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AUDIO - HSP #242 - Edward Carlson
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VIDEO - HSP #242 - Edward Carlson
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• Creating a practice vision
• Changes in Endodontics in past 25 years (technology, competition, success/failure)
• When to buy/move into new technology
• and more
Edward Carlson, BS, DDS:
• Raised in Utah the son of a Turkey Rancher.
• Attended BYU with a BS in Zoology and minors in Chemistry and English. Degree awarded in 1980.
• Attended West Virginia University for Dental School 1979 to 1983, DDS degree.
• Worked as a general dentist for the IHS in Ft. Duchesne, Utah for four years -- Lt. Commander in USPHS.
• Endodontic training at the VA hospital in Long Beach, California, certificate program 1987-1989.
• Board Certified by American Board of Endodontists 1994, Certificate No. 1000.
• Co-founded The American College of Endodontists, Fellow in International College of Dentists.
• Established Superstition Springs Endodontics in 1999.
• Eagle Scout, awarded Silver Beaver in 2013.
ed.carlson@superendo.com
Superendo.com
Howard: It is a huge, huge honor for me today to be in the office of Dr. Ed Carlson, who is a very distinguished Endodontist in my backyard of, we're in Mesa, which is a suburb of Phoenix. Mesa's what? The fourth largest city in Arizona?
Ed: It may be even increasing a little bit.
Howard: I heard it was the 17th largest city in the United States or something.
Ed: You know it's been a good place to live.
Howard: Ed's just a really good guy, and how many associates do you have right now?
Ed: Right now we have two. We're looking at bringing another one in pretty quickly.
Howard: So you have three. Ed it's an honor for you to be here. You're 61, you're turning 62 this year. We're both short, fat bald guys with four kids. I think the funniest thing Ed ever told me ... tell them the story ... tell them the story where ...
Ed: I was at a dental convention, actually doing pro bono root canals for somebody, and with my back turned a member of the state delegation came up behind me. He actually sent a gal over first, and she started flirting with me, and wanted to know what I was doing when I was done with root canals. I was just ... I had no idea who she was. I was just a little bit flustered. She could tell I was a little flustered, and right then a guy came up from behind, and kissed me on the top of my head, and said, "Man I just love seeing this guy here." I turned around to look, and I had no idea who he was. I know he thought I was Howard.
Howard: The same thing happened to me because you sponsored my first bike race when I started doing tri's. The first race I ever did was a 70 mile Tour de Mesa. I wore your jersey, Super Endo. Three times during the race, someone's coming up behind me yelling, "Ed! Ed!" Because there's this bald guy wearing this 'Super Endo' shirt, so they just know I was the Endodontist Ed. Thank you for ...
Ed: Also a little bit broad shouldered.
Howard: Thank you for supporting that race.
Ed: You bet.
Howard: Before we ... these podcasts are great because they're mostly kids. Everybody that contacts me is under 30. A lot of them are from the dental school right up the street from you, AT Still and Mid Western are huge to these podcast fans. They're multitasking, and I just think it's an honor that you're going to sit there, and spend an hour with them, telling them what you've learned in Endo. Before we jump into Endo, which is a specialty, you were in another specialty, which was public health. Let me read you Ed's bio. Ed was raised in Utah, son of a turkey farmer. There's so many jokes there, that I'm just ... what's your best joke for raised as the son of a turkey farmer.
Ed: Oh, I don't know. They're not as dumb as the guys who raise them.
Howard: They're not as dumb as the guys who raise them. I love that joke. You attended BYU, with a BS in Zoology. Where you thinking about Vet? Was Vet your alternative to Dentistry?
Ed: Well no, at BYU they didn't have a Biology degree. It was either Zoology, or Microbiology, or Chemistry. So I picked Zoology because I didn't like looking through a microscope, ironically enough, because that's what I do all day now.
Howard: Then you have minors in Chemistry and English, then you attended West Virginia dental school. '79 -'83. Then you worked as a general dentist for public health. Public health is one of the 9 specialties. You worked for the Indian Health Service in Fort Duchesne, Utah. Then you were a Lieutenant Commander in the United States Public Health Service. Then you went to Endodontist training in Long Beach, California. Board certified Endodontist, co-foundered the American College of Endodontists, Fellow in International College of Dentists. Then you established Super Springs, Endo. The Eagle Scout awarded Silver Beaver in 2013. I want to start off with, before we jump into Endo. Endo and Implants gets all the attention, but the specialty public health, no one ever talks about. What did you learn from your years of public health? What do you think public health dentists, what is their mission today? A lot of kids might be listening to you right now that are thinking, maybe I might do public health.
Ed: The reason I did public health is because I got in dental school, and one day in a mailbox at school, I received a notice saying all my dental school could be paid for, and I could have a monthly stipend if I agreed to work for the government for a couple of years. I signed up. I had a three year commitment. I ended up working four years. I was on a wonderful little spot in Roosevelt, Utah working with the reservation Ute tribe. I did mostly bottle mouth baby carries. Most of my patients were under 10 years of age, and I learned real quickly I didn't want to be a Pedodontist. I learned the value of fluoridation because they had fluoridation on the reservation, and the Ute's did not drink it. They did not drink the fluoridated water. All the white people in the area did, and none of the white people had carries, but the Indians did. It was a ...
Howard: Why did they not drink the fluoridated water?
Ed: I think they just liked their own source, their own wells wherever they could get it just because it was a traditional way. They are wonderful people. They treated me great. I played on their tribal basketball teams, and softball teams. They'd show me where to go fishing, but they never would take me hunting.
Howard: Why do you think that is?
Ed: I think they didn't want me to find their Elk.
Howard: Well you know it's funny because ...
Ed: It was a great experience.
Howard: You notice that the non fluoridated Indians has greater decay rates than the white people drinking fluoridated water, and race was the first thing that caught my mind. I didn't realize going to UMKC dental school, the hardest requirement to get was your chrome steel crown for your pedo. Every Tuesday who passed away, left money, and they would every Tuesday, a bus would go pick up the 2nd graders, and bring them in. We were all excited to see this fresh load of kids coming in from school, and we'd say, Well do you have a toothbrush? Nope. So you don't brush your teeth? No. Do you floss? Nope. Then you're like okay, I'm going to find my pulpotomy, and you'd take bite wings, and they'd have nothing.
Then I moved, I graduated, and I moved out here to Phoenix. I'm in Phoenix, but they call it Ahwatukee. So I'm in Ahwatukee, and if 5 white kids came in, 2 of them needed a pulpotomy and crown. That made me call the CDC. I can't believe I got out of dental school, and never learned that black people have much better teeth than white people. The guy is like, what are you talking about? I told him the deal, and he was like yeah you went to dental school in Kansas City where the water has been fluoridated, and you live in Phoenix without water fluoridation. I'm just like oh my God. It's just such a ... so you lived through this too.
Ed: Right, and we did the Head Start exams, and 50% of the kids under 5 had baby bottle tooth decay. They were decayed multiple molars and front teeth. I actually wrote a paper that was presented back in Washington D.C. having to do with the incidence of that amount of carries.
Howard: What would you say to a 4th year, or a 3rd year dental student right now who's thinking maybe I'll do a couple of years in public health dentistry?
Ed: I think it's a wonderful experience to give you a chance to see the specialties of dentistry, to increase your skills, to learn how to relate to patients. The first day in public health, I saw things I never saw in dental school. Doing a stainless steel crown on a 3 year old was pretty scary the first time. Then it got very routine. You got to learn how to manage patients, you got to work with staff that were diverse, and they end up paying for education. I think there's a lot to that right now to that too. I think there's a lot of trade offs, because if you agree to go work for the public health, they forgive a lot of your education, and I think it's a chance to give back. You may get bumped back a little bit from where you were ultimately going to live, but in the long run it paid big dividends for me. It helped me decide what specialty I wanted to go to, because I would never have picked Endodontics had it not been for my public health experience.
Howard: Really?
Ed: Really.
Howard: That's interesting. Arizona ... 25% of the state is Indian reservation. I think we're the most Indian reservations of any state. Is that right?
Ed: You know I don't know that statistic, but that's ... that wouldn't surprise me.
Howard: I've heard there's 217 Indian reservations, and Arizona has like 19, but as far as land, a quarter of the state is Indian reservation. They've had huge problems with decay, obesity, diabetes. Do you think that's improved over the last, in your lifetime since working on public health?
Ed: Not that I have seen. It was a terrible problem. Diabetes was a terrible problem with the people that we treated as well. I haven't seen that getting any better. My wife actually has a half sister who is Navajo, and we have contact with them. They still have a lot of the same problems on reservations today ...
Howard: Do you think that is a genetic predisposition?
Ed: I think ...
Howard: [inaudible 00:09:27] many variables, but do you think there is a genetic predisposition?
Ed: I think there's genetic, and I think there's is cultural. I think sometimes when you have younger families, married younger, they don't have the maturity to take care of children. They start feeding them things to help the kids be quiet. I think a lot of things contribute to the dental, and overall health problems that they have.
Howard: In Ahwatukee, I'm across the Guadalupe Indian reservation, which still to this day doesn't have a dental office. A quarter of my practice has always been Guadalupe Indians, and it's very challenging when they bring their patients in the room, and they're pipeting them Mountain Dew in their mouth to a crying child that's screaming from a toothache, and you're like ... and their feeding it Funyuns in my dental office.
Ed: Sure. I took a photograph that was part of my lecture when I presented my paper back in Washington D.C. of a mother that brought her baby in with a bottle full of Coke. Just drinking Coca-Cola.
Howard: That's where I'm so excited about the American Dental Association now is because they never did the marketing when we were young, which would have been television. They weren't on ABC, NBC, CBS. Now social media, now all the dentists are posting all of these memes, and public health. Brush twice a day, pictures of [inaudible 00:10:53], and I'm so excited. The reason I work my Facebook page so hard is because I know these dentists are sharing it, and I think social media might actually making a dent in public health. I wish dentistry would spend a lot more time focusing on public health, and preventing disease, than all the talk about [inaudible 00:11:15].
Now I want to ... this is dentistry uncensored. I want to get to some ...
Ed: You mentioned Facebook. Can I just throw something in here?
Howard: Yeah.
Ed: Facebook is ingenious about the way they just remind you, this is what happened 5 years ago, would you like to post it again? Well I got one of those. 5 years ago, just last week, I had a root canal, and I came in, I'd broke off a cusp of a tooth, and had my partner do it. Halfway through I said, "Stop right there. Hand me a mirror. Go get a camera, and frame this so it looks like I'm doing my own root canal." So it shows the x-ray in the background, from the back of my head with a rubber dam, I'm holding a mirror and I've got the file up inside the tooth. I posted that on my Facebook page, and at the time I was working with some Boy Scouts. The next week I heard one scout say to another scout, "Don't mess with him, he does his own root canals." You're right, you can put a lot of things out there, and it raises eyebrows, gets awareness, draws attention to the individual practices in a way that you just can't advertise any other way.
Howard: Congratulations on the East scout. I grew up with 5 sisters, and about the boy stuff I ever did was in the boy scouts. I mean, I got to go to Cimmeron, New Mexico, and climb mount Philmont. Philmont Scout Ranch. That's just God, that was some of my greatest childhood memories are all boy scout stuff, and then I'd go home back to my 5 sisters playing Barbie dolls.
Ed, let's talk about ... this is dentistry uncensored, let's talk about some of the dark side of Endo. When I grew up in Kansas, everybody did Sargenti paste, and a lot of these kids though graduated from dental school. They were ed-um-ma-cated by sharp Endodontists like you, and then they go get an Associate-ship, and a 60 year old dentist says, "That's bullshit. I've been spinning this paste on there, and it's got para-formaldehyde, it's going to kill all the bugs. They have an almost conspiracies to why, but you know, it's not ever talked about, but I look at the lawsuit deals. In just the last year I've seen 1 million dollar settlements because the N2 Sargenti paste when out the apex and pickled the inferior alveolar nerve, and it was a full blown parasida. Do you ever see Sargenti anymore, or is it completely gone?
Ed: No it's still around. I don't think it's still being actively done in this area very often, but I still see cases that were treated with Sargenti. I see cases that were treated with silver cones, and patients that were treated in other countries, and here locally. I think there are lots of ways to do what we do, and I know that those Endodontists as my school in West Virginia were adamant that gutta percha was the only way you could do things, and I get out, and I see cases that have had Sargenti that have worked for a long time.
Silver cones that have worked for a long time, and I'm not proposing that anybody use those, and do that because the mishaps happen. They're going to happen with anything, but they happen more often with things that you're not taught in dental school. Things that you pick up on a weekend because your uncle Lenny said, "Hey, I saw this on tv, let me do this." I would stick with the tried, and true things. I would only change if you have a very valid reason to change. You don't change just for the ease of doing it, and just to make money.
Howard: Phoenix is a big retirement area. If you're West of the Mississippi ... oh, it's okay, the phones, it's no big deal. If they're Minnesota, North and South Dakota, they retire to Phoenix. If they're East of the Mississippi, they retire to Florida. We have a huge abundance of senior citizens out here, and when you see a silver point Endo, and it's lasted 40 years, does that just reinforce that it doesn't really come down to how you obtrate a tooth, it's how you clean, and shape and disinfect a tooth. That these things just got so cleaned, and disinfected that they worked, or do you think there are other variables involved?
Ed: I think there are a lot of variables. I think number one it begins with doing a good technique, and using good materials. I think silver cone is a good material. When it corrodes, it's anti-bacterial. The corrosion by products of silver sulphate-fides they cause problems themselves, but they don't corrode if the coronal restoration doesn't break down, typically. So if there's something else, a crack in the tooth, or decay underneath the restoration, saliva, moisture gets in, they're going to corrode. Then they're going to have problems, but if they stay protected in their own little mausoleum, if you will, they can stay there a long time. That's what I see.
Howard: Ed, I want to go to a very controversial thing, that I don't think a lot of dentists like to look at objectively. They bring bias to the table. There's a lot of dentists out there that thing these silver fillings lasted twice as long as composites. A lot of people say, oh the silver fillings they break all the teeth, but then a lot of people are saying, well 40 -50 year old people their teeth are breaking regardless. A lot of the amalgam people are saying, I put in these amalgams and they lasted 25 years. I've been putting in a lot of the tooth colored stuff, and 5 or 6 years later they had recurrent decay. It wasn't the type of recurrent decay they saw under amalgam which was a little bit of decay. They're taking out some of these white tooth colored fillings, and they're saying I had to take a number 4 round boar, it was mushy. My specific question to you ... do you think switching from amalgam to tooth colored composite increased your business, the Endo business for the Endodontists around the United States, or not really?
Ed: You know, I guess if I had to say does it? I would say sure, I think the way I look at it, every time a tooth gets worked on, the nerve can get bruised. If work is being done needlessly, and the filling is being taken out just because it's a silver filling. I'm not a fan of that, because I've seen a lot of pulps that have gone bad.
I can share one story with you. I had a patient come to me years ago, she was a nurse. We know sometimes about nurses. She was living on the street with a dentist. The dentist husband, and wife became very good friends with this nurse wife and husband. The nurse and her husband were being transferred to Georgia. She has a mouth full of silver fillings, so she went to her friend the dentist who she trusted and liked, and who I personally know is a good dentist, and said I would like to have all of my silver fillings taken out before I go to Georgia to make sure that I don't have to look for a dentist, and not run into any trouble. I just want to get it done. It's that time in my life, I'd like to have it done.
Over the course of the next week or two, he changed out 12 restorations. Over the next 2 months I did 8 root canals, and none of her teeth were hurting. It ruined their friendship, and she filed a complaint with the board, and I know he didn't do anything wrong. He just worked on the teeth. The restorations look great, but just the fact of working on those pushed those over the edge. Now that doesn't happen all the time. That's a pretty rare case, but I think if a restoration breaks down, and needs to be replaced, boy let's replace it with the newest, and the best stuff we got. Just to take one out ...
Howard: What is the newest, and best stuff we got?
Ed: That's a good question. I'm not a restorative dentist.
Howard: From an Endodontist point of view.
Ed: I can tell you, if it were my back tooth, it would either be gold or amalgam.
Howard: Yeah, all of mine are gold.
Ed: Yeah.
Howard: My boys, I put gold in their mouth. I just don't get the culture. What I can't figure out the most about women is that they'll put gold in their earrings, their rings, their necklace, their ankles, their belly button. I mean they got gold on every appendage of their body, and then say, "Can I put a gold tooth on your second molar," and they're like, "Are you crazy?" I'm looking at her, and she's got like 6 gold things in one ear.
Ed: I know.
Howard: She's the one that can't stand needles either.
Ed: Yeah.
Howard: I just wish we could, maybe if the dental society's got the most rocking hot women to get gold fillings, then maybe if Madonna and Britney Spears, and those girls were all sporting gold crowns maybe it would take off.
Ed: I'm with you. In dental school I had some of my silver fillings replaced, and put in with gold because we needed requirements to graduate. I still have those restorations, and it's been almost 35 years since I graduated.
Howard: I wanted to ask you another ... I'm going to stay with uncomfortable questions.
Ed: Sure.
Howard: A lot of people on the Endo threads on Dental Town, you can see how they're confused. They're like okay, I did it ... I removed the decay, everything's fine. I have a pulp exposure. What's the better way to seal that pulp exposure. Would it be to go down, and do the Endo, and you're sealing it at the bottom of the tooth, or would you seal it right on the place. Some of the old school people say, you know if you put something like calcium hydroxide, which has a real high pH, it's kind of an irritant. It will get the tooth to repair. Other people are saying, well there's this $100 a gram MTA stuff that cost about the same as heroin, or cocaine, and patch that one there. So I just want you to say, she's 25, she was doing an MOD, and she's got a pulp exposure. She's got a pulp exposure. What would you recommend?
Ed: I think there's ... that's a great question. I think there's conservative ways, and there's aggressive ways to treat it, and then there's deciding well what would I do with my tooth. I'm an Endodontist so for my tooth, I'd take the pulp out, and do a root canal. Not everybody's in the category where that's the best decision either, as a patient, or what I'd recommend. I think it's best on the size of the pulpal exposure, and if we think it's curiously involved. If there's decay and bacteria that's very obviously already in the pulp chamber. I think that's an issue. Years ago ...
Howard: Describe that. Most people that are listening, describe that pulp issue more. I mean, how would she know looking?
Ed: If you've got a little pinpoint exposure, and you can take a moist cotton pellet. Don't use a dry one, but you a moist cotton pellet with just some saline, or even tap water. Just put that over the pulp chamber, and hold it with just a little bit of pressure for just a couple of minutes. Take the cotton pellet away. If it's not bleeding, it's red, but it's not bleeding. That's probably a pretty healthy pulp. If it's bleeding, and oozing into that area then there's something still inflamed inside of there, and you have to take out a little bit more.
Well pretty soon, if you take out too much, you could get down to just the pulp stump at the bottom, covering the roots. You can do the same thing at that level. You can do it at any layer where you have good, healthy, non inflamed tissue. If you can stop the bleeding with mild pressure just after 2 or 3 minutes, that's probably healthy pulp. If it keeps oozing, it's not. Well there's a trade off. How far are you going to go down to keep exploring that, and then what's going to be the ultimate restoration. Every pulp that gets drilled into, and even gets close is probably compromised on some level.
You have to decide, is it compromised where I'm going to have to put a crown on this tooth? Now if I have a compromised or questionable pulp, I'm going to have to drill through the crown, or do I take care of that right now, and then put a crown on. If it's just a young kid, and the crown is not anticipated, and you're going to treat it with a conservative restoration. I'd try to repair it. If it's ultimately going to need a crown, I'd probably make that decision to do root canal before I'd put a crown on, and then have to drill through a crown.
Howard: When you have a pulp exposure, how should dentists think about treating a pulp exposure, on say a 20 year old kid, versus a 40 year old kid, versus a 60 year old grandpa?
Ed: Well, I think that my feeling is that the principles are still the same. If it's not inflamed, you probably can get away with a little bit more.
Howard: Do you think a 60 year old man will heal just as well as you know ...
Ed: I think a lot of times they do, because there's a lot of secondary dentin already there, that process is already continued. You may be a little deeper down with that, but I don't have anything wrong with somebody doing a conservative approach, and just repairing that. If they're going to do a build up for a crown, then get to that point, but don't commit to a crown until you give it maybe 10 days, 2 weeks. Make sure it's out of the woods. Maybe a little longer, and then do the crown.
Howard: How would you treat that pulp exposure? What ... would it be calcium hydroxide? Would it be MTA? Would it be ...
Ed: I still like calcium hydroxide.
Howard: Dycal.
Ed: Yeah.
Howard: Is that the brand you use? Dycal?
Ed: Yeah.
Howard: Who makes that?
Ed: I don't know if it's Dentsply?
Howard: Is it Denstply?
Ed: I can't remember. My assistants order all this stuff. They squeeze it out, and put it on a tab for me.
Howard: So still just good ol' Dycal?
Ed: I think that's great.
Howard: Then what do you put over the Dycal.
Ed: Then I remember attending a seminar years ago by Bertolotti.
Howard: Ray Bertolotti. Do you know Ray Bertolotti's wife used to be in the same Catholic nunnery as my sister Mary Kay? Cloistered Carmelite Monk.
Ed: Wow. He got her out.
Howard: He got her out, married her. My sister's still in, but yeah.
Ed: I remember him, what I thought was just him being a heretic years ago, when he said just to protect that, just etch around it, bond it, and there you go. You know, that works a lot. I think again, you protect that little pulp, and you got the decay out. There's no bacteria, it's not inflamed. You build that back up, and put a little insulation over it. I think it's going to work.
Howard: Okay, I wanted to ask you another stressful thing that these kids see. They're taking out an MOD amalgam because it has recurrent decay. They've got the rubber dam on, they got everything all cleaned out. There's a crack on the floor, and they're like, okay I took it out for decay. The patient didn't have any symptoms. Talk to these kids about what ... how was ... what is Ed's mind thinking when you see a crack underneath an amalgam?
Ed: Boy that happens every day just about. I think that's a great question. I think the first thing I always try to think is, well what would I do if it were my tooth? Would I hang on to this, or would I throw in the towel? There's different kinds of cracks. We often will see a crack going over the distal marginal ridge of a lower molar, disappearing down into the distal canal, but not coming up the other side of the pulpal floor. I don't hesitate at all to fill those teeth, and inform the patient that there was a little hairline crack, it doesn't seem like it's spread ...
Howard: Fill it to the filling, or fill it with an Endo Root Canal?
Ed: You know I'm taking this position from a root canal standpoint, so I'm already looking at the pulpal floor. If you're down above the pulp, and you see that hairline crack, and there's no decay, and there's no soft dentin, you know I'd sure be tempted to just shave a little bit of that off, and put a little etch and bond, and try to cover that up. Then put an on layer, a crown over the top of that.
Howard: You wouldn't necessarily go to Endo.
Ed: No. No. If there's not symptoms. No radio-graphic sign that there's a radio-lucency, you can't probe anywhere. The tooth's have been asymptomatic, I would not commit that tooth to Endo.
Howard: What would make you commit the crack to Endo?
Ed: If it had some decay, and you had to keep softening, or chasing that out, and it got down to a pulpal exposure. Then you got into the pulp and you could see where you removed that, the crack was still at the bottom of the tooth. I'd say send this to an Endodontist. Let him look at it with a microscope. Let him find out how extensive that crack is. If that crack goes all the way from the mesial, down into a mesial buckle canal, back up across the pulpal floor into the distal canal, back up the distal wall and across. Those don't have a great overall prognosis. It's sad because a lot of them are asymptomatic.
Howard: What are you thinking when you see a crack, and it's just almost like barely ... I mean almost translucent versus black. I mean sometimes a crack just looks like black pen, and other times it's like tooth colored.
Ed: Yeah I think, I guess I would think that the tooth colored one's probably a little more fresh. Especially if there's not been a restoration in it. I do not like to see teeth with cracks in them with no restoration, but now have symptoms of pulpal problems, because that crack is extended in the pulp somehow, and if it's that extensive, and that small, you can't see these on an x-ray. You can't see them to the extent, all the way they go on a microscope either. You got to really have a good discussion with the patient. This is what I'd do if it's my teeth. These are the possibilities. Since you're not having any symptoms we think we can hang on to this tooth for a long time. A long time is different to everybody.
Howard: One thing that might be flying over your head. One of the reasons some doctors can sell so much dentistry, and other can't is because when you give a patient 4 options, and you don't have you know, what I would do for my teeth. I mean when you give someone 4 options, and say what do you want to do? They're looking at you like, I thought you were the doctor. When older guys say, well you know you could do these three things, but you know what, if it was my tooth I'd really do this. This is what I would do for me. Then the patient, it's a lot easier for them to say, "Okay well, let's do what you would do for you."
Ed: Right.
Howard: I see the younger kids give them 4 options, and the patient's looking at them with a blank stare like, "Well aren't you the doctor?" I mean, am I supposed to ... a doctor that treats himself as a fool for a patient ...
Ed: That's a great observation. Dr. Barney here, he's blessed with young gene's, and so he looks young, and some people think, "Well are you really out of dental school?" Well I came out of dental school bald, and so I had an advantage where people thought I looked older than I was, and so you're right. I think talking to them in lay terms helps communicate that, and you have to really believe what you're saying. You have to be sincere. If you're pitching a sales pitch, it's not going to come across as if you're really talking from your heart. This is what I've seen, this is what I'd do. There's not getting around the fact that having experience adds to that. That depth of understanding of what you could do, and how you can present that.
Howard: I'll never forget when I opened up in '87, I was always doing 2nd opinions from these 2 dentists that practiced together across street, and they were like 7 and 8 years older than me, but I was the bald guy. They'd always say, they're so young, I don't even know if they ... I'd rather see what you thought was better. That bald head they just thought I was their dad almost, it was just crazy. I want to go back to that Dycal versus MTA. What are your thoughts on MTA? Do you ever use it? Why is it so darn expensive?
Ed: I don't know why it's expensive, and I do use it a lot. Where I use it is if there is a perforation, so let's say we're looking at really calcified canals, and there's an opening into the forcation, a perforation. It's not very big, but it's bleeding, it's not healthy tissue, we treat it just like pulp. If you get that PDL to respond, and calm down, then that's where we put MTA. We put MTA when it's a surgical approach on apicoectomies. There's a lot of various materials to use on that too, but MTA is probably used by more Endodon than other products. I don't use MTA coromally for a pulpal exposure, because it has a lot of staining ability. It's a medial grade Portland cement, is basically what it is. It has calcium and other derivatives in it. Mahmoud Torabinejad is the one who developed that out of Lomalinda, and it's just maybe a coincidence ...
Howard: Is he a friend of yours?
Ed: I know Mahmoud.
Howard: Can you email me Howard@dentaltown and cc him?
Ed: Sure.
Howard: I'd love to talk to him about that.
Ed: I remember talking to him about how he developed it. He said his dad laid concrete for a living, and he said the concrete was impervious to moisture and everything else once it's set up. So I thought if it can work on a side walk, it ought to work in a tooth. So he went through all kinds of renderings of different formulas, and came up with MTA. They also make MTA where it doesn't have the opacity to it, so that you have the tooth colored MTA. We have found out by trying to do pulpal regenerations, and other procedures, that stains teeth as well. We're just not a fan of MTA on the chromal part of a tooth, because that leads to darkening, and making a tooth look bad.
Howard: You know that's ...
Ed: A posterior tooth, that could work, but I wouldn't do it on an anterior tooth.
Howard: THat's funny because that's how a lot of us older dentists back in the 80's who had swimming pools, we'd see how the myriad gas that would clean the pool, and then I just went to my pharmacist, and bought muriatic acid acid, which is pool cleaner, and I'd mix that up with some pumice and a propy cup, and my God stains on teeth. You know they might have the brown, the rust stains, just weird stuff, and just polished out those enamel pearly whites.
Ed: I can tell you, when I did work for the Indian Health Service, I had a lady come in with her husband once, and she said, "Dr. Carlson, would you tell my husband to quit washing, quit brushing his teeth with Ajax?" I said, "Well they do look white." He said, "It works, it works."
Howard: Ed, a very stressful question that a lot of dental school graduates, and the like are having is they are coming out of school $350,000 in debt, and they are told by a lot of companies that if you really want to do quality Endo, you need to buy $100,000 3D CBT x-ray machine from Carestream, or Galileo's. For someone to do molar Endo to the level you're doing, should they buy $100,000 3D x-ray machine? How big a part of that is your practice? How often do you use it?
Ed: To cut to the chase, the answer is no. You don't need a cone beam to do root canals. You need a microscope to do root canals. There's a lot of things you don't need to do root canals, because guys have been doing them for years without them. They have very successful practices with long term success. I like to look at things that make my life easier, and less stressful, and that bring value to the practice. We do have a cone beam here. I use it less than any of my other associates.
Howard: What specifically when cone beam did you get?
Ed: We have the Marita.
Howard: The Jay Marita?
Ed: Yes. We've had it for about, going on 4 years.
Howard: What did you pay for it? Do you remember?
Ed: I think we paid $115,000 for it.
Howard: Are you glad you bought it?
Ed: Yes. That being said, I probably ask for 1 scan a week out of all the patients that I see a week. Whereas my partners might get 3 or 4 a day. They use it a lot more than I do. I've looked at it as, it helps us see things we couldn't see before, especially for resorptive cases. So you can see the extent of the external resorption. Things that are going on to let you know if it's even feasible to put a filling internally, or if it's all going to spill out.
You still can't see micro fractures with a cone beam. You can see curved roots, you can see if it has multiple canals, but the cone beam doesn't help you get into those. You still have to mechanically find those, and get into those. There's times when I've been doing a case that's difficult, that I've stopped and I've taken a cone beam, and I could see where I'm making the access, and I'm just barely off where I want to be for the canal. That helps me redirect. There are cases like that, but by and large my feeling is that the cone beam helps us satisfy our curiosities, and it's kind of a crutch more than it is a necessary tool. That's probably not what the mainstream Endodontists are saying, but that's the way I look at it.
Howard: Ed, there's 3,800 dentists in Arizona, and most of those, well over half are right here in the valley. If one of those guys or gals are listening to you right now, would you ever let them come by your office? Do you ever do that? Do you let dentists observe?
Ed: Absolutely. We have that almost on an ongoing basis. Not everyday, but we get phone calls more than once a month asking if people could come by and watch us work, explore the office. There's a lot of pre-dental students. There's a lot of students that want to get into specialty to come watch. There's a lot of hygiene students that need to get some credits, so we have people here all the time watching what we do.
Howard: What about just general dentists?
Ed: Sure.
Howard: Now what are your thoughts on that? If a general dentist comes in here. A lot of, I think, street smart dentists go watch a specialist friend of theirs up the street. I don't understand why they have to get on a airplane, and fly 4 hours across the country, pay $3,500 for a weekend course when there's someone far better than that instructor right in your own medical dental building, but a lot of them feel like, they think why would Ed show me how to do a molar root canal if that's going to hurt his financial pocket book, because I want to learn how to do molar Endo, to do molar Endo. Why would you let them observe?
Ed: Years ago we started a seminar series called inter space seminars. The whole idea behind that was to show a dentist what we're capable of doing, but my approach was, let's show them how we do it. Let's spell it out. If you go to an NBA basketball game, you watch people dribble down the court and shoot. They're showing you how they do it. I can't do that. When a general dentist comes here, and they see everything that we put into pulp testing, and to isolation, and to finding canals, and sterilizing, and keeping things the way we think it ought to be. Most of them think, there's no way in heck I really want to do all of that if that's what it takes. It doesn't take that on simple cases, but sometimes it takes it on the tough cases.
If we let people come in here, and they pick up some tips, and they see the scope of things that we can do. Then it helps us, and it helps us with goodwill in the community. We're glad to do all of that. Anything that helps the overall dental health, I think it's good for the population and public in Arizona.
Howard: It's the one thing that I've noticed in all successful business people, is they always think in hope, growth, and abundancy. They never think in fear and scarcity. The dentist that seems like that view the other dentists in their same medical dental building as competition, and their whole life they go avoiding the other person, they're always miserable, and they're never really successful. Guys like you who don't think in fear, and scarcity, and just think grow the pie ... and I think the street smart dentist can learn a hell of a lot about Endo by observing great ones like you, but ... go ahead.
Ed: Where this all started was years ago I was working with another associate here in town. I was actually his associate, and became his partner, and then we started to get busier than we wanted to be, and we needed a larger location. We found this property with other dentists, and decided to purchase it, and build our office. Just as we were getting ready to do that he said, "You know I'm getting too old. I don't want to do this. I'll let you just run with it, and we'll still be friends, but I'll stay here, and you go there."
We've been friends over the years, and he's a wonderful guy -- Mike Bailey, here in town. I learned a lot from Mike, but because I was going to start out on my own, I thought it's going to be my office, I need to have it my way. I need to find out what I'm made of. I sat down, and I wrote a vision statement. I thought when I walk to work, what do I want it to be like? What do I want it to feel like? What do I want the end result to be? I spelled out that I wanted people to come into our office, and to have kind of a wow experience. In order to do that, I needed to support the general dentists. I need to help with continuing education. I need to reward my staff in an abundant way, and we need to be a team. A lot of these things that we've done here are reflected in that.
One of the things I'd encourage general dentists to do is to sit down and say, "How do I see myself?" How do I want my practice to be a reflection of my personality, rather than just what they told me to do in dental school. If it doesn't reflect your personality, you're not going to have longevity with it. I think you have to be consistent in all aspects of your life. Your personal life. Your spiritual life. Your family life. Your business life. Your dental life. They all have to be consistent. You're right, if you have an attitude of abundance and generosity, it's going to come back, and you can be successful. You'll be happy.
Howard: Absolutely. You opened up a can of worms when you talked about resorption, and internal/external. I know their minds are thinking what's ... how does an Endodontist look at internal and external resorption differently? How is it treated differently? Talk about that since you did say it, not me.
Ed: Sure. There's almost never pure internal resorption. There is, but 98 out of 100 cases that a dentist sends over to me and says, would you please evaluate this internal resorption. It's external. Cone beams show that really, really well. With the peridontal ligament being irritated somehow, and the cementum in the dentin being resorbed away. Sometimes there's no contact at all with the pulp, but it wraps around the pulp. Pulps are vital, but the tooth is being eaten away. We don't always know why. I always assume it has to do with trauma, whether it's ortho trauma or regular trauma. I'll bet half the patients I have where I see that, have never had ortho, and they don't remember being hit in the mouth with a softball.
Howard: True or false. It's mostly seen in boys. Boys have more trauma.
Ed: I don't think that's true. I see it a lot on girls too.
Howard: You see it a lot on girls who didn't have ortho.
Ed: And women.
Howard: What are you thinking it might be?
Ed: I just think it's our bad luck of the draw. I know that in cats for instance, there's about 65% of cats have tooth resorption. I've thought, I have a brother who has his PhD in chemistry. One who is into marketing. I have another brother who is a patent attorney. All 6 of us boys grew up on a farm. We thought we ought to develop a cat food that is aimed at the higher end owners to fight cat resorption. Tooth resorption in cats. We haven't come up with that formula yet, but when I retire I might. We don't know. That's why they call it idiopathic. We just really don't know what's causing it.
Howard: What does idiopathic mean?
Ed: Unknown cause.
Howard: Unknown cause. My job is to guess questions that thousands of people out there are asking. When you see external resorption, when do you say I'm going to do Endo, and when I'm going to extract?
Ed: Most of the time my argument has been if there's a pulpal problem, and this seems to be a slow process, let's do the root canal and hang on to the tooth as long as we can. If it's an extensive problem, and there's no pulpal problems, I don't recommend any interference at all. Just let it run it's course. When it starts to bother them, take the tooth out because changing the internal pulp on a tooth with external resorption, doesn't do us an awful lot. Almost does nothing.
Howard: You know it's funny, because it's embarrassing how much I've learned over the years from the patients who didn't accept my treatment. When I got out of school, if a baby tooth didn't have a permanent tooth underneath it, you had to pull it, and do a bridge or an implant or something because it was going to fall out anyway. Well anyone who didn't accept the treatment, 28 years later, that baby tooth is still sitting there. It's the same thing with external resorption, when you said, "Well you know you need to do a root canal, and we need to do that." Because I literally thought in '87 that something in the pulp might be feeding the bugs, and the people who didn't get the root canal. The external resorption, a lot of times it was still there 10 years later.
Ed: I had a case, he was the brother ... my patient was a CPA and his brother was a state Senator. A prominent guy on the radio and tv all the time. The dentist sent this gentleman over for a root canal because he saw internal resorption on tooth number 28, and we could tell that it was external resorption, and the only way to treat that and to slow that down would be a surgical approach on the facial where that resorption was, which would then violate the pulp, which was normal. We weighed everything, we decided to do a root canal. Sent him to a periodontist, who then laid a flap and did the surgery, and he ended up with a dehiscence of about 12 mm, and the tooth spiraled downhill. He lost the tooth in a couple of years. Whereas if we'd a left it alone, he might still have the tooth. He might not but ...
Howard: Okay same question I asked you on the CBT. Scope. If I want to be a good ... if I want to do great Endo, do I need a scope?
Ed: Yes.
Howard: Interesting. Don't have to have a CBCT, but you have to have a scope.
Ed: I guess I should qualify that because I went through all my training without a microscope. It wasn't until about 1992 or '93 that I got a microscope. To me the revolutionary changes in Endodontics for me, and my 26-30 years has been digital x-rays, and a microscope, because it just takes the stress out of finding those extra canals. I have colleagues of mine that are still in practice, and they find those canals without a microscope. It is not malpractice to do a root canal without a microscope, but it sure makes it easier.
Howard: What microscope did you get, and how much did it cost?
Ed: Let's see, I have an Urban microscope.
Howard: U - R - Ban?
Ed: You know I'll have to go look. I have to tell you, when I bought my microscope, I went to a course by Gary Kaar, down in San Diego back in '92 or '93, and I called him up, and he said, "Ed just do it. It will change your life." He said, "I guarantee your gonna get a second one if you get one." I paid about $25,000, and it had 2 scopes for the assistant to look through, and a month later, or 3 months later I bought another microscope. My first one was floor mount, so I could roll it anywhere thinking I'm going to do that. They're to dang heavy, you put it somewhere. I didn't even use it for a month because it was in the way. Then I thought, I better use it. Then I was hooked. Then I got a ceiling mount one, but then it's always in one spot. Then I got a wall mount one that's in the way of other things. When I built this office, we have 6 operatories, we have 6 scopes, they're all mounted from the ceiling. They're all the same.
Howard: What are the 6 scopes now?
Ed: They're all the ...
Howard: Urban?
Ed: Yeah.
Howard: U - R - Ban?
Ed: I think so, but ... It's Global.
Howard: Oh it's Global. Oh.
Ed: Global Surgical.
Howard: Oh, I thought you said Urban.
Ed: Well I think they went by two names, so Global Surgical.
Howard: They're out of St. Louis?
Ed: Mmm hmm (affirmative)
Howard: Did I ever tell you my Gary Kaar story?
Ed: I paid for these so long, I don't go look at the brand name anymore.
Howard: Did I ever tell you my Gary Kaar story?
Ed: No.
Howard: So he was putting on this Endo course, and me and my buddy really wanted to go, and they said, "Well it's Endodontists only." So I thought well, you know, I'll just lie. So wrote Endodontist. So I went in there, and everything was going great, and I was talking louder than I thought. I was in the back, I didn't think anybody heard me, but he over heard that I was a general dentist from Phoenix. Oh my God, he was so mad. He was mad as hell. Is he still that way? Is he still like you're either an Endodontist or not. Is he still ... do you still talk to him?
Ed: Not very often.
Howard: Does he still have his Endodontic software for Endodontists?
Ed: He does. You're either in that club, or not in that club. We're not in that club.
Howard: What's the name of his software?
Ed: Total Dental Office. TDO.
Howard: Yeah, you know my best friend from 7th grade all the way to dental school, John Lees. We actually met in scouting in the 7th grade, and we both went all the way to dental school at the University of Kansas City. He's an Endodontist out in L.A., and he uses Gary Kaar's TDO. He did tell me not to go to the course.
Ed: Gary does marvelous work. I have referred patients to him back before I was really getting into microscope. I thought he handles cases that nobody else can handle. I've referred patients to him, and he treats patients wonderfully well.
Howard: Yeah the Endodontists love him. The Endodontists love him, and isn't he into race horsing too?
Ed: Now that I'm not close enough to know that.
Howard: Something with horses.
Ed: He's got a ... he's a pretty amazing guy. He's developed a lot of tools that came a long because we have microscopes. Ultrasonic tips, and he's innovated the way we do an awful lot of things. He deserves a lot of credit.
Howard: Okay so let's ... I'm going to ask you the same question. Another amazing Endodontist, Ben Johnson in Tulsa, Oklahoma started Thermafil. Is leaving a carrier for the gutta percha, does that make your job harder? What would you .. there's other brands aren't there ...
Ed: Sure.
Howard: But what are the other brands of the carrier ... what do you call those? Carrier base? Gutta percha?
Ed: Yeah we call them Thermafil. We just say generically they're all called Thermafil.
Howard: Some Endodontists, when you say, what do you think about Thermafil? They'll say, I didn't really think about obtrating, I think about cleaning and shaping. If you get in there and clean, and shape you can fill it with quote, "Bird shit." That's what they say.
Ed: They used to.
Howard: Then they'll say, "Sterile bird shit."
Ed: From a sparrow. It was an English sparrow.
Howard: An English sparrow? A lot of old Endodontists say, I don't care what you obtrate it with, if you get it properly cleaned, and sterilized, you can fill it with sparrow bird shit. Back to the question. Obtrating. Let's just talk about obtrating. There's single cone. You and I had a friend who passed away, Joe Dovkin, he called himself a squirter. He only like the 3D. He actually, it was 2 doors down from me at Creighton University. He was a squirter. Some say lateral [inaudible 00:51:56], some like Thermafil. Talk about obtration.
Ed: I've heard somebody say Endodonists that I trust, say you know everything in the last 3 mm is single cone anyway. You can tell yourself whatever you want, but you put a main cone in, and you start obturating whether it's lateral or vertical. That's your main cone right there, and it's hard to do an awful lot different. I don't know how we know that unless we take out a tooth and dissect it, or take a look at the clear teeth that we do. That's been done. I'm not ... I don't totally dismiss Thermafil. My concern is that nothing lasts forever. Whenever you have to retreat it, Thermafil is a bugger to retreat sometimes.
Howard: Sometimes or all the time?
Ed: Sometimes. Most of the time.
Howard: What's some of the time?
Ed: 10% for us are harder to get out than. Most of the time, we have our techniques to get Thermafil out. We just don't give it a 2nd thought anymore. Sometimes you've got those little plastic carriers at the very end, and it's hard to get those out just because they've deformed with the heat, and they've adapted to the canals. My feeling about Thermafil is, one of the reason it doesn't work sometimes, and I would say it works in the vast majority of the time. I really believe it does, is if you've got a pretty tight canal, and you're inserting the Thermafil, the gutta perch, and the sealer are peeled off before they get to the apex. At the apex all you've got is that plastic rod there. I've done a lot of apicoe's where I've uncovered the apex, and the only thing there is a plastic rod. There's no gutta percha.
I think that sometimes they fail because they don't have anything really sealing at the end. That being said, I think no matter how good the seal is, no matter how good the Endo starts off, if you have a restoration perionally that leaks. Gutta percha doesn't withstand constant bombardment of bacteria, no matter how good it is. You've got to put it in there, you've got to clean it out, you've got to fill it well, and you've got to keep it isolated. I think if you can keep Thermafil isolated, and it's solved the original problem, it's probably going to last a long time.
Howard: This is going to be a softball question, and them I'm throwing off a cliff with this, but there's dentists doing everything right. They took out the amalgam. They took out the decay. They did everything right, and they're trying to save the pulp, and the whole nine yards. They do their pulp capping, then the whole thing blows up, and now the patient is pissed off. You did filling, and now it's got to go back and do a root canal, blah blah. I had an Endodontist at UMKC who said, you hold the PA, back when it went to digital. You hold the PA at arm length, and if you think it's in at an arm length, you do the damn root canal. If you sit around worshiping pulps all day, your patients aren't going to be very happy when they blow up on you. Then if you're too aggressive on the ... well, you know if in doubt, pull the nerve out, then some people might say, "Well you're just too aggressive." My thinking is always going to be this person, most likely every one of your patients are going to live another 10, 20, 30, 40, 50 years.
My question to you is this, if I've got a pulp exposure, and I'm doing everything just right. Let's say the patient is my age, 53. The average white male lives to be 74. I mean, all that stuff you did, what's the chance it's going to be Endo'd by 74 anyway. How do you manage the patients mind, because mental health is going to make you, or lose you more money than their dental health. If you do too much of the right thing, if worshiping pulp tissue, and then these things turn back ... like your friend who did a bunch of composites, and then they turned Endo. Ed, I know I just asked you 50 questions, right? I'm trying to build the deal, where is the line? Because these are young dentists. Where's the line between worshiping the pulp, and then the risk of you didn't do a root canal. The think needed a root canal anyway, and it's after the fact. Now the person doesn't trust you, and they're going to live in your zip code for the rest of your life. Is that enough questions for one question?
Ed: Sure. Sure. I think we ought to respect the pulp. My tooth is better off if I can keep the pulp in tact, and healthy for the life of the patient. But pulps are expendable. They can be taken out. I just think we have to have a healthy respect for it, and the dentists that I see that are successful, set their patients up in a way, and say, "Gosh, this is really deep. I thinking that we can do this without a root canal, but we don't now. We're going to have to give this a few days, and maybe a week or two, and see how it does. Let's try and be conservative."
I think patients like dentists to say, I'm going to be conservative with this. If we approach it, and they think we're not just looking at them, and thinking about a cash register, but we're thinking about this really looks like it's what I'd recommend. This is how I'd approach my tooth. I used to say this is how I'd treat my Grandmother. Then I'd say my mother. Now that my patients, I say this is how I'd treat my daughter. I think if we have a healthy respect for the pulp, we realize it's expendable. We're honest with our patients. We can't do any better than that.
Howard: How long are we out of the woods? We do all this pulp capping, how long until I'm really out of the woods?
Ed: I'd tell them ... I tell patients that every time the nerve gets worked on, or gets close, it can be bruised. It may take 6 to 8 weeks to go through its symptoms. After 8 weeks, it's not going to change an awful lot, because that's how long it takes to have secondary dentin laid down.
Howard: 8 weeks you say?
Ed: Up to 8 weeks.
Howard: A good rule of thumb, if you're going to do a pulp cap, I want to see you back in 2 months.
Ed: Yeah, that's a great way to put it.
Howard: That way, and on the bell curve of distribution, how many of that would cover I'm out of the woods?
Ed: I would say probably 80% - 90% of the time.
Howard: 80 or 90%.
Ed: I do see some of those. They do great, and then 10 years later they need a root canal. Then that's 10 years they went without needing a root canal.
Howard: Yeah.
Ed: Then I think the right decision was made.
Howard: You do any of your root canals today, as you did 10 years ago?
Ed: Do I do as many now?
Howard: No do you do them the same way as you do 10 years ago? Don't you think you do them better today than you did 10 years ago?
Ed: Yes, undoubtedly.
Howard: Then the last question. I've only got you for 1 minute, so my last question is ... sometimes people think too simple, and they're told that all root canal teeth need a crown. What I see a lot of times, especially with lower anteriors. They did a root canal, they just had this blanket statement that all teeth with a root canal need a crown, and by the time these lower incisors have a constricted [inaudible 00:59:10] neck. By the time you prep that all the way around, it's basically just gutta percha in your prep. How do you save teeth by removing the whole damn tooth?
Ed: I agree. I'm in that camp as you're alluding to right there. I see cosmetic dentists. So called cosmetic dentists they're teeth look so horrendous, I think how can they ever sell that to a patient? I tell patients almost all the time, if you have a root canal done on a molar, you need to get a crown. If it's on a bicuspid, most of the time, but I'm going to leave it up to your dentist. If it's a front tooth, most of the time, you don't need a crown. Unless you need one, I think I would rather have my own teeth show. Especially those lower teeth. They're problematic.
Howard: Can't we both say, after both doing this for 3 to 4 decades that when you prepare and incisor for an upper or lower crown, you've totally weakened the tooth, and increased the chance that it's going to fracture, and snap off.
Ed: Yes, you can say that.
Howard: If you were to put a composite on the access prep?
Ed: Absolutely. You bet, that's why I tell patients, this is not a foregone conclusion that you need a crown on this tooth. If it were my tooth, and I have to be real careful how I word that because I'm trying to support the dentist, and the patient. No, most of the time anterior teeth do not need crowns. If the only reason it needed a root canal, and the only breakdown is the access opening, boy I'd avoid a crown. On any anterior tooth.
Howard: Yeah I would too. Ed, that was the fastest hour I've ever spent in dentistry. Gosh darn, you've got just the most amazing reputation. Everybody loves you. You're so involved in the community. Thanks for turning me on to my first bike ride. 70 miles of precision. Man, seriously thank you.
Ed: We'll have to do this more often.
Howard: Thank you so much for all you've done for dentistry.
Ed: Thank you, Howard.