Friday, June 12, 2015

This Is Something You Ought to Know...

Hey. 

I am 46 years old and kind of starting to feel it—physically and emotionally. For example, I dove for a baseball at my 11-year-old’s baseball practice (trying to show off) and I have been in physical therapy for almost four months. I’m now just able to put my elbow above my shoulder. 

But at work I feel it, too. I am getting a bit crotchety. I like what I like and I don’t want to change it. Even it saves me money or it is faster or better. I don’t want to change.

But there are some things that you have to know. I am not saying you have to change, but I want to tell you and then let you make the decision. On a side note: I don’t know if you know me very well, but I am very conservative. I think less is more and I want to think that most AGD dentists are not over-treaters. 

Lately, I have seen a rash of patients wanting second opinions, because they don’t have any trust in their insurance dentist (imagine that!!). Dentists who see a small DO and tell the patient that he or she needs a build-up and crown. One patient came in and was told that she needed to replace the dental work that I did three years ago with a couple of crowns. (Now they stepped over the line…my work?!!!!).

So now you know that I am not one to see a broken tooth and tell someone, “You need a post core crown,” like I am a robot. For some dentists, that is all they say, all day long. “You need a post core crown, post core crown, post core crown, post core crown…” It kind of just rolls off their tongue.  

Also in my old age, I am starting to read about dentistry more. Of course I like AGD Impact magazine, but I find myself reading General Dentistry with a lot of interest.  

I want to know the science. I want to know the research. 

Along with the above magazines, I really like the magazine called Operative Dentistry. I even joined the Academy of Operative Dentistry. These are my kind of weird people.  

I am starting to write authors of articles. I ask questions.  In my discussions with people, I came across the following YouTube clip:


This video is by a scientist from the University of North Carolina School of Dentistry and discusses the state of the science on deep caries removal. The guy is pretty good, but it is 18 minutes long. Some of you will eat it up, and others may just want the bullet points. Well, if you want bullet points, I am your man. 

If you have a deep caries lesion, what do you do? 

If the tooth is showing symptoms of reversible pulpits, that is temp sensitivity that goes away in a normal amount of time. If the tooth doesn’t hurt on biting, if there is no signs of PAP, and if the tooth does not hurt spontaneously, you do an indirect pulp cap. 

You remember what this is, don’t you? This is one of the things they used to teach us in school that as soon as some of us walked out the door we never did again. Remember, basically, you take out decay until you get it all or feel like you are going to get a pulp exposure. 

So that means it doesn’t matter what it looks like on the X-ray. It doesn’t matter that it looks like it is in the pulp. Take the decay out, put a glass ionomer on the deep part, and do the filling. 

Wait, do a filling right away? 

Oh, yeah, that is the second part of video. He talks about the results—the hard numbers. (In school we used to put in CaOH, add some IRM in there, and then bring them back six months later to do the filling!) In the lecture, he talks about how going into a tooth a second time increases the failure rate fivefold. 

If you do it all in one visit the failure rate is 1 PERCENT!!!! If you get all of the decay and do the filling, it’s a 1 percent failure rate. If you leave some decay, put a liner on the pulpal floor, and then do the filling, it’s a 1 percent failure rate. If you get a pulp exposure, the failure increases, but not by much. 

Now, I hadn’t seen this science until about three months ago, but I have been doing it in my practice for, well, my whole career. I use to say to the patient that you might need a RCT. Now I don’t even mention RCT to them. I am that confident. 

So needless to say, we do A LOT of fillings (I looked it up, and in 2014 I did 898 fillings), and we do A LOT of very, very deep fillings. And, by my recollection (which is suspect), we get less than a 1 percent failure rate. I would say after all those posterior restorations, I get two or three a year that have pain and need a RCT.  

The proof is in the pudding. Science and all the research agrees. I have almost 20 years of personal research in my office. I have thousands of satisfied customers.

I just thought you should know.  




Let me know if you are doing this. Let me know if you are having success. Let me know if this is not something you would consider (what the heck … it is anonymous).  

See you next month,

John Gammichia, DMD, FAGD



7 comments:

Inna Dunker said...

Do you really believe performing an indirect pulp cap is a long term solution? Thanks for sharing!

Lilya Horowitz said...

This is what I try to do also! I did not know however that failure potential increases with re-entry so thank you for posting this video!

Andy Alas, D.D.S. said...

John,

Great blog!

Does the same hold true for crown preps or decay under old crowns?

Andy Alas, D.D.S.

Jennifer Davies said...

I would love to see a dentist as thorough as you. It's true, I think some professionals get caught in their ways. It can be easy to recommend something to every patient, but sometimes you need to do more research and make a specific suggestion. Your patients will be extremely grateful. http://www.nwidentist.com/

Anonymous said...

Great post !!
I am also a conservative practioner. Agree with you 100%

Anonymous said...

I AM 82 YEARS OLD...WORKED IN A PRISON FOR 8 WEEKS RECENTLY...DID A LOT OF THAT STUFF THERE....JUST ABOUT AS YOU SAID. I HAVE BEEN DOING THESE FOR ALL MY LIFE..i USE THE SAME DIAGNOSTIC CRITERIA AND SAME TREATMENT. FILL IT NOW.......I JUST DO NOT GET TO SEE MANY PATIENTS WITH THAT KIND OF DECAY ANY MORE...NOT EVEN IN SOME OF THE FREE DENTAL CLINICS WHERE I HAVE VOLUNTEERED...DENTAL DISEASE IS BEING ELIMINATED...NOW WHAT DO ALL THOSE DENTISTS COMING OUT OF DENTAL SCHOOL GOING TO DO TO MAKE A LIVING? THE SCHOOLS KEEP EXPANDING...KEEP CHURNING OUT DENTISTS IN COMMUNITIES THAT DO NOT HAVE MUCH DEMAND... THINGS HAVE CHANGED DRAMATICALLY IN THE LAST 15 YEARS. BE AWARE...THAT IS ONE REASON FOR ALL THE OVER TREATMENT THAT IS BEING PROPOSED...THANK GOODNESS THE PUBLIC IS TRANSITIONING INTO BECOMING BETTER DENTAL CONSUMERS....GETTING SECOND AND THIRD OPINIONS. YES, 82 AND STILL WORKING...ACTIVE LICENSE, CURRENT NARCOTICS LICENSE. ETC. JUST CANNOT DISLIKE HELPING PEOPLE WITH KEEPING THEIR SMILES. DENTISTRY AS A PROFESSION IS IN A DEATH SPIRAL. RBA VIRGINIA

alexi said...

Very interesting post thx for this blog!

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