Dr. Richard Mounce practices endodontics in Eagle River, AK. He has lectured globally and is widely published in the specialty of endodontics. Dr. Mounce has been a consultant and key opinion leader for a wide number of companies including SybronEndo, Vista, Mani, EasyEndo USA, Tun Ultrasonics, and Metabiomed.
VIDEO - DUwHF #1185 - Richard Mounce
AUDIO - DUwHF #1185 - Richard Mounce
Howard: It's just a huge honor for me today to be podcast interviewing Richard E Mounce DDS who practices endodontics in Eagle River, Alaska. He has lectured globally and is widely published and especially the endodontics Dr. Mounce has been a consultant and key opinion leader for a wide number of companies including Cyber on Endo, Vista, Mani, Easy Endo, USA, Tune Electrasonic's and Meta biomed he graduated from dental school of Northwestern University in 1985 and Oregon Health Science University endodontics in 91. Richard I have been a fan of yours for ever forever and ever number how are you doing today?
Richard: I'm doing really well the feeling's mutual.
Howard: So the first question I want to ask you so many questions but the first thing I want to ask you is you know these kids I'm you know whenever they raised the tuition of dental school ten thousand dollars a year it has no effect on the number of applicants. So we've seen dental schools go from you know forty thousand a year to a hundred thousand a year I'm I think there's over five dental schools now that over a hundred and ten thousand dollars a year and they come out of school and you know the most dental office practice management consultants say that you know if you're not getting seven tooth aches a month something's seriously wrong with your demographics your location your you know it just it's a huge red flag in fact some of these DSOs if they open up an office and after three months they're not doing seven tooth aches a months they just they do they just roll up the office and say it didn't work. Yet these kids come out of school and half of them you know they got all the student loans to pay back and half them say I hate endo I'm not doing molar endo and it kind of hurts the public health side of dentistry when you got when you might be the only dentist in a small town and and Melinda just decides she doesn't like you know I mean imagine you going to the hospital after you fell off your bicycle with a broken leg in the hospital setup we don't do legs we only do arms ears noses. So what would you say to that young 25 year old dentist, she graduated and she already hates molar endo and doesn't even want to do one? Talk to that girl.
Richard: Yeah that's a really tough one because you'd have to break it down into all the steps of what it takes to do a molar endo properly and to cut to the chase the difference of practicing a specialty at the highest level with cone beams and microscopes and activated irrigation and bioceramic sealers and all of the different top-of-the-line technology and what you're going to know coming out in a dental school you have a significant experiential gap and literature-based gaps so that one's really tough. My best advice as a starting place would be go watch an endodontist work take every endodontic class that you possibly can across the entire spectrum. I would subscribe to endodontic practice USA Lisa Molar's magazine that's an excellent source of street smart information I'd get a subscription to the journal of endodontics and you know the AAE has an amazing educational portal called endo on demand every lecture back to 2013 that's been given at any national...
Howard: Who has this?
Richard: The AAE The American Association of Endo and literally every lecture that's been given sponsored by the AAE is there in the whole presentation including the slides and the audio so you can listen to an unbelievable variety of different lectures. I listen to about two hours a day of that now and you can get CE for it so point being to the young graduate who doesn't like molar endo this really feels like it's foreign and is uncomfortable you know there are a tremendous amount of resources out there for that person to gain experience. At the end of the day whether they like it or not and whether they want to continue or whether they want to do molar endo is a different story but there's a lot of great educational resources available. The other thing would be very very few general dentists talk to their specialists or treat them as a partner in the process so that young doctor calling the endodontists and saying I'd like to learn from you I'd like to be able to call you ask questions talk about cases come over up to work sit down over a cup of coffee that doesn't happen very often and it's really a missed opportunity. So I think all of those things could certainly help a young dentists in that situation and at the end of the day if they don't like endodontics then they should find an excellent referral source or someone they trust who can do it for them.
Howard: So you're talking about and by the way you said a shout out to an endodontic magazine with Lisa Molar she's right up the street for me she's a great person. The AAE.org you said you go there and where do you go on AAE.org
Richard: It's called endo on demand and it's a
Howard: Oh it's a separate website endo on demand?
Richard: Well there's it you know I don't know because I'm just automatically plugged into it but if you go to the AEE you'll find a portal for endo on demand and it's an incredible resource you've got the best speakers in the world, the top specialists in the world talking about dozens of subjects within endodontics and it's the most updated recent information presented at the highest level and I love it really good stuff.
Howard: Alrighty well I learned something on my own show like I do everyone it's you go to AAE.org/specialty/education-events/endoondemand they definitely and so is that how much money is that does it cost of money?
Richard: Yeah it costs us I want to say it's under three hundred dollar surcharge a year on top of our membership I'm not sure what the solo cost is for for utilizing that resources.
Howard: Endo on demand and they're on dentaltown we on our continued education endo now we have 33 classes on endo too. So that endo on demand that is I did not know they have that thanks for thanks for coming on today and telling us about that and by the way to the listeners like to talk about companies and products because if you took away about 500 dental companies dentists would be sitting outside on a rug with a bunch of pliers and forceps from Home Depot and then and then dentists sit there and say on don't on they say yeah but that guy he's selling this stuff for money it's like what are you a volunteer dentist are you doing free dentistry at a public health clinic. I mean there's a lot of when I graduated in school 87 to the first five years I had a blister on my thumb and my finger from doing this whole day and when the first person turned me on to rotary remember John McSpadden out of Chattanooga?
Richard: Oh yeah
Howard: and he got into that because he happened to be like what six foot four and 280 pounds and his hand was the size of you know my head and he had to figure out rotary endo back then it was cyclical stainless steel and so with you and I have seen so many innovations going on in endo and I want to talk about as many of those I can because you are tied into so many endodontic companies. Everybody's talking about Sonendo why is that?
Richard: Well it's truly transformative technology you know there's play hype in the universe and dental space but Sonendo really does have the potential to I would say both change and potentially end endodontics as we know it. To describe it for the listeners who have never not familiar with it there is a console that looks like a laser and the technology involves a handpiece that fits over the top of an access cavity there's a seal created and solutions of hypochlorite and EDTA are flushed through the tooth using multi sonic energy and the solutions are degassed there de bubbled. So essentially what's happening with neutral to negative pressure you're putting these waves of bleach and liquid EDTA through the twos in a highly controlled manner and the levels of disinfection are according to the literature that we have significantly better than the competing technologies. Now significance kind of a that gets into some other connotations but the gist of it is that it's taken the disinfection stage of endodontics which is the most crucial portion of the process and mechanized it in a way that's never been done before so it has just a phenomenal transformative potential in endodontics.
Howard: Well when you're mechanically finding all the canals cleaning them out shaping them getting ready to operate them and what percent is physically to breeded and then what percent of all those little tubes and Flair's and shapes of the canals are not removed and would benefit from something like that?
Richard: Yeah my best reading of the literature that's a really good question Howard and your question is kind of twofold what percentage is taken out from debridement through rotary and reciprocating files and how much is the fine tuning or the microscopic cleaning through activated irrigation and it's probably 90% of the debris or better is taken out ish during the gross debridement and the remainder is done through your irrigation technique and your activation. You know the term activation in the general dental communities not well appreciated or potentially understood and I don't have statistics on what percentage of general dentists activate but if you walked in and asked a hundred general dentist you activate your irrigation you probably get about 90 blank stares so that is using sonic ultrasonic negative pressure mechanical activation or something like Sonendo to enhance the performance success solutions but at a specialty level it's absolutely critical that the and I think in the general dental endodontic treatment as well that irrigation is activated because it makes that much difference between the gross debridement and then the cold passive irrigation compared to what something like Sunendo or ultrasonic technique could do.
Howard: So what is this doing to the success rate because one of the most exciting lectures I ever gave my life was in Florida to a dental insurance convention and they were showing me all this data about their insurance data and they don't share it, I mean it's private data and I wish this data means so much and it should be mined and transparent all the stuff I yeah but they were they were they were show me data that if they just measure a root canal success rate as in five years is that tooth still in the human's mouth or was it extracted and they were saying that endodontists 5% of their molars are extracted in five years and general dentist it's ten percent. So the difference between an endodontist and a general dentist is about one in twenty molars do you believe those numbers I mean that's I mean these are based on millions of claims?
Richard: Yeah a really good question again Howard I do believe those numbers because the vast majority of endodontic procedures done are not by general practitioners are not done under a microscope and secondarily I can't quote you for statistic but there's a significant number of endodontic procedures done without rubber dam and then you have a significant number of procedures not done with activated irrigation. So when you take you know those facts and you transfer them into success/failure literature or statistics that number of five percent ended donek endodontist molar or failure ten percent that kind of passes the smell test to me. Your other question was related to Sonendo success verse is success without Sonendo that's a trickier proposition because my recollection of the literature there was a study that came out recently I want to say was in the Journal of endodontics that quoted success with Sonendo somewhere in the 97 give or take a percentage point range and that and the accepted success for all the endodontic procedures is in the 93 and 95 percent range amongst endodontists I mean in the most recent studies using the optimal technologies so you know is Sonendo gonna lead to a greater success rate and is it worth the cost that's really the million-dollar question because the Sonendo console cost about eighty thousand dollars each hand pieces single-use disposable cost somewhere between 15 $100 apiece. So to utilize this technology it is arguable I'm gonna be diplomatic it's arguable whether it's applicable to the average clinician working and doing two or three root canals a week that gets into a whole other conversation is the cost versus the benefit and is it worth it.
Howard: So you're saying the Sonendo the gentle wave system costs how much for root canal?
Richard: Well the console is about ballpark is about 80,000 give or take some depends on what you negotiate and the handpieces are about 50 to 100 dollars apiece depending on how many you buy at a time.
Howard: How much are the hand pieces?
Richard: Fifty to a hundred dollars per case.
Howard: Wow so you have a fifty dollar disposable handpiece fifty two hundred dollars per case per molar work.
Richard: Well per tooth, period.
Howard: Per tooth that right that's a chunk of change.
Richard: and you're adding about eight to ten minutes per procedure and I want to be clear I don't have any commercial interests with Sonendo I don't work for them I have no connection to them officially or unofficially but so I'm not I'm not connected to them. I just I find this particular technology to be the one the one or two things that's come up since I've been in endodontists including rotary, nickel titanium, controlled memory nickel titanium and the microscope that has really been had the potential to change the specialty.
Howard: Yeah that is a serious on costs eighty thousand dollars is so obvious so what percent of endodontists do you think are gonna get this there's what about 4500 endodontists in the United States?
Richard: Yeah good call how many endodontists do you think are in the United States and how many are in the world?
Richard: 4500 is a good is a good number and there's probably ballpark four to six hundred endodontists in the US who have the general wave now and somewhere in that range that's my best guesstimate I don't work for the company.
Howard: So you know it starts off why does endo fail, that's what we were talking about endodontist 5% failure a general dentists 10% the first things you said they weren't working under a scope or rubber dam. Do you think if a dentist is doing a root canal every week that they should get a scope?
Richard: Yes
Howard: and would you recommend Global or Zice?
Richard: They're both excellent machines there to think about microscopes Howard is that you can buy a used five-step microscope and I have one sitting in my garage if anybody wants to buy it call me. I have a five-step scope with inclinable binoculars that you know you could buy them used for 5 grand 4 grand 6 grand they're not really very expensive and you can put them on a floor stand you can move them between your operatories so there's a lot of used like you could buy a used car a new car you don't have to you know you don't have to go big on a scope and if you're doing one a week and you bought a microscope for three or $4,000 it's more than gonna pay for itself in canals you found and seen as you saw and cracks you saw things like that.
Howard: Well you know um you said you got to use in your garage I think the most hidden asset a dentaltown is we have dental town classified ads and there's about 5600 ads on there and it's amazing what you can buy half off used I mean everybody does it with cars but you should just put that scope on the classified ads.
Richard: I will do it.
Howard: and it will fly away so scope is important you said you know my big deal is it doesn't seem like anybody's doing anything faster easier higher quality if they're not and profitable if they're not doing it once a week like people will get into sleep medicine and they'll do one case every other month but when you factor in all the continued education and all the everything you know if you can't hit critical mass which I believe is one a week you're not gonna ever do it well enough or profitable enough and you know when I got a vasectomy I didn't want to go to some guy does like one every five years I want to go to the best guy. So rubber dam that's still an issue?
Richard: It is still an issue. I'm looking at a now private I do I'm starting to do a fair bit more an expert witness for legal cases and I'm looking at a case right now where there's not a single picture in the chart there were five ish root canals done there's no images of a rubber dam clamp or any cone fit pictures in the charting and only half of the teeth that were done even have a rubber dam notation but there's no proof that a rubber dam was used. So it's an issue it's an issue it's an issue in 2019 hard to believe but true.
Howard: What about the other issue will you and I got high school when you and me were babies Sargenti was still the big deal I mean I I am making my gosh around here all the old when I when I got a school 25 anyone who was sixty was still using it did that go away completely is it gone or is it?
Richard: I think so I haven't seen a Sargenti treatment in a long time it's supposed if you practice in a place where you had a lot of people from Eastern Europe you may still see the Russian red paste kind of material what exactly is in that's always been a bit of a mystery because sometimes it's sludge and sometimes it's concrete but I don't practice in an area that has too many of those cases anymore just kind of like silver cones so it's been a long time since I've seen a Sargenti type fill.
Howard: So for you kids who I mean if you just got a dental spa don't know how you would have ever heard of Sargenti but basically was a good theory the theory was we're just gonna get down into the tooth and put a bunch of toxic para formaldehyde down there and that will kill all the bugs and germs and when we're done with it but looks like it was coming out the apex of the tooth and and there's a lot of what do you think put the nail in the coffin for Sargenti?
Richard: Oh just the toxicity and the lawsuits and the bad outcomes ultimately you know the combination of those three things brought that to an end. You know it's interesting you bring this up because one of the challenges we've got now is extrusion of calcium hydroxide so I won't name manufacturers but there's one particular brand of calcium hydroxide which is much more viscous and flows far more freely than others and there have been a number of lawsuits where the mandibular canal gets filled in with calcium hydroxide. So if I had a little bit of caution to give to a young dentist using calcium hydroxide is no easy this is one of the benefits of having a microscope is you got to know exactly where the tip of your extruding needle is in relation to vital structures like the mandibular canal the mental nerve things like that. If you have an open apex in a lower second molar and you have a non vital tooth that you're splitting in the two visits you want to proceed with extreme caution because it is easy to with the wrong technique to extrude calcium hydroxide and cause permanent injury so that's a it's a variant to Sargenti in a sense and there number of cases legal cases in the last few years with that problem.
Howard: because the calcium hydroxide instead of a neutral pH that a bugs love to live in it's making it real basic so that would be the active activation and killing. So back back to that are you a pulp lover or an apical barbarian? I mean which one are you? I mean there's two types of endodontists and one wants to just get a half millimeter from the apex and have it look all pretty another one's like no way man I want to see that sealer paste bust out there and make sure I got it all. So are you a pulp lover or an apical barbarian?
Richard: Well I'm an apical barbarian because I think when you're a pulp lover you tend to always end up a little bit shorter than where you intended but I also am not impressed with extruding a lot of excess material and I don't I don't have to have a puff to feel like I got where I wanted to go. I'm very precise about trying to locate the minor constriction and know where that material is going and try to prevent you know stay Payton but prevent extrusion if I can but to me if you're pulp lover you're gonna end up shorter and leave more debris than you will if you're an apical barbarian. One of the trade-offs though how it is if you're an apical barbarian you're by almost by definition gonna end up with a little more post-op discomfort so you know people's need patients need to know that that debris when it's potentially extruded during instrumentation and maybe during down pack if you get some material extruded they're gonna have more post-op symptoms.
Howard: So I've been talking to a lot of endodontists to tell me their molar times are actually slowing down they you know I think the average endodontists you know then when I got out of school they were usually completing three to four cases a day and then and with rotary instruments and all that it got up to more four or five cases a day but now with scopes and all the technology and all that they're they're back down to three or four a day so molars are instead of taking an hour they're taking an hour and a half what is what is your time on a molar endo?
Richard: We book so I'm in a little bit of a different situation but we book two hours because I spend a lot of time initially in the examination phase. I think that the case is won or lost before you ever pick up the syringe so you look at the patient you look at the tooth and you say this is a patient that I can treat successfully and this is a tooth that I have fully examined in every way to know that I can land the plane so to speak of the procedure. So a patient knows it could be cracked that there may be an extra roots there may be five canals there's gonna be an MB2 sometimes we need a cone beam before we start so my time from start to finish between inform consent and everything else it's probably an hour and a half to an hour and 45 minutes plus the examination time and to answer why it's it's taking longer as I think that with the cone beam especially we're learning how much more complicated these spaces are and how much more Anatomy there is to address that we never really fully appreciated before because we couldn't really see it in two-dimensional x-rays and you know we know from both the cone beam as well as a microscope that you take into account instances and fins and lateral canals and all of the different anatomy that things are much more complicated than we were thinking before and if you're practicing with a conscience and you're really trying to do comprehensive treatment cleaning and shaping and obturation you're gonna spend that extra time making sure that you take all the steps diligently through the process.
Howard: and you know you're doing a lot of expert witnesses on because you will consult on it on that for the dentist or the patient just depend on who hires you?
Howard: Well generally it's attorneys are contacting me both on the defense side and on the plaintiff side and you know if I had if I had let me digress Howard for about 30 seconds if I had a little bit of advice for the young dentist right out of school the I would say two things come right to mind one would be you know inform before you perform make sure you have confirm consent make sure you've reached the diagnosis make sure that everything is documented extremely well and resist the temptation if you work in a big DSO to cut corners trying to save time to stay on schedule because at the end of the day the common thread of virtually all of the cases that I see is that either somebody's doing something that they're not qualified to do or that they basically were in a hurry and didn't assess what was right there and I'll give you a quick example, I saw a case where a dentist did a one-shot endodontic procedure on a patient who had true swelling and and firm numbness and anesthesia in their lower jaw on number on a lower molar and so that the dentist went in and did a one-shot procedure on that and the patient ended up in the hospital with all kinds of bad sequelae and a huge bill and a lot of other problems and you know that's basic endodontics 101 the patient is numb the patient has swelling the patient has a firm mass in their in their lower jaw there was no discussion of referral no discussion of incision and drainage no discussion in the records that I was opening that tooth and putting in calcium hydroxide or any of the normal steps that are appropriate for that treatment and so then compounding the issue and this is another ubiquitous thing I've seen in my records the dentist doesn't either apologize or give the money back and the patient if a patient asks you for the money back at a zero when you write the check because by the time you go through the process of the lawsuit - you know somehow massage your ego your gonna spend a lot more of your stomach lining than you ever would have just writing the check in the refund and these things are bad but you know it's bad juju in the community and all the way around but that's the other ubiquitous finding is there's an insensitivity on the part of the clinician that makes the patient pissed off enough that they want to go back and sue the through the doctor.
Howard: Yeah and I love the fact that you spend so much time with the patient you know but you know make sure before you you informed before you perform. These dentists don't realize I'm I had a friend who had a problem it went to a full jury he lost the maximum the insurance covered 1 million dollars and you know what he never smiled about dentistry again it burned him out completely he retired a few years after that he just he just left on a sour note and you know it's just a shame that some of the stuff has to happen. What would so that's a diagnostic malpractice or you have a lot of other cases because a broken file and by the way has the broken file incidents dropped significantly from when they first started coming out when we were using them in the eighties?
Richard: Yeah you know again I don't have any commercial interests in this I'm gonna drop a name of a file system that nobody's ever really heard of but it's Bassi Endo and Henrique Bassi makes a controlled memory file that called a logic system like logic and I don't you know in full disclosure I used to be the general manager for him in the United States and I have no profit no interest no commercial relationship with him now. Those files you really have I mean to break a file in 2019 it happens but in an endodontic practice an endodontist who's doing it all day long is probably breaking one a year and you know there are certain curvatures and certain situations where you never really fully know why it happens but I mentioned Bassi's files because his method of manufacture and we get into that if you want to is so unique that it's just hard to break them if you use them the right way so the incidence has dropped and having patency and having a glide path and being able to see what you're doing through the scope and having your motor settings be correct the incidence of file fracture is significantly lower and then what it was back when I started.
Howard: Is that is Bassi Endo is that after an endodontist named Bassi?
Richard: Yeah his name is Henrique Bassi.
Howard: Well tell him you come on my show and tell us about his file.
Richard: Yeah Bassi is a really fascinating guy in you know one of the quick thing I wanted to mention later in the show is there's a lot of people in dentistry who have product ideas and they want to become wealthy through a non practice based income source and I've spent a lot of time in industry and Bassi is really an inspirational story and the short version is that he was frustrated in Brazil with the big the big boys and the prices of files so he went out and bought a grinding machine started grinding his own NiTi and now he is the largest producer of NiTi in South America he's much bigger than DENTSPLY or cybron or edge or anybody else in Brazil and he is the big boy in Brazil and it all started because he went out bought a machine 20 years ago and started to grind his own Ni Tech files it's an amazing story but a true one, a good guy really good guy.
Howard: That is amazing I remember when rotary files start taking off I mean there were some just incredibly I mean it was someone really aggressive people like one company was making a file one of their competitors bought the company that was making his NiTI files and you remember all those stories?
Richard: Those things are still going on maybe not quite in the same way but those those types of litigations are still ongoing, purchases in different things.
Howard: It reminded me of the book you remember the book the chocolate wars where was basically they were there was two major competitors in chocolate and what were they trying to remember what they were but what it's Hershey's and Mars is that what it is Hershey's and Mars and oh my god I mean you you think they were just playing for you know you you do you think there one was ran by Napoleon and one was ran by Genghis Khan. I mean you know they one of them we could go to a foreign country and bribe the dictator with a big old bribe and then that dictator would pass law that only that company's chocolate could go in that entire country and I mean it was just stuff like that all day long and they were doing that same type of deal with endo files and so Bassi started making his own files that is I and Henrique Bassi interesting. So this files I you say they're safer less likely to break or they lower cost?
Richard: They are lower cost and they so the magic sauce in it is that they put the control memory into the instrument which means that when you put a force on the instrument it maintains the curvature, so if you have an instrument that's controlled memory if I bend it it stays curves so it remains curved as it rotates around the curvature of the canal so what Henrique was able to do was he can grind the flutes of the files after they have the control memory put on them which means that they maintain their sharpness. So all of the other manufacturing processes in the world they grind the files and then they put the control memory on them which makes them dull so that sharpness that's maintained in addition to the controlled memory is the secret sauce and if you think about a wire that's point one taper you know or one taper that's a tiny tiny taper and to be able to take a little tiny wire like that and you know I know one taper and and grind on it that's just spectacular that's that's a real feat to be able to do that.
Howard: You lectured I mean all around the world we're talking for the show you luxury in Kathmandu we have a similar buddy there I'm gonna keep going around the world just because some of these people I mean that that was so fruitful in what you said about a Bassi Endo yeah another one is the Japanese company Mani.co.jp you like any of the Japanese stuff?
Richard: Well Mani is a very interesting company I was both a Mani dealer as well as a Mani consultant I don't mean to toot my own horn but probably when I'm sitting in my rocking chair one of the things that I'm gonna be the most proud of was that as a foreigner I was a Mani consultant and I was the first foreigner to be a consultant for them on the dental side ever and that was a real honor to because the Japanese companies tend to be very very Japanese and their thinking and their personnel and their customs in the way that they talk to each other the way they communicate so you know it was really a privilege and an honor to be able to work with Mani. To answer your question Mani has the best selection of hand files stainless steel and files anywhere in the world the variety the sizing the different indications nobody in the world comes even remotely close to Mani in terms of variety as well as selection across indications in platforms. The challenge I think is well the thing to keep in mind is globally you know if you go to a place like Bulgaria or Bosnia or parts of Russia you know very few people can use nickel titanium files because they're too expensive so root canal in Russia costs depending on where you are or in certain places in the world it'll cost a hundred dollars for a root canal well you can't pay sixty five or a hundred dollars for a pack of nickel titanium files so where Mani is so tremendously successful is that with this variety of hand files they have they have solutions for clinicians who practice in places like Thailand or in Malaysia or wherever where they're not using nickel titanium and they're still using gates drills as well as stainless so to answer your question I like all of the Mani hand instruments they're the best quality in the world and a variety is second to none.
Howard: So really good is the founder president CEO that Tasha Hyde Takei is he an endodontist?
Richard: No Mr. Takei is the he's the chairman of the board he's excuse me he's I think he's the chief executive officer Mr. Matsu Thani I'm forgetting his first name he's still...
Howard: Misaki?
Richard: Yeah he was the past president of Mani and his I believe his brother or his father was the previous president and it's funny because I bet Mr. Matsutani actually still owes me a bet from the 2016 election so if he listens to the podcast he bet me over dinner and at you know tsunami that Hillary would win the election he was sure of it and I said no she's not gonna win I didn't know that Trump was gonna be the Republican nominee but if he's listening he still owes he still needs to pay up for that bet.
Howard: Oh my god why that election cause this podcast III owe all this to Trump and Hillary because it was a year before the election I start getting all these emails saying dude I got an hour commute to work and I can't listen to this crap for an hour each ways too toxic and insane and all that kind of stuff that was uh these are wild times I'm bullets but what do you recommend any of their products today I mean are you using any Mani products today?
Richard: Yeah I use I use a wide variety of all of their hand files in all of their gates drills.
Howard: and why is that?
Richard: Well because you know to me I can't practice endodontics without a number six file or a number eight file you know and so much of the quality of your endodontic procedure has to do with the having the right equipment at your fingertips when you need it in the right length in the right size. So you know when you if you ask me what does an endodontist do about half of what an endodontist actually does is get patency and we're picking through you know calcifications and getting around curvatures and so Mani hand files are have the right blend of stiffness and flexibility to get around those curvatures and then there's a lot of specialty indications so for example if you want to use a flare file which is an 05 taper to hand file to determine you know if you have a certain dimension in the junction of the middle and the apical third if you've created that particular flow and deep body shape then they have a file for that if you're doing a lot of retreatment there Hedstrom files are excellent and the variety of sizes like they have an 18 millimeter a twenty one a 25 a 28 and a thirty one millimeter length. So when you need it you need it and Mani has all of those indications so my sponge is full of Bassi Logic NiTI and Mani hand files.
Howard: Now when you were talking about Bassi Endo that's also Easy Endo USA?
Richard: Yeah they changed names they did that at the end of my tenure of being the general manager we went from being Easy Endo USA to being Bassi Endo.
Howard: because it was more global instead of endo you easy endo USA you said you sound a lot of them in Brazil?
Richard: Well they're selling a lot actually they're growing all over the world leaps and bounds and they're doing I don't have proprietary information but I'm confident that they're also either going to be doing or doing some oem but they're there they're there now a global company selling all over the world including Japan.
Howard: What about ultrasonics I know you consulted with Tune Ultrasonics are you is that did I pronounce that right Tune Ultrasonics?
Richard: Yeah so yeah there are two excellent ultrasonic manufacturers that nobody's ever heard of and they're a lot less expensive and one of them is Tube and the other and they're based in Wisconsin and the other one is Helse down in Florida and they're two very different lines. You know the tune tips are more for gross indications vibrating posts doing mb2 location they're very inexpensive they're 20 bucks for the non coated tips and 24 for the coated tips and then the Helse tips are much more finer indications you know they have a wide range of tips including surgical tips and pareo tips and different range of instruments but the the Helse tips would be in my hands more for removing separated instruments or trying to get around an obstruction or to get out a if I ever needed it to get out a thermos filled device or a lentil or something like that but those are those are two sets of products that represent excellent excellent quality for a really good value and their not household names.
Howard: So the company's name was Engineered ended onyx but also goes by tune ultrasonics or is true Sonics the main product of engineered endodontics?
Richard: Well I think I'm not sure but the owners Mark Fiorina and I think they're changing the name to Tune ultrasonics but don't quote me on that I think that's what they're doing.
Howard: Would you say the owner's name was?
Richard: Helse
Howard: That's his first name?
Richard: No that's the company name though.
that's the company name oh that they're gonna change engineered endodontics too?
Richard: No Engineered Endodontics will become Tune Endodontics I believe.
Howard: Okay
Richard: and Helse is a different company entirely.
Howard: Okay and who's who's the CEO of tune ultrasonics?
Richard: Mark Fiorina
Howard: and is he an endodontist?
Richard: No I believe he's an engineer by training.
Howard: That is amazing how people are getting into something we could you imagine getting into an endodontic company and you weren't even an endodontist that's amazing how that works. So any you just mentioned in Thermafil, I remember when that came out I'm having a carrier was kind of mind-blowing and some endodontist had a hard time accepting that would it's a name I haven't heard in a long time Thermafill hows Thermafill doing and what are your thoughts on cutting gutapercha it down with the solid carrier?
Richard: Yeah good good question how's it doing I think it's got a stable base of users and you know it is it gonna grow in popularity over time probably because I think that the brass ler technique of bio ceramic sealer in a single cone for the general practitioner in particular there's a simpler less technique sensitive solution in the brass flora option no disrespect to DENTSPLY. So to answer your question Thermafill probably used by 20 to 25% of the general practitioners it's probably used by less than 2% of the endodontists if that in the U.S. I've never used Thermafill a technique and the problem really Howard is not Thermafil a challenge is that if you don't shape the canal appropriately and you just take a carrier and you heat it up and stick it down you can get a white line to the end of the route but you really haven't truly cleaned and shaped and operated the canal and when the canals are under prepared and not irrigated properly and you just stuff you know a guttacore or a plastic carrier down the canal you really haven't fulfilled the biologic objectives of endodontics so I've had to retreat too many of those underprepared canals so I am a little bit biased. It's not a technique that I would personally use but it's certainly a valid one.
Howard: That was started by Ben Johnson and oh my god that guy was so cool I got our school is 24 and I was a baby and I was doing these endos and I called him and asked him a question and he just flipped Willy said well you're in Phoenix Southwest Airlines flies nonstop from Phoenix to Tulsa Oklahoma for buy two hundred bucks why don't you jump on a plane and comes from the night and me and I said well what's the name of the hotel that I could make a reservation I guess I screwed I just stay at my house. I mean and I went and spent the whole damn day with him he was an amazing man he was inventor he live in Tulsa Oklahoma so that's why they started Tulsa Dental Products Ben Johnson. I want to go back to you know I asked about you know why do root canals fail and then we talk about a lot of things what about CBCT if you're doing again critical mass one root canal a week is the CBCT standard of care and I know and you do a lot of defense and an endodontic work and I know standard of care is about as definable as a pink unicorn on another galaxy is CBCT standard of care?
Richard: At times in certain indications certain cases I'd have to say yes endodontically I would have to say yes because you know all of the surgical indications for sure and in the retreatment realm there are certain cases where yeah I think you you would be hard-pressed to say you fully diagnosed the case without it. You know it gets a little bit gray if you've got you know number eight and it's wide open D&E; to CBCT potentially you know not in that case but the thing is Howard that there's so many non endodontic uses for CBCT and non implant uses for CBCT that and CBCT is a really exploding kind of body of knowledge and technique driven tech you know the technology is really driving technique and treatment planning and thinking and endodontics across a wide range of things not just how we do the root canal but how we measure success and failure and things like that so to me it's an indispensable tool and if I was a general practitioner even if I didn't and I only did one endo a week I would potentially yeah I mean I'd go out and get a CBCT because when you need it you really need it and there'll be plenty of places where even in non endodontic indications you'd want to you'd want to see what's there three dimensionally so yeah I'd want to have it I wouldn't want to practice without it.
Howard: Is there any CBCT that you like more than us I mean they can be very expensive?
Richard: Well I'm gonna ask you two ways I've always practiced in places that already had one so no I can't say that there's been one that really stands out I know that the the Carestream is probably I'm gonna swag that that's the most widely purchased one amongst the specialist community but one of the things about CBCT's is let's say you're a general practitioner and just like a used microscope there's plenty of used CBCT's out there that would cost fifteen twenty thousand dollars and if you're only gonna use it twice a week and maybe you're not placing implants but you just want to have it at your disposal you know there's ways to get in and expensively and play with the technology and not have that 80 to $100,000 buy-in so there's ways there's ways to get in less expensively.
Howard: I asked you about the Japanese company so it wouldn't be fair to not ask you about Metta Biomed the Korean company next door do use any of their products?
Richard: Yeah traditionally I've used their sealer but I'm going to slowly I've been transitioning away to you go from their resin based sealer to using bio ceramic sealers I think that the bio ceramic calcium silicate sealers are really ultimately the way to go for a biocompatibility. You know one thing I was going to say which is you know related to a lot of our conversation which is that a lot of these dental companies don't have dentists on staff and I think one of the things that the general practitioner and maybe even some of the specialists may not realize is that a lot of these companies have engineers who are literally reading text books and scientific articles in the background and they're designing the products that are ultimately being put out into the marketplace and it's the marketplace that's really doing the beta testing and it could be NiTi Flies it could be you know certain devices that are used in the operatory so I just I don't know that I have a point other than we think that dental companies are you know doing a lot of prototyping and that things are really well thought out and well organized and there's a clear demand for the product and it's really interesting you know kind of what gets commercialized and what doesn't and how tested it is before it's released to the market so when you get something that isn't really working the way you think the reality is that company may not have vetted that product with a wide range of clinical prototypes even though they have a 510 K and I think that kind of stuff is really fascinating to me and I think there's there's a company called Cellarent, Marty Jablow and and John Flucke and there's some other doctors involved there one of the things their company does is vet products and test products in create design suggestions and you know hats off to those guys i think that's a really valuable service.
Howard: What's it called?
Richard: Cellarent
Howard: and Flucke, he's my classmate from UMKC dental school class of 87 love that guy and so Cellarent any other Cellarent Consulting?
Richard: Yeah
Howard: Is that what it is?
Richard: Yeah
Howard: Yeah in our life time, yep there's John Flucke there they all are on the Cellarentconsulting.com well how many companies have you and I been tested on in our 30 years I mean my gosh I mean there was our there was a targis vectris as there was I mean there were so many do you think it's still an issue or do you think that companies are getting it that they they they really need more R&D?
Richard: I don't think that I don't think the companies are getting it because there's kind of two models of companies you know there's the big behemoth that that you know there's the dense plies of the world that have well designed and and organized opinion leader groups and then there's a host a wide number large number of small companies that don't have the resources to have a dentist on staff or an endodontist whatever on staff and or what happens is the companies run by a clinician who's the only clinical input into the kind of the design and the manufacturer of the particular product and that's not a good thing either because you don't have a diverse set of opinions about kind of what features or benefits the particular product needs to have. So I guess my point in bringing it up is one of my frustrations over the years has been you buy something only to find out that it really doesn't work the way that you thought it did and you spent anywhere between a thousand and five thousand bucks to find out that it's going to gather dust and that's really frustrating so I guess it's a buyer beware from the clinicians standpoint.
Howard: Yeah and the other thing is just just don't if your listeners don't be bleeding edge technology I mean you know I see all the kids diving on stuff when they're right out of school because humans the human condition is they want to believe stuff and a lot of the stuff they they say they they just want to believe it and my gosh in in dentistry it's a business so when you try these new art glass crowns are these new Targis crowns in two to three years later the whole thing is falling apart guess who's gonna redo that crown for free otherwise you're gonna you know you don't want to have someone upset with you that lives five miles from your office and hate you for the rest your career you don't want a lawsuit I think I've avoided all my lawsuits just because I just like you said you give him their money back you showed you care you didn't lie you're honestly had empathy and sympathy and so when this new stuff comes out let the idiot down the hall try it let them do it for two three four or five years. I mean you got great technology that's working it's like when people want to take away my Impurgum dude I've been using it since 1984 you got to give me a really really really good reason to try to throw away my Impurgum I mean hell it's made in Germany the home of Mercedes Benz and all those great products is just it's just perfect. Let's switch gears completely from technical endo to again advice for the these young kids they're coming out of school there are 400 thousand dollars in debt they're the majority of the listeners of this show. What advice you give them?
Richard: Yeah you know I appreciate the question because I wish that I had somebody speaking to this when I were in 1985 when I graduated you know right off top my head the first thing that comes to mind is one don't get divorced number and number two you know you gotta know where you want to go in your career which means you can't spend five or ten years kind of muddling around in DSOs or maybe you want to associate to learn the business you know there's there's nothing like getting in there and going straight towards what you really want to achieve so if you if you're thinking about specializing you know you know then then fully pursue investigating that if your hearts in public health there's nothing wrong with being in public health you know we spend some time reflecting and learning and asking a lot of questions about both of yourself and the people around you about what what that best outcome is what a success look like later on down the road and one of the other things which is kind of a cow point to the divorce comment is you you absolutely positively have to restrain your impulse to go out and buy stuff now you graduate from school now you're 400,000 in debt and then they're willing to give you money to buy that big car and buy that house and all of a sudden you're a million dollars in debt and now you have to go to work not because you want to but because you have to and now you feel a certain pressure that you wouldn't otherwise have and the years go by really quickly so you know if I had some advice it would be have your financial planning sorted out related to your career goals and you know in making sure that whatever you're doing on the relationship side and and in your in your personal life is compatible so that you don't create unsolvable problems where you have to go to work and you're really not liking it and you know a lot of older dentists collectively and more of them you speak with the more wisdom that you're gonna accumulate through those conversations. One thing I think is a fair statement is where clinicians were not business people and we make really bad business decisions even cuz we're not really trained along those lines and you know one of my other little bits of advice would be to go to your book store or your Kindle and start to read all of the classic business books you know I did that and it made a huge difference business you know books on customer service pricing marketing advertising because ultimately at the end of the day patients know your bedside manner they get a sense of your empathy your caring they don't really ultimately care as much about they care about how they're treated personally not so much about how tight your margins are. So having a business sense blended with the right human touch in the right value system going into the operatory that's a really important really important set of things to get right from the beginning and in putting the patient first and it's not a you know it's a marathon it's not a sprint you're not gonna arrive five years out of school and well now I got the big car I got the big house I got the whatever you know those are kind of illusions because you got to pay for them and it's a lot easier to buy it than it is to pay for it and it's kind of funny because my income obviously is changed because I don't own a practice anymore but I have more money than I ever had before because I don't spend it because I Drive a 2009 CRV that's got hail damage on it but it works just fine I don't have to have a Range Rover I'd have two or three of them and it's funny how just that sort of peace of mind especially financially relationship wise really makes the difference and makes going into the operatory a little easier because I want to go in not because I have to go in.
Howard: So you know when you're coming out of school and the average is on two hundred eighty nine thousand dollars of student loans they think it's a big deal but you said don't get divorced the average dentist divorce is over a million so if they're coming out of school 280 to 300 their divorces are a minimum million dollars so what advice you give them on how not to get divorced?
Richard: Well that's not a question I expected this morning but you know here's my observation empirically and this is a little bit off color and I'm treading on thin ice but it's my observation that a significant number of dental offices have the spouse in the office and my interpreting I've been in a I've been in probably more dental offices than anybody on the planet I've walked into a million dental offices as a endodontists meeting dentists in different locations and you know it's my observation that the spouse is there not necessarily to pitch in at the front desk the spouse is there to help how would I say this delicately protect their assets and how do you not get divorced you know one you my single advice to be the person that your your spouse wants needs you to be and you know that you know be the person that you want to find because if you're doing all the right things in your relationship then you're gonna attract that kind of person back to you I'm very happily married and to my wife I say unconditionally yes I trust her unconditionally and I was divorced twice before so I know of which I speak but you know finding someone and nurturing that relationship you know why we're not here on a marital podcast but that just takes a lot of work and a lot of humility and time. When you're in the office you know it's called resisting temptation and that temptation oftentimes if you're a man is sitting across the chair from you and it's just one of those kind of how would you say its gravitational. So you know you know in faith somewhere definitely comes into that as well to have the right values to be faithful to your spouse but all of those things wrapped into one I think they can help you from from getting divorced.
Howard: Awesome advice well you know these kids come out of school the the ADA says are their about $289,000 student loans but again a kid cost that much. So in 1945 the average of America's having five kids four family now it's two so just look at your student at as like one kid maybe instead of getting married and having three or four kids like I grew up in a family of seven kids I had four kids maybe you have one less kid and there's a lot of if you're saving the planet the one thing no one ever talks about is the fact that you know what's destroying the planet is too many homo sapiens I mean there's coming we're coming up on eight billion and that's just a lot of people considering at 1900 there's only two billion but the other thing is you said you mentioned about owning your in practice dental specialists according to the ADA dental specialists average 320 general practitioners average 197 but if you micro down on those numbers dentists who own their own practice made 244, dentists who are employees are 147 that's $100,000 difference so three years working for someone else would have paid you're off your entire student loans I mean if you're gonna make a hundred thousand less than an owner do and I'm gonna ask you about that because you said something that I want to challenge you said when you're a man you know I'm you know you have to resist temptation but the literature is pretty clear that men and women are equal in that I mean you know when when a man is stepping out you know 95 percent of time it's with a woman I mean it's kind of an equal thing and a lot of people are saying that since the demographics has changed in dentistry since when we were in school is 80 percent males now it's half women have then that a lot of these women aren't gonna want to own their own practice they just wanna be employees are you buying that or do you think that's just some weird assessment?
Richard: You know I don't really have any inside information into the workforce statistics of what the female graduate is doing so I can't I can't really ultimately speak to that but you brought up Howard you brought up one interesting point which is it's really interesting to me there's so much debate and consternation and anxiety amongst young dentists about purchasing a practice and going into practice and whether they would could or should buy practices and you know the specialists are not immune to this either and ultimately if you want to be your own boss then you need to buy the practice and if you're comfortable being an associate and you want somebody else to manage the business side of it then you know that's fine. One of the things that's often overlooked in this conversation about the student loan debt is if I was gonna do it again I'd go in the Public Health Service or I would go in the military let them pay for the dental school do my service and then come out essentially debt free and learn your chops in one of those two formats. I work for the south-central foundation up in Anchorage for almost two years and I really learned up there there's a public health clinic it's a Native corporation clinic and one of the things I learned was that there are a lot of non-traditional paths and that there's not one right way you know if you want to be an associate being associate if you want to go in public health be in public health if you want to own, own but whatever you do you know just I've seen so much hand-wringing and I've spent hours and hours and hours talking to young doctors and a lot of older doctors you know what kind of practice do I want to be in or you know is it time for me to sell or you know is it time for me to stop practicing or should I change where and how I practice and I I just find some of the hand-wringing to be a little bit over the top you know if you're worried about student loan debt go in the service or go in a public-health service or get in a situation where you're gonna make you know tune your lifestyle down like you said in terms of maybe children or where you live or what debt you take on so that you can afford your payment's and and enjoy your practice and live in proportion to your income.
Howard: Yeah I think it's the number one cause of almost all stress and rich and developed countries is people live above their means I mean they always they always want everything and you just can't have everything and if you if you want everything you're gonna have to spend your whole life trying to make the money for that and dentists I mean my god sometimes you look at their lifestyle it's like are you a rapper or you a baller do you play do you play for the Cardinals. I mean am I did I miss something I thought you were just a general dentist and they have every toy known to man and then you meet back up with those people and they're 50 and they're still paying money on other people's money for their house their cars they're just everything in fact it's funny when dentists get my car they always say they'll happen to your door I was taking my granddaughter to school and right as the house was the car was leaving she opened the door and it hit the garage and it bent the whole thing and I didnt want her to be sad and I got out and I had to body slam it back but I loved that dent more than anything because my granddaughter made it's a 2004 Lexus I don't give a crap about that dent and every time I take it in they want me to give $90,000 for the 2019 Lexus or spend 2,000 fixing that doors like I I know what that was like 30 years ago I don't live that way you know what I mean I mean their vacations I mean they had dinner Friday night as a couple to dentists and their their family vacation one went to Spain, Germany, Amsterdam and back home I'm like you know why didn't you just go drive up to the Grand Canyon I mean that would that would have been you know what a couple hundred bucks and you just drop 20 grand. I mean they're they just they just spend way way too much and then it's the root of all stress just just it's not what you earn it's what you burn and two PhDs wrote a book a long time ago the millionaire's next door and what blew everyone's mind is that teachers was the occupation that had the most millionaires because when you're a teacher you're like well teachers don't drive Mercedes Benz and live in big houses and take trips to Europe were teachers but they just did that consistent three to five percent savings of every paycheck throughout their entire career and when they were 65 they were the most likely to be a millionaire and I'll never forget in a Phoenix Arizona with that Keeton went bankrupt and my gosh that guy had made a hundred million dollars a year half his life and didn't have a nickel saved but he had helicopters and mansions and owned Islands and it was just just runaway debt my god. Gosh we went well over an hour is there anything we didn't talk about that you wish we did or that were you're planning on?
Richard: Well you know it's interesting in this Tabac that we backtrack just a one important point that we didn't touch on you kind of tangentially mentioned it was one other little bit of advice for the young doctor have a financial plan have a financial planner, stick to it start saving from day one because the teachers and the firefighters the public servants who have union positions you know they're kind of into forced savings that's how they end up being relatively secure in their retirements as dentists we don't have anybody kind of doing that for us we have to be self-motivated and I can't quote your statistics on the number of dentists who have nothing saved or haven't you know maximized their pension plans but you don't want to be in that group you don't want to be you know 60 years old where I'm at and I have nothing saved and then or not enough saved and have to keep practicing because that's a really dreary existence where you have to go back or you have to reinvent yourself at a certain age and try to do it again. So you know one of those other little tidbits is you know when you're 25 and you graduate from dental school you're never gonna get old you know you're never gonna head you know you're never gonna be short up here or you know bulging in the middle or those kinds of things but you know it happens in the flash of an instance and you know what you do today is your future tomorrow and one of those pieces of preparation is certainly the financial preparation and one other little tiny observation I can tell you from personal experience that everything we do in our in our careers for better or for worse comes back to either you know pat us on the back or we pay for it later every bit of karma everything we said everything we did patience it's just it's amazing how interconnected the world is in terms of what we did in certain times and it's something to be mindful of as you work through your relationships with patients you know your patient comes out of your office they had a good experience you know they might only tell one or two people but the one that goes out and tells ten you know there's just bad karma there and it magnifies both good and bad throughout the rest of your career and it's been interesting to me over the years to kind of say I met that guy 20 years ago or that gal 20 years ago and now you see them again in an entirely different context really important to you know the the you know the Karma of treating people well it's really important to keep that in mind and to basically be kind. No I guess the only the other thing I could say Howard is you know in some ways being you know I'm not exactly sure what comes next in my career I'm going to continue the expert witness work I'm very I love working in Alaska, Alaska is one of the greatest places in the world I have some incredible adventures I just got back from the Bering Sea looking for glass Japanese float balls on the beach we found seven hundred and fifty of them camping with some native men off the coast of port heiden Alaska there's incredible adventure. So you know and I'm going rafting you know you know month or two down down a river for a week and so there's this incredible adventure there but in the bigger picture trying to figure out kind of what I want to do and take my own advice just like you're right out of school well now I'm kind of at the other end do I want to take on other companies that approach me or continue working in industry. I've got to figure all that out so I'm in exactly in a sense in the place that I'm talking to your young graduates about so it's an exciting time for me just like it's an exciting time for them.
Howard: Well if you want more information as website is Mounceendo it's Richard Mounce, it was an honour to podcast you today thank you so much for coming on the show.
Richard: Thank you very much it was an honor as well thank you Howard. Keep up the good work I'm a huge fan.