A bridge over “the great divide”

Aug. 1, 2007
Dr. Mounce, the title of your recent article, “Warm carrier-based obturation: The great divide” (January DE®, Page 56), begs the question: who created this great divide, and why has it perpetuated? As an endodontist in full-time practice for 25 years, having employed Thermafil as my exclusive obturation method (in mature teeth) for the last 12 of those, I feel singularly qualified to respond to that and other statements in your column.

Dr. Mounce, the title of your recent article, “Warm carrier-based obturation: The great divide” (January DE®, Page 56), begs the question: who created this great divide, and why has it perpetuated? As an endodontist in full-time practice for 25 years, having employed Thermafil as my exclusive obturation method (in mature teeth) for the last 12 of those, I feel singularly qualified to respond to that and other statements in your column.

Introduced almost 20 years ago, the early carriers (stainless steel and titanium) quickly garnered disdain among specialists because of the abuse of the technique. Inadequate preparation of the canals and the subsequent stripping of the gutta percha from the carriers precipitated the failures seen. Retreatment of these cases was akin to removal of a separated instrument, with all the challenges and pitfalls associated with that procedure. The transition from metal to plastic carriers, in concert with rotary NiTi tapered canal preparations, alleviated most of the technical shortcomings. Unfortunately, the previously justified bias against the material has persisted until present day. Dental implants, posterior composites, and apex locators, to name a few, were afforded the opportunity to refine themselves and gain acceptance based on their previous successes and failures. Why has carrier-based obturation (CBO) been denied the same degree of acceptance after its logical evolution?

When first introduced, endodontists forecasted a decline in referrals because of the appeal of CBO to general dentists. This unsubstantiated concern coupled with the early failures of the technique bolstered the specialists to pass judgment against its use. That opinion is still held today, passed from mentor to student, but the message is being diluted by conflicting experiences once the student has commenced clinical practice. The ability to obturate a canal with the same simplicity as placing a file to working length has great appeal to a doctor who might not otherwise attempt a thermoplastisized technique. Tapered rotary preparation, essential to correct carrier placement, became widespread in the early 1990s, and bridged the disparity between the instrumentation and obturation phases of treatment. This may have been what prompted Dr. Christensen to state that “this concept probably provides better patient service” referencing an access-to-care issue. Individuals, because of physical or geographical constraints, may elect to have a tooth extracted rather than seek treatment at a remote specialist location. They are now afforded a solution that is amenable to patient and doctor alike. Unfortunately “better service” may be misconstrued by some to read “greater success” but, as you have stated, “there is no clear and statistically significant superiority of any method of obturation.”

There are still nuances that require correction; however, most mishaps are the result of inexperienced operators versus inadequacies of the material. My mantra to my students has been, “It is not the technique but the technician that is usually at fault.” Dr. Eric Hovland, a past president of the AAE, appealed to the membership some years back to bridge the gap between the specialist and the general dentist through education. Many companies accepted that mandate and offered hands-on instruction with their respective products. While I cannot comment on other vendors, the presenters for Dentsply Tulsa are, by and large, endodontists in full-time practice with a zeal for teaching and a genuine concern for the education of the participant. To reduce them to “merely advocates with commercial interests” demeans their motivation and questions their integrity.

Your article is not without merit, as it provides the perfect segue for a course to be offered by Dentsply Tulsa in the spring of 2007. It is a Thermafil obturation course exclusively for endodontists, designed to expose them to the correct techniques of carrier obturation and retreatment. It is not meant to convert the specialists; rather, the goal is to present evidence-based research in conjunction with the opportunity to experience the material hands-on in a group of their peers. Armed with this, the endodontist who attends can formulate a more informed opinion. I cordially extend my personal invitation to you.

Stephen P. Niemczyk, DMD, Private practice, Drexel Hill, Pa.
Director, Endodontic Microsurgery, Harvard University School of Dental Medicine, Director, Endodontic Microsurgery, Albert Einstein Medical Center, Dental Division

Response to “Editor’s Note”

Dear Joe, I just wanted to make a comment about your recent article in February DE’s Editor’s Note (Page 10). I am a solo practicing periodontist and I have to admit I found your comments very offensive when you stated that you found your relationship with your referring specialists frustrating and that “many” patients came back to your office disappointed in how they were treated in the specialist’s office.

I can tell you first hand that during the past 15 years we have made it our practice to try to treat our patients with such wonderful service and caring attitude that our goal is for those patients to go back to their GPs saying, “If I have to go somewhere, please send me back there!” I can’t imagine any specialists who want their patients to return to their GPs with anything but a positive experience. Otherwise, how could they make a living? Most periodontists “survive” by general dentists’ referrals, so how do you think we could stay in business if your statements are accurate? I think the undertone that GPs should “think twice” before sending patients to specialists is the wrong message for your readers.

When I read this article, I found myself feeling like you were trying to sell general dentists on keeping all of their patients and only sending out the “most complicated” ones. One of the concerns we have in perio is that we have been getting patients referred so much later in their disease process than ever before. This makes the treatment choices so limited that it seems like we suggest implants over conventional periodontics, which “still work.” We can do more in our specialty to save teeth than we ever have been able to before.

Our biggest challenge is getting dentists to recognize when their patients are not stable and need additional care. There is plenty of dentistry to go around and patients are the ones who get the wrong end of the deal when they are kept too long in the general dentist’s office. It makes us all look bad when patients ask, “How long has this disease been going on, Doctor?” Let’s strive together to improve our ability to work together in diagnosing our patients’ diseases in a timely manner for the improvement of their dental health.

One thing that is still a national concern is that less than 20 percent of dentists probe patients regularly! How can you diagnose someone’s condition when you don’t even do the minimum to find it? I enjoy working with lots of very good dentists, ones who belong to a continuing-education study club with me. We pride ourselves at treating patients with the highest quality of care available. I would like to see some type of rebuttal to my comments in DE. I think you owe it to every hard-working specialist in the country who try every day to make their general dentists’ patients feel wonderful about dentistry and to encourage them to return to their general dentist when their disease is more stable. I am extremely concerned that there is a national push for doing as much dentistry in your offices as possible, and to only use the specialist as a last resort. Whatever happened to “teamwork” and caring for the patient “together?” I look forward to your comments, because I truly feel my concerns and comments reflect those of many specialists across this country.

Mark Sutor, DDS, Bloomington, Ind.

The remarks in my February 2007 Editor’s Note were anecdotal experiences in my practice. My patients were reluctant to go to another office for treatment. Over time, they had developed a trust relationship with my team and me. Going to another office requires them to build a trust relationship with that dentist and his or her staff. That simply does not always happen, for whatever reason.
Dr. Joe Blaes, Editor

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