Dr. Mommy Dentist

Saturday, November 11, 2006

pulpotomy or pulpectomy, shouldn't you know the difference?

so this happened about a week ago, but i've been waiting until i had the time to jot this down in completion. this was the situation that took place and the conversation that ensued:

got called into the office an hour earlier than my start time to see an emergency. sure, no problem. boss lady pulls me aside and says, "hey, this emerg is actually a classmate of my daughter, he's in a lot of pain. they actually want to see me, but, well, i just can't right now, i don't have the time. just take a look and see what you can do."

"okay, sure no problem."

a brief history, 6 year old boy had a bunch of restorations completed under general anesthesia about 2 weeks ago and was having spontaneous pain in his upper right quadrant. i seat him and take a quick peek. no fistual or parulis, but #54 has a composite resin resto, is very percussion tender (all other teeth WNL) and is slightly mobile and extruding from the socket. my assistant takes a periapcial which showed a deep MO resto on #54 touching the pulp horn, but no evidence of furcation or periapical radiolucency. my diagnosis was pulpal necrosis with resulting acute periapical abscess, pretty much a no-brainer. the only treatment of choice for a non-vital tooth is pulpectomy, but on a primary tooth that treatment has a very limited prognosis due to the tortuous root canal configuration and limited use of obturation materials (can't use gutta percha because it can't resorb during exfoliation). i decided that the best thing to do would be to extract and place a space maintainer. now, i see kids and they're alright, and i do some extractions, but here's a six year old who goes under for treatment and who is already antsy and fidgety in my chair. needless to say, this was not something that i felt comfortable enough to take on. also, the infection was pretty nasty and that would make it even more difficult to freeze him completely. my recommendation was to place him on antibiotics and have him return to have the tooth taken out in about a week, with subsequent placement of a band and loop space maintainer on the #55. i was all ready to go and was just finalizing things with the mom when you-know-who walked in and starts examining my patient, asking him where it hurt, et cetera.

i told her, "i already made my diagnosis, #54 is necrotic and needs to be extracted and we're going to place a space maintainer."

"well, it's better to save the tooth whenever possible. you should try to do that."

the mom says, "just do whatever it is that will guarantee that he will not longer be in pain and that he won't have to come back here again."

boss lady: "oh, sure, baby teeth root canals have a great prognosis."

mom: "but if they take it out, i know there will be a problem with shifting, right? my other son has a space maintainer."

boss lady: "oh, he doesn't need one because the canine and the second baby molar are there, the teeth won't move that much, right dr. mommy?"

me: "actually, i would place a space maintainer, just to be on the safe side."

boss lady: "well, maybe that's what they teach in the states!" chuckles, then exits the room.

at this point i'm fuming, but i know that woman was an acquaintance of hers, so i wasn't going to make her look bad in front of an acquaintance. i go to the ladies room and when i come back she's in the room with the mother again, talking.

"so dr. mommy will go ahead and start that root canal for you." and she indicates she wants to talk to me.

"okay, go ahead and start the pulpotomy on him."

"um, dr. boss, the tooth is necrotic, and you can't do a pulpotomy on a necrotic tooth."

"right, okay, go ahead and start the pulpotomy and bring him back to finish it a nd you'll need formocreosol, too."

"the tooth is necrotic, you use formocreosol for a pulpotomy, which is for a vital tooth. i think the tooth really should be extracted, because it's necrotic and has a very poor prognosis. i want to place him on antibiotics and bring him back for the extraction when the infection has cleared up."

"yeah, but he's in a lot of pain and i told the mom that you would treat him today. and now she wants to save the tooth."

now, i should have told her then and there to fuck off. i should have told her that if she wanted to save the tooth, go ahead and do it herself, good luck. she interefered in my diagnosis and treatment, completely contradicted what i said in front of the patient, and was now ordering me to do her scut-work. but i didn't. i had a kid in pain in my chair who was now prepped for me to start work and a mom who just wanted some relief and a good night's rest. man, was i in a pickle. so i went in there, numbed him up, and opened up #54. pus came up thru my access and the tooth stunk, but surprisingly there was a vital nerve in the palatal canal, which i removed. as expected, he was crying and uncooperative and i felt horrible doing putting the kid through all of that. i wasn't able to modify my access in any way or open it up more because after a while the poor kid just pooped out. there was probably some pulp tissue left, but the tooth was opened just enough to relieve the pressure. i irrigated with some saline, placed cotton in the access, gave some to the mom, telling her to change the cotton several times a day, and put him on 300 mg Pen VK three times a day for a week. when i called later that evening to see how he was feeling, she said he was sleeping for the first time in days. without the boss breathing down my neck behind me, i told her to have the tooth taken out, and she did a few days later. and he WILL be getting a space maintainter.

the best was when i had stayed behind for over an hour after the office closed to see two walk-in emergencies. one of them was a patient who hadn't been there in over two years. #37 was broken, ML cusp sheared off. i told the patient the tooth definitely needed a crown, spoke to him about the treatment, insurance and financing options, et cetera. he was good to go, wanted to book it ASAP. now why is it that i and the other associate had all these openings in our schedules and this guy had to wait three weeks to book the crown with her? even though i was the one who stayed behind and treatment planned it? and she never even said thank you for staying late, even after those emergencies that i stayed behind to see booked hygiene appointments for themselves and their families.

i officially gave them notice last week. and i've never felt better.


  • I would have done the same thing with that tooth as you had planned, but then again, my training is partly American. The decision on how to treat these kind of cases draws on many factors. In the end, it's a deciduous tooth that will be lost anyway. If it's that badly infected, lose it now, minimize potential re-infection, and deal with the space issue.

    The hospital for Sick Kids in Toronto does tons of deciduous endos with ZOE. I even had a pediatric dentist supervisor who used gutta-percha for deciduous endos. The outcome will depend, as usual, on the elimination of infection within the tooth.

    I'm glad you're moving on. This was the Bolton office?

    By Blogger Ameloblast, At Tuesday, November 14, 2006  

  • yeah, that was the place (i love my downtown office and that would never happen there). it wasn't so much that she disagreed with my treatment, i understand everyone has a different way of doing things. and sure, i've seen ZOE pulpectomies completed with pretty favorable outcomes. but that's not something that i would personally do. and if i'm the person who is seeing the patient, they are in my care and it is my decision. don't waltz in there and tell me what _you_ think should be done and then expect me to just go ahead and do it. and doing this all in front of a patient!

    i'm glad to be getting out of there. i'm all for second opinions and bouncing ideas around, but i'm no longer a dental student, haven't been in a while, and i don't appreciate being made felt like one.

    By Blogger Dr. Mommy, D.D.S., At Tuesday, November 14, 2006  

  • It was maybe more of a merengue than a waltz...just kidding.

    Any luck finding a new office?

    By Blogger Ameloblast, At Wednesday, November 15, 2006  

  • hi,

    i never knew one dentist could interfere with the diagnosis and tx planning of another dentist's patient. and that she could pop into the room and check on the patient before you dismiss him


    By Anonymous viv, At Saturday, November 18, 2006  

  • I would have done the same thing you wanted to do with that tooth.

    I am so glad to hear that you gave notice! Boss lady sounded simply unbearable!!!

    By Blogger MomEtc., At Monday, November 20, 2006  

  • Dear Dr. Mommy,

    I am a designer who works on projects to benefit people with disabilities. My current project involves designing a mouth piece for painting; used by mouth painters. I am looking for possible non-toxic materials and processes to fabricate this product so that it is safe to be used with the mouth and dentures came to my mind. Is it possible to use this process to mold my product? What is the process, material and costs like?
    More details of this project can be viewed at my blog: http://www.woogleworks.blogspot.com/

    Looking forward to hearing more from you.

    Best regards,
    +Wai Lam.

    By Blogger Woogle, At Tuesday, November 28, 2006  

  • Just to drop by and say hi. I am a 4th year dental student in Australia. I enjoy reading your blog.

    By Blogger padi_friends, At Wednesday, November 29, 2006  

  • I am a Board certified pediatric dentist who just happened to read your blog. The space maintainer is NOT indicated when you ext. first primary molar and the six year molar is in occlusion. Kid should be about age 7 or after the complete eruption of a six year molar. The space loss is NOT clinically significant at that stage of the game. Pulpectomies are successful in kids and there are many articles to support that, even in necrotic teeth. The academy, however, supports and leaves the tx. for primary second molars. Vitapex filler is HIGHLY successful in most cases and there is an evidence against ZOE. In your situation I would have ext. the tooth though and left it along without a spacer.

    By Blogger Anonymous, At Wednesday, August 20, 2008  

  • I am a Board certified pediatric dentist and a Board certified orthodontist. In my past experience, I have seen plenty of children lose space after the loss of their first primary molars. What you have to look at is the patient's facial type. If the patient is brachycephalic (strong masseter, short face), they will not lose space. But if they are dolichocephalic (long face, open bite) or sometimes mesiocephalic, they will definitely lose space.In your situation, I would have ext. the tooth and depending on the facial type - evaluate for a spacer.

    By Anonymous Anonymous, At Wednesday, August 05, 2009  

  • I totally agree with saving the tooth whenever POSSIBLE. I would've done a pulpectomy and used Vitapex as a filler, it doesn't impair resorption and it neutralizes the infection. I had a pretty similar case a year ago, necrotic #85 very mobil; antibiotics for a week, since there wasn't any mobility or acute symptoms, I did a pulpectomy w/vitapex and restored with stainless steel crowns (school protocol). Worked great..

    By Anonymous Anonymous, At Wednesday, December 01, 2010  

  • Well i am a pedodontist from india, i too agree on saving the tooth when ever possible, i too have come across sane condition,and i went for pulpectomy,with good result, for a 6 yr old space maintainer is not recommended at tat early age,by the age of 7 or 8 years u can surely plan for it....but thanks for sharing it

    By Blogger Life Moments For Eternity, At Saturday, July 23, 2011  

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