/AP or a necrotic pulp."

WHAT?!!!! A 19.1% failure rate on primary root canal treatment?!!!! A 13.9% failure rate of crowns in 3.9 years!!! This is absolutely crazy talk. These numbers are alarming to me. I reread some of the article again because I was so shocked. I asked myself what failure is. There was a lot of mumbo jumbo, but it appears that failure means the necessity for a new restoration. Wow!!!

In my practice, I basically have a "no questions asked" policy. If something that I did doesn't last five years, I am doing it again for free. There are no stipulations to this. If they don't ever come back and they show up at 4 years and 11 months and a filling that I did has decay under it, I am doing it again. If there is the porcelain chipped off a crown and they are a professional rock-eater, I don't care; I am doing this again for nothing. I have a lot of confidence in my work. I know that my stuff should last more than five years.

People ask me all the time how long their crown will last. I tell them that I would disappointed if it didn’t last 15 years. And root canals too. If I do an RCT and it fails, I will refer to a specialist and tell them to send me the re-treat bill.

All this being said, I don't do a lot of redoes. I pay for a failed RCT about once every 8 years. This is about a 1% failure rate. I redo about 1 or 2 crowns a year. For me, that is a 4% failure rate. I know some of my stuff is failing but the patient has moved away or hates my guts and doesn't want to come back, so my confidence in my personal study is plus or minus 2%. But, still… If I am 1% failure, then someone else has to be 26% to make the mean 13% (or something like that). Where is this dentist? How is this dentist staying in business?

Is this dentist going with the budget lab that may look good on the surface but uses poor quality porcelain or ovens that are not calibrated? Dare I say, shipping them overseas (and I am not saying this is bad, I am just saying) where there is not much oversight? Where is the dentist with a 19% failure rate on his RCT? The endodontists say that they have about a 2% failure rate and I have a 2% failure rate. That means someone is working with a 34% failure rate (again, don't check my math). Who is this guy?

I don't know. I just can't imagine a private practice guy running those kinds of failure rates. I can't imagine them making any money or having patients coming back and sending their friends. I have a hard enough time getting my patients to come back and send their friends here. You know who keeps coming back? The professional rock-eater.

Anyway, something to think about.

Have a great weekend.



Lilya said...

Hi John,

I will answer your question about where all the failure rates come from. I am sure you are a great dentist, and do your RCTs well, using all the right protocols. Sadly, there are a lot of dental offices in this country that are known as mills. They accept every insurance under the sky, may of which pay very little for RCT and therefore these offices plow through these RCTS very quickly, often without a rubber damn and gutta percha fills that are often very short of the apex. I see many patients come into my practice with PAPs from RCTs that have been done recently, and it is really upsetting for me to have to inform them the high cost of retreating and saving the tooth at this point.

gatordmd said...


I totally agree with you.
I wanted to say it in the blog but I had felt like I was corporate bashing too much. So I am glad you said it.


Anonymous said...

You say that you can't imagine the dentist that has high crown and RCT failure rates making any money. Well of COURSE they make money - WITH THE RETREAT of a failed composite (crown). and the retreat of the crown (RCT). And the retreat of the failed RCT (extr and implant). If patients think it's just them and not the dentist because the dentist has a really nice demeanor, why wouldn't they trust enough to keep coming back?

There's LOTS of money in less than optimal dentistry.


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