The Story #4: The Tooth Root Connection

I’ve been plagued with problem teeth ever since my first visit to the dentist when I was six. I had seven cavities. All were filled with silver (mercury) amalgam fillings. My filled teeth got cavities under the fillings, so the dentist would replace the old fillings with new deeper fillings. I recall there were four levels of fillings, and I swear it seemed like at least half my teeth were each drilled over and over four times. I remember nearly gagging on the silver chunks of amalgam that shot out from the tooth and landed on my tongue as the dentist drilled. This took place during the time dentists still used the adjacent swirling water spittoons. Most of my amalgam fillings have long since been replaced with crowns and bridges. But even some of the crowned teeth later needed root canals, so a couple of molars still sport metal fillings.

June 15, 2004. I needed to replace the bridge covering my lower left molars #18-20 because the post anchoring #20, a premolar, had come out. From the notes in my dental record, I was experiencing “a bad taste” and discomfort when chewing. As part of the overall bridge prep work, the post canal was irrigated with Perioguard before being re-cemented, then covered with the temporary bridge.

The next day, I was in what I consider excruciating pain. I wanted the tooth pulled. To me, there is little more irritating than being in so much pain that you just want to be shot and put out of your misery and have someone look at you like you’re insane and say, “But I don’t see anything.” I believe we see what we want to see without regard to truth. Dentists don’t make money extracting teeth. That’s why their protocol mandates doing everything possible to save the tooth – even a root canalled tooth – before they’ll write the referral to an oral surgeon required for tooth extraction. Someone please tell me. When did my teeth get more rights than me? I never got the memo.

Notes from my visit with Dr. Eric Forsbergh stated that magnified examination of the surfaces of the teeth showed no apparent sign of distress. It was surmised that the previous day’s post prep trauma aggravated the nerve or that an abscess was beginning to form. I’d endured enough root canals and problems with previously root canalled teeth to know that infection from the tip of the tooth root was infecting the pulp chamber. Infected pulp is not visible on an x-ray.

Dr. Forsbergh recommended that Dr. Jeffrey Thorpe, an endodontist at The Reston Dental Arts Center, evaluate the subject teeth, which had already undergone root canals. Working under the auspices of the “save the tooth at all costs” axiom, many dentists leave it up to an endodontist to refer patients to oral surgeons. Dr. Thorpe wrote a referral for Dr. Henry Zussman, an oral surgeon, to have the teeth extracted. When I reached Dr. Zussman’s office, I was told that a Dr. Jonathan Park would see me after he completed another scheduled surgery. That surgery experienced complications. My three hour wait in pain seemed like an eternity. I can’t understand why one of these dental experts wouldn’t give me a shot of Novocain to dull the pain while I waited. Nonetheless, I was relieved that I was able to get a same day appointment.

Because both teeth (#18 and #20) had had root canals at some point, both extractions were difficult. Root canalled teeth become brittle and break into pieces during extraction. I asked Dr. Park if I could keep the remnants of the extracted teeth. I thought maybe they held clues to my illness, and I could get them looked at under a high powered microscope. He refused perhaps because the blood stained remnants were considered a biohazard.

June 24, 2004. Oral surgery follow up visit with Dr. Park. I arrived at my appointment still grateful that Dr. Park had squeezed me into his schedule for oral surgery on the 15th. A tooth (#21) adjacent to the extracted teeth had started to become inflamed, and I wanted Dr. Park to take a look at it. I thought maybe I was only feeling referred pain from the adjacent traumatized site, but then again, maybe this tooth was also infected and on the verge of exploding. If possible, I wanted to avoid a repeat of the previous emergency situation.

When Dr. Park entered the examination room, he looked like he had just stepped out of surgery. His mask was covering his mouth, and he kept it that way during my entire follow up visit. He seemed nervous or anxious, reluctant to move from his stance a few feet away from me. When he examined the extraction site, he moved only one foot forward as he leaned to peer into my mouth. “Looks fine. Everything looks fine,” he said. I asked him to examine the adjacent tooth. “It’s fine,” he said and raised one hand in a reassuring manner. He hadn’t moved from his stance a few feet away. His actions were the epitome of what I would consider the classic jittery jig someone does when they’re not telling something they know. He was the cat that swallowed the canary.

I told him Dr. Forsbergh, my dentist, was encouraging me to get implants. I wanted to know how long he thought it would take the extraction site to heal enough for implants. “Oh, don’t get implants,” Dr. Park said. “I don’t recommend implants.” When I asked why, he realized that I knew he knew something he wasn’t telling me. And that something had to do with what he found on those teeth remnants he wouldn’t let me take. Aside from his credentials as an oral surgeon, Park had an M.D. and had interned in an infectious diseases specialist’s office.

“Look,” he said. “I don’t practice in that area anymore, and it’s inappropriate for me to discuss it.” He told me I needed to see an infectious diseases specialist and dictated specific things to request. These included a bronchoalveolar lavage (used in the diagnosis of pulmonary infections), a CT scan of the chest, blood and sputum cultures. I asked him to please recommend a specialist, and he gave me the name of Dr. Donald Poretz in Annandale, Virginia. Dr. Park said he interned with Dr. Poretz for a short while many years ago. So long ago, he said, not to be surprised if Dr. Poretz does not remember him. I called Dr. Poretz’s office for an appointment that afternoon.

The next day the tooth adjacent to the extraction site, the one I asked Dr. Park to examine, started to throb like a tooth does when it’s beginning to abscess. It felt like someone was squeezing a shrunken fist tightly around the inflamed tooth. That was a Friday. The earliest appointment I could get with the dentist was the following Tuesday.

June 29, 2004. Appointment with Dr. Dillon regarding tooth #21. My regular dentist, Dr. Forsbergh, was not scheduled to work at the time of my emergency appointment, so I scheduled to see Dr. Dillon. I arrived at the Reston Dental Arts Center 15 minutes prior to my 11:30 a.m. appointment. Two x-rays were taken while I waited 1 1/4 hours because I was told Dr. Forsbergh insisted he examine the tooth himself. Whether this was the case or, upon examination and not “seeing” any surface decay, Dr. Dillon felt it would be better if Dr. Forsbergh came in, I don’t know. Dr. Forsbergh said the x-rays showed nothing and that the enamel was intact. He referred me to Dr. Wayne Dollard, an endodontist downstairs within the same facility. After performing a cold sensitivity test with ice on the tooth and the surrounding teeth and gums, Dr. Dollard said it was obvious to him I needed a root canal.

Dr. Dollard performed an emergency root canal on the tooth. Once he drilled into the tooth, he verbally confirmed that the tooth nerve was dead. He surmised the nerve was dead not from a cavity, but from the trauma caused by the abrasion needed to adhere the anterior resin filling to the surface of the tooth near the gum line. He said roughing the area caused a hairline fracture that, over time, allowed the root to deteriorate. He said because the nerve damage was in the pulp of the tooth, it would not show on an x-ray. He told me that most dentists don’t know you can’t see tooth pulp on an x-ray.

I had heard the same thing from dental assistants who had worked with oral surgeons. They told me that dentists aren’t used to looking at the root of the tooth on an x-ray and hence can’t discern abscesses. They said dentists are oriented to looking for decay coming from the top or side of the tooth.

Over the next few weeks, an exostosis (a benign bony growth) protruded from the gum beneath the extraction site for premolar #20. This growth, a bone spicule, was in the same area in which I had had periapical surgery in the 1980s by Dr. Alan Peiken to clean out infection left around the tip of a root canalled tooth. The ballooning of my lower left cheek then from the abscess made it appear as an animated portrayal of tongue-in-cheek humor.

Because I was still experiencing discomfort in the gum area of my lower left jaw after over two months since the extractions, Dr. Forsbergh referred me for evaluation to periodontist Dr. Nicholas Ilchyshyn. Dr. Ilchyshyn saw nothing that would be causing discomfort. In fact, he found that I was an excellent candidate for implants. After an overview of the implant process, he took an impression of my upper and lower teeth and provided a cost estimate for the implants and crowns he thought I needed. The estimate came to $8,600. A bit hefty for the chronically ill, unemployed — never mind that, to me, my gums were inflamed.

On July 13, 2004, I saw Dr. Allan Morrison, an associate of the infectious diseases specialist to which Dr. Park had referred me. I was told by staff that Dr. Poretz was now engaged in outside activities and saw patients rarely. I told Dr. Morrison about Dr. Park’s insistence that I not get dental implants. Without further information about Park’s concern, Dr. Morrison said he felt there was nothing he could do with that statement. Attempts to get the two doctors to speak with one another proved futile.

I told Dr. Morrison that I suspected at least part of my deteriorating health was due to inadvertently inhaling mold spores while cloroxing fungus stained ductwork in my utility room. Due to the skeptical response from other physicians at the notion, I brought, but kept in the car, proof in the form of a dried section of molded pink HVAC insulation that had been sealed in two large plastic bags for over a year. I intended the sample to be used only if necessary to show the type of mold I may have inhaled as it left a distinctive pattern similar to molds I’d seen in photos on the internet. I wouldn’t have brought it anywhere if I believed that the substance was still viable and toxic.

Dr. Morrison said he wanted to see the mold sample. After I retrieved the sample, he suggested testing the mold for identification. He then opened the baggies and with a cotton-tipped swab rubbed what had become, in essence, ashes on the insulation hence smearing the substance so that it was no longer recognizable. Although Dr. Morrison’s progress notes reference obtaining a swab of the black mold sample from insulation for fungal smear and culture, the swab was labeled a skin culture and sent to Quest Diagnostics for testing. Not surprisingly, partial test results reported two days later on July 15, 2003 and the final report issued three weeks later showed no fungal elements. (I didn’t expect dead matter to test positively.)

At my request, serum was drawn to test for H. capsulatum antigen on July 13th. The serum was sent on July 14th and received at MiraVista Diagnostics July 16th. According to the report, the serum tested negative the same day. I thought it took weeks for a fungus culture to grow. In fact, sputum cultures for fungus and myco bacterium tuberculosis can take from six to eight weeks. It seemed almost no lab technicians were allowing enough time for fungal cultures to grow. Knowing how easily test results can be negated by sample mishandling and temperature fluctuations, I wondered about the reliability of lab results. Not that it would have made much difference in this case anyway given that, according to Dr. Morrison’s notes, I had been taking the anti-fungal Sporanox for a week and a half prior to the blood draw.

Dr. Morrison also drew blood for a complete blood count and serum tests for hepatitis and prolactin. All results were within normal limits. The prolactin test was prompted by recent inappropriate lactation I was experiencing. This condition, called galactorrhea, is relatively common in approximately 25 percent of women. Among its numerous causes are stress, exercise, sleep, hormones, various medications as well as numerous diseases and conditions.

During the examination, and as indicated in his progress notes, Dr. Morrison heard lung crackles in my left infrascapular region which did not clear with coughing. He ordered an MRI scan of the lungs due to the abnormal left lung exam and chronic dry cough.

Dr. Morrison’s office assistant/insurance liaison was unable to convince my medical insurer, Cigna, to approve an MRI. Cigna did, however, approve a CT scan of the thorax. My faxed copy of the pre-authorization notification for the CT scan from MedSolutions, which handled such requests for Cigna, showed the approved procedure as “CT scan, thorax; w/o contrast, then w/contrast and further sections” with the appropriate CPT code 71270. The notification’s ICD9 diagnosis code 793.0 that supports the medical necessity, on the other hand, proved problematic.

ICD-9-CM Diagnosis 793.0 is a specific code to indicate nonspecific abnormal findings of skull and head. ICD-9-CM Diagnosis 793.1 is a specific code to indicate nonspecific abnormal findings of the lung field. Perhaps no one noticed the discrepancy in the pre-authorization notification at the time, but after getting my CT scan of the lungs on July 20, 2004, I was informed by Dr. Morrison’s office staff that the doctor also wanted me to get a CT scan of the head.

It took a couple of tries to get the pre-authorization notification from MedSolutions correct for the head scan as I received a couple of different faxed approval forms. One dated August 12, 2004 listed the CPT code as 70486 “CT scan, maxillofacial area w/o contrast” and the ICD9 code as 784.0 for headache. Another faxed on August 25, 2004 listed the CPT code as 70470 “CT scan, head/brain; w/o contrast, then w/contrast” and the ICD9 code as sinusitis, chronic maxillary.

It may have been the CT scan technician’s concern that an MRI rather than a CT scan seemed more appropriate for detecting head abnormalities that prompted him to speak with me prior to taking the scan. Then again, he might have just been trying to get a better handle on the doctor’s concern and hence, on which area of the brain he should focus.

Dr. Jerome Groopman writes in his book How Doctors Think
about radiologists and the daunting volume of films each is called on to analyze daily. A CT scan or MRI generates a multitude of images, and the radiologist has to select the key images to analyze from this multitude. Radiologists are expected to look at and analyze images very quickly, Groopman writes. In fact, he says, conclusions from first impressions or “gestalt” are supposed to be the mark of good training much like shooting from the hip is prized among ER doctors. Under this scenario in which radiologists are expected to draw conclusions within seconds of viewing an image, he concludes, there are admitted missed important findings. Of the many scans taken, this was the only time a scan technician spoke with me. I suspect such action is unorthodox and even frowned upon within the industry.

The August 27, 2004 report from Fairfax Radiological Consultants titled “CT SCAN HEAD WITH AND WITHOUT CONTRAST” reported a finding of a 2 mm microadenoma on the right side of the pituitary gland. I was referred to endocrinologist Dr. Frank R. Crantz for further evaluation.

Oct. 13, 2004 Dr. Crantz called for an MRI scan of the pituitary to more definitively determine whether I, in fact, had a pituitary microadenoma. The MRI performed on Oct. 15, 2004 found no microadenoma present. I’m still confused about why doctors considered the MRI negative finding the definitive diagnosis since research indicates microadenomas may not show up on brain MRIs. In fact, patients suspicious for pituitary disease are encouraged to get blood and urinary hormone levels checked by technicians specially trained in pituitary testing due to the complexity involved in measuring pituitary hormones. All I know is I still have pus oozing from pores in my scalp as draining inflammation reduces swelling in the periphery of my head. I also have issues with stunted growth, glucose and calcium metabolism, hypo- or euthyroidism, an hormone imbalance and other symptoms that could be indicative of pituitary or some other disease. Why is it that doctors like to repeat tests with abnormal findings until the finding falls within normal limits? What makes the last negative test result the correct diagnosis?

In his report, Dr. Crantz wrote: “I feel that the patient’s galactorrhea is most likely the result of her therapy with Prozac. Prozac is a known pharmacologic cause of prolactin abnormalties and galactorrhea.” I stopped taking the drug when Dr. Crantz told me that, in his opinion, it was causing some of my health problems. The galactorrhea ceased until I started taking Tagamet (cimetidine) regularly rather than Zantac. Cimetidine, I found, is also a known cause of galactorrhea.

Dr. Crantz’ office wouldn’t tell me by phone or fax me the results of the ordered prolactin test or MRI. I had to come into Dr. Crantz’ office and pay $90 for a five minute meeting that culminated in the doctor’s telling me the test results. “Negative,” he said as he handed me a copy of the report. The initial meeting and brief exam was $250 plus $76 for the prolactin test. “That’s it?” I asked, wondering why, given all of my endocrine system related ailments, there was nothing else he was planning on doing to help me get well. “What can I do?” he said. “I’m only an endocrinologist.”

To say hindsight is 20/20 is an understatement. I never followed up with Dr. Morrison on either the CT scan of the lungs nor on my request for a bronchoalveolar lavage. At the July 13, 2004 initial consultation, Dr. Morrison advised postponing the discussion on lavage, an invasive procedure with risks, until after we obtained the results from radiology. When we met again on Sept. 28, 2004, the conversation centered around the finding of a pituitary microadenoma, which Dr. Morrison felt would best be handled by an endocrinologist. Still, you’d think he might have noticed in his write-up of my visits that there is no mention of ordering a CT scan of the head. It also doesn’t mention receipt of the results of the CT scan of the thorax, which he did order. In his Sept. 28, 2004 report, he wrote: “…I do not see an antibiotic-responsive lesion at this juncture. Thus, there is no needed follow-up through this office.” To me, he seemed relieved to be handing me off to another specialist.

There’s something telling in Dr. Morrison’s conclusion that his services were no longer needed because there was no need for him to write a prescription for an antibiotic. Dr. Morrison’s note makes it sound like all that doctors do is prescribe broad spectrum antibiotics. The notion is quite incongruous to the statements I heard his associate, Dr. Poretz, former president of the Infectious Diseases Society of America, make on NPR’s The Diane Rehm Show. Dr. Poretz was lamenting the spread of both community-based and hospital-acquired antibiotic-resistant MRSA infection and was advising patients to make sure their doctors did a nasal swab culture to test for staph infection.

Dr. Poretz said he’d been seeing increasing numbers of MRSA infected patients in his private practice in Fairfax, Virginia with the USA300 mutation, which causes virulent skin infection boils. While much attention has focused on hospitals as the source of infection, Dr. Poretz alluded to the growing incidence of community-acquired staph infections. By culturing patients upon arrival, during their hospital stay and upon discharge, the University of Pittsburgh Medical Center determined that only 1-2% of patients with staph infections actually acquired the infection while in the hospital. Many who have the organism, don’t know and show no outward signs of infection. The infection goes undetected in these carriers, who spread disease.

Perhaps because Virginia recently made reporting cases of staph infection mandatory, doctors are reluctant to test for it. After all, no test, no results, no paperwork to file. Perhaps with its seemingly limitless ability to cure whatever was ailing the patient, the broad spectrum antibiotic negated the need for doctors to look for visible signs of infection on patients’ skin. Perhaps doctors forgot what to look for, or they just stopped looking once it was no longer necessary for patients to undress to be examined.

~ by doctorblue on November 12, 2008.