Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard: It's just a huge honor the podcast interview today the legend of endodontists and of Arizona Bill Leibow, how are you doing?

Bill: Fine and you?

Howard: I am doing so great I'm so curious to know if you remember this but I graduated in 87 I came out here picked my location it was May 20 by Senate Lisa graduated May 11 87 got open September 21 87 and for a May 1187 to September 21 87 I was working at sunshine dental you remember Sunshine dental?

Bill: I remember those names

Howard: and I was my first big molar root canal and after about three hours I had no idea what to do and I called you and talked to the receptionist and she said well just send the patient home right now and and in any way the that I called back and I said well you know can I talk to the endodontists and you got on the phone and yuri treated my first molar root canal did you remember that in 87 you'd have no idea but you were so nice about it you were so sweet it was so bad I completely botched it I said well I'm so dumb I said well how do I do it you can just here you go and so so now it's so funny because that was 32 years ago and so I still feel like I can feel a little bit about what it feels like to be that kid walking out of school because the only real memory I have of my first endodontic nightmare was with you. So when I go to those dental schools what I feel is sad is you know there's 10 specialties and you're an endodontist.

Bill: That's right

Howard: but another one is public health and I just when these kids walk out of school and they don't want to do molar endo and that cuts down public health access and availability but I start talking because I am I'm such a fan of yours I'm starstruck but I need to read your intro first Dr. Bill Leibow DDS MSD graduated from Indiana University dental school in 1974 and then went on to Boston University of Graduate dentistry for his master's degree in endodontics and in 76. He started private practice in Phoenix Arizona that same year and was the fifth trained ended on us to start a practice in the state of Arizona. He began teaching as needed in 2003 at the Arizona School of Dentistry in oral health in Mesa Arizona with Jack Dilionberg who we had on the show earlier, when the clinic opened in 2005 he closed his practice and went to work for endodontist Robert s Rota endodontist who's been on the show just an amazing guy just a great guy two days a week and then taught the dental clinic at ASDOH three days a week as co-director of endodontics instructing students in the pre-doctoral ended on a clinic. In 2010 when one of his pre-doctoral students finished his residency in endodontics he left the practice and became a full-time instructor at arizona school when he continues to teach to this day he says he's gonna teach until he can't hold a file. He is responsible for all the preclinical didactic education and code directs with Dr. Jean Jasper and for other an Adonis overseeing all the clinical endodontic treatment Dr. Liebow enjoys spending time with his wife Ellen his two Standard Poodles Roxie and Bailey his Corvette and photography and I am loved the article you did Oh what what's her name on Lisa molar right there's another dental magazine right up the street Lisa molar class act lady great magazine and you did an article with her top 10 favorites and you knew your wife would read it because the first thing was your wife so I figured either your wife wrote it or you knew Lisa was gonna send her a copy she's top 10 favorite or my wife my Standard Poodles my Corvette my life Arizona School of Dentistry & oral health Dentsply tulsa dental specialties for all they do,Vortex blue files, Brasseler USA, Endosequence, for pulp cap and root repair, photography designs for vision thanks so much for coming on the show.

Bill: Well thank you for having me.

Howard: So how does endodontics look how long have you been an endodontist?

Bill: Well that'd be 43 years

Howard: You said one of the things in Lisa Molars article what is it called?

Bill: Endodontic magazine

Howard: Endodontic magazine, you said Dentsply tulsa dental specialties and what it is...

Bill: That's now Dentsply Sirona they changed their name.

Howard: They got married and is it one word or two?

Bill: I think I don't think, Dentsply is one word and then Sirona probably it's probably a

Howard: They're not one of them hiffin marriages?

Bill: I have no idea

Howard: No they're not their two words.

BIll: They're a good brand

Howard: Well you know I'm when I think of Tulsa dental brand, who was the guy who founded that?

Bill: Ben Johnson

Howard: and he sent Brad Getlemen who wrote chapter 8 in pathways appalled by Stephen Cohen we were classmates he bought the oldest endodontic film ever did you see that?

Bill: No I didn't

Howard: It's the first film and it's a hundred years old and I'll pull it up or send it to your order and let me see it and it was so funny because Iremember getting out school that was one of the earliest arguments like well if you need to do all that then why do these silver points last because they got a a in finding all the canals cleaning and shaping and so who cares what they'll optrated with but I got to show you that video but anyway but who's the founder of tulsa dental?

Bill: Ben Johnson

Howard: Ben Johnson when I had another endodontist it was in 87 I called him up and he had just started Tulsa because he's in Tulsa Oklahoma right and I was calling up and he was explaining something goes what you know he could be so I could show you in five minutes of you're here and I said well I'm in Phoenix it's a two-hour flight on Southwest Airlines for a hundred bucks he was a flying animal say and I said oh and and then I said I'm well we're we're what's the closest hotel to where your office is you just stay at my house would be a lot easier so I flew down there it spent the whole day with them and here was this guy you know just showing me everything and I that's why I've always loved dentistry there's so many people like you and Ben Johnson. So I've so yeah he gave me that film I said well can I post this on social media downtown he was sure I mean he paid a penny for it but so how does endodontics look differently now than it did 40 years ago?

Bill: It's more sophisticated there's it's still basically the same principles you have to clean and shape and you have to have a good pptration and a good seal and those are the core principles uh rubber dam still is a preeminent a lot of people think they can use mr. Thirsty's or there's a lot of suction devices out there.

Howard: Isolate

Bill: Isolate that's one but that still is not standard of care and doing endodontics you still need a rubber dam

Howard: So you're saying you have to work under a rubber dam?

Bill: Have to work under a rubber dam

Howard: and it's so easy because the first day I opened my practice I took a rubber dam right above me and I've been underneath it for 32 years.

Bill: Absolutely and but surprisingly I mean as an offshoot to this I worked for the Board of Dental Examiners overseeing endodontic cases that the board gets and a huge amount of them are done with no indication that there's a rubber dam.

Howard: So they took a working leaf film and you can't see a clamp.

Bill: Take a work, well you know you have to put it in your record you have to say I put a rubber dam on that tooth you don't put it in the record it doesn't happen.

Howard: So do they need to see we're in the trialing?

Bill: Well because I can put a I can put a rubber dam on without a clown a lot of people can and but my notes always said there's a rubber dam on the tooth and if my notes don't show if my don't have x-rays of a file length for a trial file length I have a notation that I did that with an electronic apex locator so I know that it wasn't I feel there was a reason for me to have that length. I see cases all the time there is no indication of how they achieved a length there's no indication that they did a rubber dam and that's the beginning of why they get to have a case against them or root canal.

Howard: You know I never write on the chart that I've used her over dam but I just don't use profanity that's just me so it's still finding all the canals.

Bills: Finding the canals knowing anatomy you have to know the anatomy my first associate in private practice was a microscope train ended honest and almost every day in my practice he would tap on my shoulder and say I can't find the canals and I virtually spent a lot of time learning tooth Anatomy and thinking about tooth Anatomy I still think about tooth Anatomy and I would take five minutes to find the canal because I knew where to look and that's half the battle that's what I teach the students at school.

Howard: Okay let's I want to I want to work backwards okay conversation because you I mean I really feel like I mean you I mean you were the fifth right in adonis in arizona and today there's the ADA launched a class action lawsuit against delta dental did you see that?

Bill: No I did not.

Howard: and so let me find it for you and it's all over dental town me because it serves the point in time drawn so let me go to the website the american dental association has filed a class action lawsuit against delta dental plans and the delta dental plan association the complaint alleges that Delta has engaged in anti-competitive conduct and violated federal antitrust laws by allocating territories of operation and dividing the national market in order to restrict competition and reduce reimbursement rates to dentist the complaint goes on to allege that delta is anticompetitive acts herbo dentists and their patients by limiting the choices of dental care available to patients making it more difficult for dentists to deliver the care the patient need want in addition to the ADAs complaint individuals have filed several class action complaints against Delta who alleging antitrust violations and these complaints ADA and the individual dentists are requesting that the court certify the proceedings as a class action the court ruled many requests and with the the one they're talking about is the suit against Washington by doctors dentists Bradshaw Todd Erwin Nathan Russell who talked about the lawsuit at length on the show number eleven sixty four and the bottom line is I don't want to get into all that because I'm nobody likes competition I mean the dentist they wish that they could charge $1,000,000 for a crown do one every January first and then layoffs and they're always mad that Delta won't do this a nap but how much insurance is the American Dental Association cell none and when Americans go buy a thousand dollar iPhone do their employers pay for part of it do they want the government so the and it's supply and demand its checks and balances the liens not gonna sleep with the lamb because the lamb knows the Lions gonna eat it and but but that's not the point I want to bring up the point is that Delta has more research on dentistry lasting but and they'll never show I mean when I go down to Chicago the ADA here Delta's here I go talk to the ADA chief economist and they're like no they won't show me their data they won't even return a phone call because of this type of relationship but when I'm drinking with them at the bar and I lectured to the Insurance Association or anyway there were about a hundred dentists there that are the claims adjuster guys or whatever they were showing me data that they would not post on dental town or let me publish in magazine that basically when they look at hundreds of millions of claims that go back you know as longer than your career that when you do the molar root canal in five years five percent are extracted and when I do it ten percent are extracted so it's kind of like I feel like no matter what all this dentists are doing wrong about 90 percent of them work.

Bill: Right

Howard: So my question is why do you five percent of yours fail to need extracted and why is ten percent of mine? So let's talk about that could be first of all do those numbers do they sound about right to you?

BIll: No I never pay attention to those numbers I know that the endodontic Association I know that molar root canal done by an endodontist is predictably probably about five percent greater success rate of a none endodontist doing a root canal.

Howard: and that's what I just said.

Bill: Yeah that's what you said and I would say that's a problem that's probably reasonable it's there there's it's their complex teeth and if you study anatomy they're very complex teeth, the problem I think with general dentistry in doing endodontics is number one economics especially the kids coming out of school today are in such debt that they're doing everything. I think that's one reason some of it is the pre-doctoral education pre-doctoral education xand schools that have postgraduate programs do not share and do not give the pre-doctoral students enough practice to be marginally good at doing molar endodontics.

Howard: So do you have an endo program at AT Still, I know?

Bill: We do not have an endo program.

Do you have any specialty programs? I know you got ortho.

Bill: We have ortho and we have an AEGD program and our AEGD program is the endodontic is overseen by two endodontists.

Howard: and what about the other dental school?

Bill: They have two endodontists, Brad Gettleman works there and Larry Johnson works there but all the endodontics and that school is overseen by General dentists.

Howard: but do they have an endo program there?

Bill: No

Howard: but Brad is amazing so they got two endodontists for...

Bill: They oversee the endodontics in the clinics when they're asked right.

Howard: Two guys for the whole school? When Brad and I were at University of Missouri Kansas City we had six endodontists.

Bill: We have two full-time endodontists and three part-time endodontist at asdo.

Howard: Do you remember ever hearing of an endodontist named...

Bill: No

Howard: That was my favorite endodontist at UMKC just amazing but anyway

Bill: So it's education I mean when I have a kid leaving I call them kids because I'm 72 years old.

Howard: You look great though

Bill: Thanks when I have a student who leaves that school they know what molars they could look at and they know what molars they shouldn't try we spend a lot of time educating them to to be aware to look at radiographs to think before they jump and so and they all leave with my cell phone number

Howard: Are you serious?

Bill: Since the school has been open, they all leave with my cell phone number and every month I get two or three calls an x-ray sent to me should I do this should I not do this what am I doing wrong those kids have bought me for as long as I'm around and can answer questions they all have...

Howard: but you're only 72

Bill: I'm only 72

Howard: and your mother just passed

Bill: 101

Howard: At 101

Bill: I don't think I'll be at school at 101 but so and then even the doctors that ira mediate for the Board of Dental Examiners because I do remediations all have my cell phone number and are all free free to call me anytime and ask me any question send me any xray and I will help them if they went through my class if I've educated them I'm theirs and I don't charge for that afterwards I think it's my duty.

Howard: You're so adorable I mean really I mean where does that come from?

Bill: I have no idea.

Howard: Your mom probably right?

Bill: Probably not

Howard: Probably not

Bill: Just me

Howard: Just you huh that is amazing you said so many things I don't even know where to start but

Bill: but kids do Moeller endodontics from as though when they get out of school they do them for midwestern also they're pretty well trained there are schools and I can't give you names but there are students that I encounter or some of my students well let me know that their associates have maybe shared a molar root canal in their pre doctoral program and that's their total entire molar experience or endodontic experience. Well you're gonna have...

Howard: You got to tell me what name of the school and what city was it in.

Bill: I can't tell you

Howard: Okay just the state

Bill: No

Howard: but and do you do you agree though that when we look at this especially a public health that having all the dentists being able to get some happen I always do the analogy of an emergency room imagine if you broke your leg and you went to the emergency room they go oh we're sorry we don't do legs we just do arms and I you know I grew up in Kansas ah I know how those farmers are I mean we if you tell someone well you go to drive an hour and a half down highway 51 to get to it and they're gonna say just pull it do you do you think that public health and endodontics as far as availability are kind of linked?

Bill: Probably a little bit you know I'm not a public health

Howard: Well you got ot get them out of pain

Bill: Got to get the patient out of pain so I think that we because a lot of the asdo students go to rural areas and work in FQHCs in rural areas and are in small towns they need to know how to do molar antibiotics they need to know how to do a diagnosis and they need how to learn how to make somebody more comfortable to get them out of pain and my students can do that.

Howard: You got to explain what FQHC is.

Bill: Federally qualified healthcare programs

Howard: So if you're over overseas that's a, explain what that is to someone from another country.

Bill: That's a program that takes care of indigent people and it's government's help government funded.

Howard: and when you see indigent people that were Mesa?

Bill: People from Mesa no, there are so few you know I think St. Vincent DePaul maybe a federally qualified health care program there are a few of them around the city I'm not familiar with all of them but a lot of them offer programs if the kids go and work for them for five years they subsidize their educational cost.

Howard: but I want to hold your feet to the fire why do five percent of endodontists root canals fail and then we'll go...

Bill: I have cases that fail

Howard: but what do you think they fail?

Bill: It may be anatomy maybe the tooth has a crack in it that we can't see more there than we can treat the faster we do endodontics the less time there are arrogance like sodium hypochlorite in the canals and the canals may not be as clean I think predominantly if it's not an anatomical issue some of that adonus - lousy root canals.

Howard: Really

Bill: Oh yeah

Howard: So you think they do that because they're burned out or where we haven't been

Bill: Maybe greed

Howard: Greed okay

Bill: Got to do it too fast make more money I mean I have to tell you the greatest pleasure in my life was to retreat other endodontist root canals and have them be successful.

Howard: That was your that...

Bill: and my good friend Dr. Rhoda does that all the time.

Howard: Redo other endodontics root canals

Bill: From other endodontists yeah and or another dentist yeah I mean it's not common. Endodontists are better trained today with microscopes and now we have CBCT scanners that they all have in their offices, it's easier for them to find canals the technology is gone so far it's how much money do you want to spend, I mean you have all kinds of devices there to help you.

Howard: Well that's why this whole healthcare deal it's hard for me to listen to it becauseyou know I don't like ever talking about religion politics sex violence but you know there's always this big old debate that you know health care should be free and it's like okay so they don't even want to pay for their teeth so they'll pay their biggest expenditure is a house second biggest one is a car their damn iPhones a thousand dollars and if their employer or the government doesn't want to pay for their root canal they don't even care so it's like well if you don't care white white you know you're gonna send an IRS agent to confiscate my wages to buy you a root canal you don't even want so.

Bill: People you know it's you can't give the stuff away for nothing.

Howard: Yeah they have no skin in the game

Bill: Have no skin in the game so my philosophy on that as if somebody was had financial problems I would help them with their root canal but I wouldn't do it for free because there's no value to it if it's for free.

Howard: and I got my MBA while you were getting an endo degree I was getting I got an MBA from ASU and when I talked to those fqh people about the bill I so what you know what let's talk about the works for flow problems and I'll say what is your number one problem and they go half of our appointments or no-shows so I go okay so how much is their copayment oh well we're not gonna charge them a co-payment I mean they act like that would be completely immoral I'm like well who pays for their $10 a day pack of Marlboro Lights who pays for their $5 a day you know so I they can buy a $10 pack of cigarettes throw money but they have it can't cost them $10 so they have no skin in the game it's kind of like a but anyway if they have no skin in the game they don't care. So I'm gonna go back to radiology because again these kids come out $284,000 student loans on average for all for all the kids and that's all the kids would debt that does not factor in right the kids who have no debt that's right that's why I have understand that number so is a CB CT standard to care you're at the board...

Bill: Not yet

Howard: You said yet though

Bill: Not yet not yet

Howard: Does that mean it's around the corner?

Bill: Well it's coming down in price you can pick up units for half of what you used to what they were selling for a few years ago they're in the forty fifty thousand dollar range I think now I just talked to somebody that was looking at one I think in the forty seven thousand.

Howard: You know the name-brand was it Korean?

Bill: No idea

Howard: I know that they have come down for but I'm what would you say so forty thousand is it a buy for you now?

Bill: For me I'm not in private practice so it's not a buy but we have of it's a school and we use it we just yesterday we had a root canal that was done five years ago at school and it's failing and it looked great on a radiograph see nothing wrong and it was sore and a CBCT show to failing root system.

Howard: A failing root system

Bill: No it's all filled it looks really good it's just not working so next week I will go in and redo the root canal on that tooth.

Howard: Wow so is the standard so back to standard care you say it's not yet.

Bill: Not yet, equipment aren't standard of care other than having a rubber dam on something.

Howard: Okay

Bill: You know a piece of equipment is using a rubber dam is a standard of care using a CBCT is not a standard of care taking diagnostic radiographs as a standard of care

Howard: Equipment is not a standard of care thinking diagnostic radiographs are.

Bill: Well yeah you have to have diagnostic radiography so the tool you use is not a standard of care but allows you to achieve a standard of care.

Howard: Interesting but you think you think now that CB CTS are down to 40,000 that...

Bill: Well there are endodontists out there that use them on every case and there's endodontists that use them only when necessary maybe a retreatment or a difficult case or they can't find a canal or it's a radiographically very very difficult different graphs very difficult case they may take a CBCT I mean they're originally couched in the idea of this is if you pay this amount of money and everybody has a CBCT and you'll make up the cost and you'll make more money from the CBCT but that's not following the least amount of radiation acceptable Alera rules so you should only take something like that when you need it's more radiation than PA.

Howard: Well you know when you take it on when you said you know some people take it on everyone they remind me of that did you see an article yesterday in the Wall Street Journal Walter Reed failed to examine almost 2,000 CT scans oral pathologist Laura Ike DDS discovered nearly two thousand scans went unread at Navy advanced dental school is in all over in Wall Street Journal Military Time Thing something when it's when you have to when everything has to have is CB CT the next thing you know you might be reading about yourself.

Bill: We have a radiologist at the school board certified radiologists that reads the CBC T's and looks for other things but the students come from this I mean I can only talk about my school okay, students come very well trained they know what to look at there the radiology department works really hard with them showing what you look for in cases we have one student who graduated a few years ago diagnosed coronary artery closing in a panorex on her father because she didn't just look for cavities and she just didn't look for his teeth he was looking globally and she found blockage in his coronary artery probably saving him from having a stroke or dying so the rule is if you take a CBCT either have to have a radiologist read it because there or know what you're looking at or now you have limited field potential where you could take a five centimeter by 5 centimeter slice and only radiograph that with the CBCT so it's a limited field so you're not looking at the whole head you're not looking at everything and you can cut your liability by that.

Howard: So when it seems like whenever I talk to people like you and Rhoda and Gettlemen um you know it's um successful and Adonis's you know cleaning shaping and operating is lease weighted and then when you go drinking with non endodontists it's always how do you operate it's never finding all the canals cleaned shaving when we're talking about CBC T is that more about finding the mb2 which it seems to me that that's the number one cause of a failed root canal because again when I look at the insurance data which tooth is the most likely to fail?

Bill: Maxillary first molars and the anterior first bicuspids.

Howard: Yeah so if you the first thing out of your mouth we started this whole deal is know your Anatomy so do you think do you think the number one most weighted reason to buy a CBCT is missed an ad to find missed Anatomy and that you could do that if you actually...

Bill: Yeah not necessarily missed Anatomy but why is something failing or you have a tooth that the the when you look at a periapical radiograph you can't see everything you need to see the roots are very tiny you can take a CBCT and see if there are canals present you have a better idea of where you're going before you get there.

Howard: Yeah where you're going before you get there huh that is that's a fun way to put it. So 5% of root canals fail because the cracks...

Bill: Cracks you have pathology you have complex cases you this diagnosis wasn't a root canal in the first place just poorly done root canals or a whole variety of reasons for root canals fail and even in endodontists hands I mean there's a very very very complex if you look at it the old studies and look at some of the anatomy that that you've seen with so I'm not really good with literature if you look at some of the old endodontic literature they show dye staining of the complexities of vascular system in a tooth they're very difficult and sometimes you can't clean it all and the faster you do a root canal the less you use hypochlorite, hypochlorite digest dead tissue and helps clean the system so knowing what you see and knowing what you read about endodontics why would any root canal because we do molars and we do lots of root canals at the school why would you think any root canal would be successful in a pre-doctoral endodontist I'm in a pre doctoral program in any dental school obviously they don't have a 100 percent failure rate we have a very low failure rate I can't give you a percentage but I haven't retreated very many teeth since I've been at the school why would you think root canals are successful in a pre doctoral program?

Howard: Because if God's not on our side whose side is he on?

Bill: I don't know, how long does it take for an endodontist to do a root canal on the average 45 minutes to an hour and a half how long does it take a dental student to do it maybe two, two and a half or three hour visits soaking in hypochlorite for all that time the chemistry is cleaning the case.

Howard: Oh I see where you're going with that, Wow.

BIll: Time, time, the faster you do a root canal the more you need to add junk materials to...

Howard: Okay so do you remember a man by the name of ML Rhine MD DDS

Bill: No I don't.

Howard: Here's the first root canal video ever done, he put it on YouTube it's look at that

Bill: Send this to me

Howard: I'm gonna send it to you and Brad Gettleman sent me that that came from Tulsa dental. I just I never thought about that the that the young kids going slow cuz the bleach is doing all the work that is so uh...

Bill: It does a tremendous amount of work.

Howard: That is so cool

Bill: and so and then you then you add some ultrasonics to that or some ultrasonics or just sonic activators that agitate it and it gets better so endodontists who are doing root canals at a quicker pace some do some don't my favorite and thus will remain unnamed one of my favorite schedules mostly to our visits for his patients it's not about...

Howard: How come you won't say his name?

Bill: because I just he didn't give me permission

Howard: Is it because I'm sitting right here and you're going to make me feel embarrassed?

Bill: No

Howard: Okay so I wanted to go back with that because I want to follow the money first because I mean I remember how many times has there been some investigation in Congress and they say you know if you just follow the money you'll find it there's another new piece of equipment beside the CBCT they got a lot of student loans it's called sonendo it's a chunk of change and I and it seems to be more people are talking about the price of it then whether or not it's an actual buy so I the man on Tim.

Bill: It's a mixed feeling between in some endodontists love it and they use it as a...

Howard: Explain to the kids what it is.

Bill: It's a device I have not seen that work is a device that uses a technology you have a specific part of its expense for each tooth is it's like a $50 expense you have to put a special device on top of the tooth after you make access and what it does is it allows the hypochlorite to flow through the canals and get into more spaces sonically I guess I don't know I've haven't really followed the technology.

Howard: So you haven't seen it yet?

Bill: I have not seen it work I've talked to people who've used it and I've talked to people who haven't used it.

Howard: and anybody any of your friends and Arizona use it?

Bill: I have a few that do and I have a few that don't and those that do swear by it and those that don't that does make a difference their failure rate isn't that high and though history has there's a lot of unknown studies yet to prove its actual validity as far as what I've been told you know there are a lot of there are a lot of if you read the journals there are a lot of articles about about it and its success but there are a lot of articles about not using it with success.

Howard: but it's basically gonna be

Bill: It's like fifty five thousand dollars and fifty dollars a tooth

Howard: Let's talk about those two numbers so you said it's the machines basically $50,000

Bill: I think it's somewhere in that range the last what I heard.

Howard: Okay and what's the difference between fifty thousand dollars and fifty dollars a tooth because I...

Bill: Well $50 a tooth is you have to buy the guide that you used to put on the tooth is like $50.

Howard: but where I was going with that is this it's $50 a tooth I mean $50,000 is a balance sheet number I like a lot of people say well I don't know if I want to buy a CAD CAM it's a hundred and forty thousand dollars well first of all no one gives them one hundred and forty thousand dollars for a CAD cam when you look at the math everybody they got they lease it so now we're looking at fifteen hundred a month so so don't even discuss the $150,000 a number if you're not gonna give someone a hundred thousand ours so it's not a balance sheet number it's a cashflow number so it's $1,500 a month so I'm asking you if every month I gave you $1,500 for the use of other people's money for this CAD CAM my office how do I get my $1,500 back and you say okay well it'll lower my lab bill because instead of to the lab I'll do it right here and I say okay well there's a National Association of accountants there's Kane Waters I mean there's there's I can think of at least three different areas where I could go and get a huge big data set of numbers and you're saying that all the people who paying 1,500 month for a CAD CAM have a large kind of Bridge lab bill so it was a return on investment and if you say yes I know one thing you didn't do your homework you don't have an Excel spreadsheet you don't have any numbers you didn't read it into math because you know see it so this Sunendo its two issues it's fifty thousand dollars the thing i don't like about it is you're not getting given fifty thousand dollars and you know why I know that because everyone that has 50 thousand dollars if you actually have 50 thousand dollars you will spend it on anything you know who buys a fifty thousand dollar new car someone he doesn't have fifty thousand ours because now they just have to do a lease payment five hundred dollars a month and people always ask me when we young Dennis get my car they go why don't you buy a new car and I'm like because this is paid for and I have cash you have to be young and dumb to use other people's money for a car. So if you don't have $50,000 then I would say well then you you absolutely they've been I'm gonna post this video today have root canal they've been doing root canals for a century without having to buy a 50 thousand dollar deal and as far as $50 a tooth Wow you just said something even amazing that the younger kids have a high success rate because of bleach is in their longer and I've noticed in my set of friends the Dinda dogs who are really amazing they say that 30 years ago they used to do five or six molars a day.

Bill: Right

Howard: and now they're down to four or three molars a day.

Bill: Because we're seeing more difficult cases cases are I don't know why they are I think the general I think one thing about that is the general dentists today in some schools are getting better training and they're doing more easy when I first started in endodontics Phoenix Arizona I did central incisors I did bicuspids I did molars I did easy easy easy teeth dentists just didn't want to do root canals today students are trained better there are more students doing the easy teeth and therefore the endodontist are seeing much more difficulty.

Howard: Plus today with dental therapists aren't they allowed to do all the single canal root canals?

Bill: I have no idea, in some states.

Howard: In some states

Bill: But so we're seeing much more difficult we're doing more retreatment we're doing more complex cases we refer probably three or four cases a week out of the school that are way too complex for general dentists to do I think that means that I make that decision.

Howard: Who do you send them to?

Bill: I send him to do a couple endodontist in the valley who are also educators at school.

Howard: Okay so I want to tell you one of when I meet a dental epidemiologist the thing that's that just is there trigger word that just really gets them upset is so many dentists after every root canal pen NBK and vicodin and the AE has guidelines for antibiotics but you there's there's 211 thousand Americans alive with the license to practice dentistry a hundred and fifty thousand are 32 hours a week or more general dentists thirty thousand thirty charge a week or more with specialist of the 150,000 general dentist 32 hours a week or more how many of them do you think give a prescription for antibiotics after every root canal?

Bill: I would say probably 50 percent.

Howard: I know so what do you what do you think of them?

Bill: Well I think it's stupid if it's not every tooth needs an antibiotic if it's a vital tooth it doesn't need in the antibiotic because it's vital it's not infected if it's infected and asymptomatic it may not need an antibiotic if they're infected and it's draining and there's pus and they're swollen they may need an antibiotic to help them get through a crisis. I see patients patients come through the school that they seen a dentist and they didn't like him and I saw him in in my practice that patients come in they got a tooth that's real sensitive to cold and dentist is too busy it gives them pain medication and an antibiotic and says come back in a week well they don't need antibiotics because their tooth isn't non-vital it's not necrotic it's not infected doesn't happen from the students at ASDO as far as I know because found that in their heads and we very rarely give antibiotics and we very rarely give narcotics at that school.

Howard: I know that's why if we go in there. So if you did 100 route cows how many would get antibiotics?

BIll: It depends on how many needed it.

Howard: but just for okay

Bill: Can't ask that question in that way okay so if you came to me and your face was swollen and I started the root canal but you added a lot of pus and I couldn't drain it and and you had an acute infection I would probably give you an antibiotic if you if you're very badly swollen and I don't want to start giving you anesthesia in an area that's infected and pass the needle through areas I may put you on an antibiotic for five days to get your infection under control before I start your root canal.

Howard: and what antibiotic would you go with?

Bill: The drug of choice is amoxicillin it used to be pen BK but the drug of choice from the ADA and the AEE now for endodontic infections is amoxicillin and if you're allergic to amoxicillin it's clindamycin.

Howard: That's why seriously I'm not even kidding that's why I always when I order a pizza always get mushrooms on it because penicillin came from a fungi I think dentists should always have to eat mushrooms.

Bill: That is a narrower spectrum pen BK but now they're using a broader spectrum amoxicillin.

Howard: So 'm just gonna go from trigger words to trigger words and trigger words I know the reason I hesitate to ask this question because channel conflict is called when someone has to deal with people that are triangles circles and squares well they don't want to come over here and badmouth the squares and triangles cuz they got a deal with them right but on dentaltown one of the biggest threads and it's a huge thread there's like 1600 on it is which file do you think is better for molar endo waveone gold or edge endo X7 and before you even answer that if I went to Tiger Woods I know he could probably beat me in golf with any clubs from anybody we always talking about to size matter does the file matter?

Bill: That's a hard answer I can't you know I'm not familiar with that Gendo we use and supply Sirona we use wave we use wave one we use vortex blue those are the two file systems we use it's a school plus a regular 02 taper hand pile from from lexicon which is a subsidiary company of den supply those files work great waveone gold is great ProTaper gold is great I'm sure edge endo is great I have here pros and cons about it I haven't experienced it I don't allow the kids to have a lot of experience with different things because it's hard enough to get them to learn what they're doing what the one system as opposed to giving them two or three systems. So they do a little bit of wave 1 they do a little bit of carrier based operation they do a little bit of everything in a narrow window I know it's not the freedom like you have in a graduate program try this file and try this file and try this file that's something that they need to research on their own when they get out of school I won't comment on what file is better browser makes a good file system they have three or four different types of systems, Dentsply has three or four types of systems, edge endo has something that they make that is comparable to three or four different systems and there's just a whole variety of stuff out there and I'm sure they're all good in somebody's hands.

Howard: Well it's funny how I look at all these on different because when you say let me see an edge endo.

Bill: It's out of New Mexico.

Howard: Yeah that's what we just gonna say when you say edge endo I think of Chuck Curtis and New Mexico and when you say tulsa dental I only think of Ben Johnson and when you say I like breslar into a sequence because out of those three guys Ben Johnson Peter browser and Chuck Curtis Peter browser could drink anyone under the table and he was a good old South Carolina boy I'm just amazing man but I so what's that?

Bill: It's an amazing company they make good products.

Howard: Was is it Savannah Georgia?

Bill: Yeah

Howard: It is just amazing but I miss I really do miss Peter Bbrowser he was amazing well I talked about CB CT as a standard of care is loops standard of care when of all the dental procedure I mean I really got to see the tooth when I'm doing a filling?

Bill: All the students in school are required to have loops to do their dentistry I don't see it as this has a requirement to do endodontics or a requirement and I mean the ASA and the A's I'm gonna tell you have to have loops.

Howard: Do you think do you think you need of all the ten especially do you think you need loops more or less an endo or you need it more?

Bill: I mean I need loops in a good light.

Howard: Do you use a minor's headlight or these over

Bill: I use a Brassler two-headed surgical operating light that it is so bright it'll almost blind you

Howard: That you were on your head?

Bill: I wear it on my head it's not on my glasses that's because I can have light and

Howard: I don't mean to be rude, I mean obviously you wear a wig is it does it mess up your wig.

Bill: My grandfather died with this hair so no we have microscopes my light is brighter than the microscope light and I use four and a half or six loops if I'm not using a microscope I use four and a half and six loops I have a lot of friends that are endodontist that do 100 percent of the root canals under a microscope and I have a lot of friends that are in the dentist that after they make their initial access they take a look at the floor in the chamber of the tooth with a higher power to see if there's any cracks or things they don't like and then they go back to their headlight in their loops it's just easier patients are if the patients are moving around microscopes are hard to deal with so microscopes still aren't a standard of care do endodontics even graduate programs they're all teaching microscopes but the AEE hasn't said you have to have a microscope to do endodontics and I doubt if they will they would probably a II would like States to come out and say molar endo should only be for endodontists and there's there have been what's the word I want there have been pushes from the from endodontist and the AEE to try to get that to be a standard of care and endodontists only do molars I don't think it'll ever happen.

Howard: Can we just kick him out of the country for asking or do we have to tolerate them.

Bill: We have to tolerate them.

Howard: Yeah of course they want to be the only ones they can do their work now there's 324 million people.

Bill: Right

Howard: and why don't they just but it wouldn't be easier just to steal everyone's car.

Bill: that's right I mean I it's all goes down also it all goes back to training what are you comfortable with I mean I see a lot of endodontics for the board that's poorly done mostly by general dentists and I see some done by ended honest and and and it's basically tincture of time and it's quality of work and care and you can be if you can be you know I have dentist endodontists friends didn't brag about their 30-minute molars well you could do a molar in 30 minutes I have another friend who I said doctor rota who retreats a lot of 30-minute molar root canals by endodontists I can't personally say what's right or what's wrong what are you comfortable with I mean for me a molar root canal and my private practice when I was doing it was an hour and a half to two hours.

Howard: When I started with this interview we talked about how dentistry has changed over the years did you mostly hand filing for you when did it go from a hand filing to rotary?

Bill: You know I can't tell you the exact date but I can tell you that I was probably one of the last people Phoenix Arizona to start using rotaries because there were a tremendous amount of them the early rotaries the sophistication wasn't there with a different heat treated metals and stuff that you have today and a lot of people left a lot of files and a lot of canals and that's something that I there was more stress and strain in my life to grab a rotary automated hand file than there was to sit there for a little bit extra time and go by hand I was the torque motor I was the torque system it was my feeling. The instrumentation today is vastly superior we use a motor that's you know today you can buy a handpiece system that has been set up and programmed to do a specific company's files and stay within safe parameters.

Howard: Do you think that the fracturing has really dropped off?

Bill: I do believe so we have probably in the last five to ten years at school I think we fractured maybe five or six files.

Howard: because you know Barry Musikant, another great man he has his own system and are you familiar with Barry Musikant?

Bill: No I am not.

Howard: He was the first dentist in the first endodontists in New York City to be open seven days a week and he was just he just thought that was important so obviously has the biggest most successful I'm off set but he started his own root canal system it was called essential dental system safe side stainless steel going back and forth so because they wouldn't break and so that was a big solution to a big problem back in the day but you think files breaking today is much less a problem would you say it's on the way of the dodo bird and?

Bill: Well no it still happens but I think it's less I will tell you this is a personal thing on my part that you probably have not heard this I don't know maybe maybe not it is not below the standard of care to separate a file as long as you tell the patient it's below the standard of care to separate a file and not tell the patient you may not be able to get the file out but you still aren't operating below the standard of care what's going to happen one of these days is if you read the product sheets for endodontic files the product sheets say they're single-use files you're not supposed to sterilize them and reuse them so some lawyers gonna say call the office does your do you see sterilize your files and use them more than once in a patient, yes well you're not following the manufacturers recommendation for that file system so maybe there's a lawsuit there I hate to say that on public, but it's you're not following the manufacturers recommendation single-use files all the files in the school are single-use files we do not sterilize and use them again in a patient all the rotary files are single-use files.

Howard:  but you're familiar with Barry Musikant's systems safe IDs safe side

Bill: I have not used it but I've read about it.

Howard: but you don't but you don't think but you think that problem has gone away less?

Bill: I think the fracture of files is is less than it used to be because the metallurgy is better has it all gone away no we still see files with separated teeth with separated files in them the anatomy of the tooth a file is not going to take a 90-degree Bend if you're pushing it really hard and not separate if you don't have proper access and you put more stress on the file it could break and separate so a lot of that has to do with how you shape the tooth and how you prepare the tooth for the root canal.

Howard: So another question they always get on this still is like one step or two stabbed there's still a lot of people back back to these hundred and fifty thousand general dentists that are full-time thirty two hours a week or more how many of them believe that if you see anything periapical says so anything periapical you can't do it in one appointment?

Bill: Literature doesn't say that literature says that the six they're probably a lot of them that don't even read the literature and just do the root canal in one visit and give them antibiotics and pain medication and the problem doesn't arise and doesn't and goes away which I'm that's something else we talked about a little bit the endodontic literature says that there's no long-term difference in the success rate of doing a root canal in one visit or two visits as long as it's done right.

Howard: So you there's nothing

Bill: but we at the school do all the chronic cases in two visits and because the kids are slow most cases even if they're not in a chronic unless they're single rooted teeth and vital to him one visit but most teeth are done in two in my private practice I did all in the chronic cases in two visits but it would put calcium hydroxide in the tooth let it sit in there for three or four days help clean the system and then have the patient back and optrate it I never did in the chronic cases in one visit that's just a personal preference on my part literature so that I can I choose not to.

Howard: Are you friends with Ben Johnson of

Bill: We know each other.

Howard: I mean is he a good friend or?

Bill: He's an acquaintance

Howard: Ok so you can talk about about his product what do you think about thermofilm?

Bill: I think thermo feels probably one of the better systems if you know the right way.

Howard: Really

Bill: You didn't expect that did you?

Howard: I did not expect that I just I think that I think that it's the most abused poorly done system out there because nobody follows the protocol and that's why it fails but if you follow the protocol and do it right I think it's the one of the better systems out there for operating at you know we teach it to school not in the clinic but we teach it in the school and a sim lab experience because a lot of the federally qualified and where the students go to different community dental centers around the country a lot of them use carrier based operation and they needed to know how to do it the right way I'm trying to get Dentsply and the school to put on a continuing education program with a particular endodontists from New York that is a master of carrier based operation and do a CE class in Phoenix on that because...

Howard: Who's that guy?

Bill: His name is you're gonna ask me that yes I'll think about it in a minute his name is Steven Nemzek he is the Guru of carrier based operation as far as I'm concerned I have learned a lot from watching him and listening to him and talking to him and if he ended on any general dentist or ended on us they could take a class from Steve Nimsik would learn something.

Howard: He's in New York City?

Bill: He's in New York but he does the lecture for Dentsply Sirona and I'm trying to get him to come here.

Howard: So why are you...

Bill: Just really poorly done if you really...

Howard: Just really surprised me I never thought I never thought I'd hear an endodontist say he likes thermofil.

Bill: We don't teach it at ASDO we teach it at ASDO we don't do it in the clinic number one it's more expensive it's more time-consuming it's you need to be pretty well practiced before you do it because it's so easy to wipe the gutta-percha off of the carrier so it's just more technique sensitive but students know how to do it and one of these days we'll probably start doing it in the clinic.

Howard: So why do you like it though?

Bill: because if it's done right it creates with sealer it creates a phenomenal seal if it's done right and and a warm vertical condensation at the school which is more difficult and time-consuming we use three-dimensional warm gutta-percha because that's how I was taught that's the system we use so we get a very good seal when we're doing our endodontics but I think that the carrier-based operation gives you an even better seal.

Howard: So he likes carrier base

Bill: He does everything he's he does all of his retreatment Sauer carrier-based he retreats a lot of carrier based in Rita he's a master at carrier based operation cleaning and shaping is cleaning and shaping operations operation and and particularly follow the tenets of how that how Ben Johnson set that up to do it and you'll get a good seal but everybody cheats.

Howard: So you were saying that it's not very good because a lot of the people that take shortcuts are gonna?

Bill: That's why it fails is because people take shortcuts and that's why I endodontist hate it because all they got to do for several years and currently is retreat a lot of failed carrier based operation I have yet to talk to general dentist in the community who does it and ask him two or three questions and get the right answer.

Howard: So another change and it's a it's a new thing you said brows is when you and I got a school whose Grossman cement that was then this cement and now a lot of people are switched to ceramics.

Bill: Right

Howard: Well where are you on that?

Bill: I am not there yet because if you operate a tooth with ceramics calcium silicates cement based sealers and you fill short and you block the canal with ceramic you're not going to be able to get through and retreat it very easily if they got a perch it goes through it you can retreat it but if you have a plug of calcium silicates cement concrete at the end of the root not sealing real well but they're it's very difficult to instrument through that stuff you almost have to go in there with ultrasonic sand a microscope to get through it.

Howard: So do you think that ethically we have we should be doing root canal so that they can be retreated?

Bill: I might be able to do one that I could retreat if I needed to for some reason because maybe.

Howard: but would you say that if a system is not re-treatable that would that would make this system not acceptable?

Bill: In my hands and my mind yes that's why we don't use it at school but in other people's hands it's a great system and they seem to have a lot of success and there's a lot of single-point techniques out there that use that so shape the canal you put your sealer in and just just put a well-fitting single cone in it you don't pack it at all.

Howard: So do you remember you remember Joey D Joe Duncan?

Bill: Yes I remember good man.

Howard: Yeah I was in Swanson Hall we were a 9th floor for three years I was 9:59 he was 919 it's I think he's the smartest person I ever met that is.

Bill: Brilliant

Howard: I mean he could do he's the only guy I knew that did all of his geometry and trig in his head he'd said well you don't need paper he was a nice guy but he when it came to arbitration he was a squirter he wanted the the liquid stuff some people what single cone somewhat lateral condensation what do you what do you talk about Joey DS squirting what do you think about hot gutta percha?

Bill: Well you we do use warm gutta percha but we use a cone instead of squirting technique and there are a couple of defconn did it and there's a couple others that can remember the names John's Tropico I think was a squirter that's right and John they're both great that you are a master of what you do when you're you when you're squirting because it's easy to overfill and lose control of that.

Howard: So what's the other way your are you?

 Bill: We use warm vertical condensation with a cone.

Howard: but squirter is one word what's the one word for that versus squirter?

Bill: That's the only thing I've ever call them is squirting.

Howard: What did they call you if you call them squirters what do they call you?

Bill: I have no idea what they call me.

Howard: because the other thing the other thing Joey D is in his language was I'm you were either an apical barbarian and always got a puff of sealer at the end.

Bill: That's how I was taught, the shoulder.

Howard: The shoulder so an apical barbarian or a pulp lover and a lot of apical barbarians didn't think much of the pulp lovers and it was vice versa.

Bill: Everybody's different today today in endodontics today because of calcium silicates because of MTA because of brass or bio sequence because of what bio Dentyne those are all calcium silicates they're very kind to pulp today we're doing a lot as an endodontist I look as a as an endodontist that part of my goal and and requirement is also to teach the students vital pulp therapy how do you preserve a pulp and maybe not do a root canal so when I finished dental school and finished endodontics if you had a curious exposure you did a root canal today if we have a curious exposure or some people are doing indirect pulp therapy before they do the exposure and then they'll put some calcium hydroxide down to to stimulate certiorari dentin formation and they'll go back a month later and clean that let's let some residual affected then not infected dentin clean that away and never do a root canal on a tooth and sometimes that works or you have an exposure you do a little bit of what they call a spec pulpotomy which is you go in with a diamond and you remove some of that inflamed pulp in the pulp chamber and you put endo sequence bio dentine MTA over that and restore the tooth and there's a good percentage of times I can tell I won't saw you 50% I'll say there's a good percentage of time that that tooth will survive and never need a root canal never a guarantee but it's always try the patients that read the video on why root canals are killing you I can't remember the name of that video you probably know it off the top of your head.

Howard: I don't talk my head but I know

Bill: What I'm talking about okay root cause they come to the clinic and say I don't want a root canal because we can try vital pulp therapy and if we win they win big because they don't have to have a root canal and if they lose then they're no worse off their tooth is gone I never I never tried to sell a root canal to anybody but I will try to sell treatment and maybe avoid a root canal if they're so opposed to it or it may not need it depends on the symptoms of the tooth it depends on the degree of exposure it depends on a variety of factors we do a lot of vital pulp therapy at Arizona School of Dentistry & oral health a lot of people walk on in there that have had exposures and aren't getting root canals that's the job of an endodontist also not just do root canal maybe avoid a root canal vital pulp therapy.

Howard: What did you think of the response to the movie root cause by your association of an endodontist.

Bill: I thought they did as good as they could do it was a good response I don't remember I watched all of it and read all the stuff and all the responses I personally my point of view and my personal point of view is that I look at the patients say if that's how you feel why are you in my office wasting my time and then I walk out of the room and they go away and they don't even charge them for the day in my time I don't want to have anything to do with them and I will personally tell you that that patient if they change their mind I won't do their root canal because if it goes wrong it's my fault so I refer them to other endodontist I won't do it.

Howard: We know when it comes to anti-vaxxers and the root cause I mean this whole country's on freedom of speech and when people want to argue with me you know in my office they i say look what you really want to do is argue because did you can you give me the text books you've read can you show many days they can can you show me any work you're done well of course you don't have any data you have anything you haven't any work you want to argue and I don't even call them anti-vaxxers I call them the control group and we need to have you know in science what do you have to have on a scientific experiment so I'm glad that people don't get vaccinated and have their teeth pulled because we need a control group and that's what they are.

Bill: I never argue with anybody who doesn't want to have a root canal for that reason.

Howard: Yeah and the other thing that's crazy is I'm pretty much you know when when people do 23andme I'll save you hundred bucks right now if you're thinking about doing 23andme you related to mitochondrial Eve she lived fifty thousand years ago in Africa and all hundred eight billion people related to her I do think it's romantic they called her Eve how did they Adam and Eve I do I think that's very romantic because but anyway you know 1993 for son of all the humans are dead III don't care if he doesn't get it back scenery canal I mean if 93 percent of all humans are mean you're alive you're in the present you're soon gonna join the other 93 percent.

Bill: Well yes and no on that if you didn't get vaccinated and you spread disease because you didn't get vaccinated that's not a good thing.

Howard: but if we but if the government forced everybody on earth to be vaccinated then it turned out that indeed something was wrong with it and all the sapiens oh what happened oh they weren't extinct because the government the other thing I don't understand but that the love for the government is when you when you look at the 5,000 years of recorded history about 1% of all the people were killed by a family member and 6% were killed by the government so you know I'm always leery of the number one killer of humans forcing me to do something because it to me when you think the government should always have all this power and ruling and all that to me it just means that history wasn't one of your favorite lessons because...

Bill: Look at polio though brings up my first wife had polio and was in a leg brace I mean she was one of the last kids to have polio but look what that vaccines done.

Howard: Oh I know so but is it but do you think it should be mandatory?

Bill: For polio, yeah.

Howard: What about the ones they talk about today?

Bill: Which ones?

Howard: Oh my gosh

Bill: There's a vaccine out there...

Howard: That you can't send your kids to public schools well unless they've taken all the vaccines.

Bill: Listen if my kid comes home with something that he could have not had because the kid next to him or my kids vaccinated it's not going to happen but maybe if there's another kid that's not vaccinated yet maybe it's a poor family that can't afford a vaccination and that could get some disease because some parents didn't want to vaccinate their kid kids it's now spreading that in the classroom that's not a good thing that's how I yeah personally how I feel I mean I'm sure a lot of people will take exception to that I don't like government telling me what to do but I also don't want to have to worry about my kid going to school and coming home with a disease that he shouldn't have gotten.

Howard: Yeah

Bill: It's a mixed bag.

Howard: So I can't believe we went well over an hour and I know I should leave you alone it's the Thanksgiving Eve but another big debate on dentaltown that's always it's always pops up for 20 years his um do you refund a root canal when someone pays you $1,000 you do a root canal and now it's in the trash can or it fails well where does a refund if you went to Walmart and bought something...?

Bill: Okay so let's go a step beyond it if you had a heart attack in you and you had a bad valve and they put it in a valve I'm not talking I'm going to talk about on a patient's perspective okay so you had a heart attack you found out you needed a valve replacement you had your valve replacing what at the hospital you spent thousands and thousands of tens of thousands of dollars to get it done and a year and a half later that valve failed and they had to go in do they do that for free?

Howard: Hell no

Bill: Hell no right right so why should i if my did everything right and the tooth didn't work why do the patients come and say to me I want my money back but they don't go to the hospital and they say I don't want to pay for that. That's so there are instances now there are instances where I'm in a dental school and a student does something inadvertently to destroy a tooth well I'm going to eat that because that happens in learning all the time in my private practice I would go to the end of the earth but if I did everything right if you came into my office and demanded the money back I wouldn't give it to you but if you were if I assessed you as a person that had not a lot of means and you spent a lot of money with me and now you're gonna lose that tooth and maybe have to have an implant or a crown I may give you your money back for that reason but that's my choice not their demand. I feel personally that if you did everything right there's no reason to give the money back if you did a crappy root canal that's a different story if you did a crappy crown that's a different story and and when you get want to get to that on into the donek level more endodontics fail because of crappy crowns and then they do because of crappy root canals.

Howard: Explain that

Bill: Leaking crowns caused more endodontic failures and well-fitting crowns if you do a poor restoration on it tooth after it's had a root canal and it leaks it'll contaminate the root canal and root canals fail or the literature will show you I can't quote who in the literature but the literature will show you that more endodontics fail because of poor restorative procedures than they do because of poor endodontic procedures.

Howard: Teah and the other thing I always thought so

Bill: but I don't think I don't believe you if you did everything right that you should have to give the money back that doesn't mean they're not going to demand it and they're gonna ask for or threaten you with a lawsuit if somebody came to me and said I'm gonna take you to the Board of Dental Examiners if you don't give me my money back I would give them the address of the board on a card and said well here's where you have to send your complaint in be my guest I've done nothing wrong. That's how I feel.

Howard: Yeah that is that I do agree that is...

Bill: You know you did everything right go you know you do not have people walking into their physician's office saying you know my cancer came back I want all my money back from my original cancer therapy right?

Howard: Right right right do you but in those modern times that the new Dean that replaced Jack Dillonberg.

Bill: He's wonderful

Howard: Robert Trombley he is a dentist and an attorney yes I say something about the times when the Dean of the dental school should really be a clinical dentist and an attorney?

Bill: I think he's just he's just a brilliant man and I don't know what it's reasons for having both degrees were but he's a phenomenal Dean unbelievable Dean he's thoughtful he thinks he's considerate he is very emotionally level he's not up and down he's calm he's got the students in the school's best interest at heart he's he gets who ASDO is and he's been a pleasure since the day he's been at the school.

Howard: That's interesting how the first thing one of the few things in describing him was he's not up and down?

Bill: Well Jack you know.

Howard: Yeah

Bill: Jack is up and down Jack is it emotional I love him but Jack is a different individual he's he does a lot of good things he's he is he's more emotionally up and down and passionate and not as level as Dr. Trombley is that's not saying that that's a bad thing that's just Jack's personality has been his personality as long as I've known him.

Howard: but it is more challenging and leading a team when someone's up and down.

Bill: I think so sometimes now waiting to the next best thing or what were well we just finished one thing when we're on to the next and I love him because of his mind and how he thought and how he worked Jack is just phenomenal but trauma is a different individual and he's a phenomenal Dean they're both for phenomenal Dean's we wouldn't have the dental school if it wasn't for Jack and all of his passions.

Howard: Right

Bill: I love them both they're both great people but they operate different ways but they both have a foundation of what's good for the school and how that school is run both of them feel the same way.

Howard: So do you feel as romantic to the American Association of endodontists as you do Jack I mean is is the lightly talked about Rhoda he's very big and he's a passionate about the Arizona State Dental Association.

Bill: I am NOT a member

Howard: You're not a member of the Arizona State Dental?

Bill: No I am not because I am retired you want to know why because I'm retired I'm a full-time educator and I would gladly give them a reduced fee but they don't discriminate the fact that I'm an educator I'm not in private practice my income is significantly less and they want to charge me about a thousand dollars for what I will support him I give them three hundred five hundred dollars but they say no that's an ADA thing I guess I have no idea.

Howard: I think I'm gonna call this video save you the whole hour it's an endodontist that likes derma fill and it's not a member because that's what they'll say these are they're all filled with specialists trying to make relations...

Bill: I'm a lifetime member of the ADA and I'm a lifetime member of the AAE. The AAE when I became a lifetime member and an educator my dues went to nothing I have to buy the journal and any other things that I want when I became a lifetime member of the ADA they at one time had a 50% subsidy they made it a 25% subsidy that they will reduce your fee by and then was told that if I don't continue that membership level I'll lose my life membership so the older faculty in dental schools are running from the ADA some are some aren't I can't say in all schools but they don't discriminate somebody I'm an educator I'm at school full-time on in private practice I'm not making the money that I used to make have a consideration for an educator that's in a dental school on your dues.

Howard: Okay one lesson I can't believe where I'm we're at an hour and a half but when I won I'm looking at the endodontic boards and it's amazing others some of these questions have been going on since the board started in 1999 but so it's confusing to a young dentist when you said well they said well what way do they go back to school they're working with their mom or their dad so why do you think that two died and well it has a crown on it and you know when you put a crown on to the lot of them die it's probably leaking all that so they say okay so probably leaking so shouldn't we take the crown off do a root canal and make a new crown and they send it to the endodontist and you drill a hole through the top of it and do a root canal so what if how do you know that it didn't die from leaking and if it did die from leaking wouldn't you have to redo the crown?

Bill: Yeah if you get inside the tooth and it's mushy underneath the crown you know the Crown's leaking if there's decay underneath that crown you know the Crown's leaking you take good radiographs and you can get it and you can take explorers and see if that's a radiograph and see if it's a well seated crown once you're into that tooth you can see a lot of I've opened up with crowns that were mush inside so that crown has to I cut that crown off before I do the root canal because if I don't it's gonna fail. I take out all the old amalgam I used to take out all the old amalgam fillings all the composites put an ortho band around the tooth before I did the root canal on it so wouldn't break because the patient decided not to go back and get a crown I didn't or take it totally out of oclusion why did you do that - mine - this is a brand new crown there's a different story but I would take the tooth out of occlusion so they would have to go get a crown on it it would be so totally out of occlusion if I didn't put a band on it so that doesn't mean you have to cut off every crown that well-fitting before you do a root canal you have to assess each case as it is but there are a lot of crowns and fillings that you can you can take a radiograph of a brand-new composite and you can see that the margins are open I'm not going to do a root canal on that until that's fixed because it's gonna leaking then my root canal is gonna fail so I'll take that composite out and I'll re-restore it and then I'll do my root canal.

Howard: Last question before you shoot me he's from Arizona probably packing a pistol.

Bill: Not today

Howard: You know when I started this conversation we started that right now the day of this podcast the American Dental Association is launching a class action lawsuit against Delta this has been going on forever and they you know there is it's checks and balances supplying demand they they're never gonna get along because they're the strategically there they're different species there they have different roles but because that we'll never get to see the data and because we don't get to see the data there's so many dentists who believe that amalgams caused more root canals for ended AHS because it's expanding contracting and leaking and that these composites were a godsend and then the and but when I look at the data I see AM algemene I mean there's so many things really at last 30 years and there's so many studies on composites that they only have six and a half years so.

Bill: If you had a mod tomorrow would you have an amalgam or a composite in your first molar?

Howard: Amalgam

Bill: So would I so now I ask you another question if you want to go onto further, CEREC crowns latest innovation all this good stuff do you have to have a chamfer you can't have a chamfer with a CEREC crown i think you have to have a butt joint right two millimeter millimeter nap by joint around the two hmm so what happens when you cut through that CEREC crown to do a root canal what's holding that tooth on the butt joint because you just took all the axial walls away in accessing the tooth right mm-hmm if you made a large access if you made a conservative access you may not so the worst case scenario was a young man who came to my office when they were first doing see a crown so I know they're better now in the cements are better I did 14 conservative root canals on that young man and he lost 14 crowns because the only thing that holding was holding them the axial walls were all gone because they were so over prepped so does that mean that every time you access a tooth that's got a 3d printed or...

Howard: CAD CAM

Bill: CAD CAM crowned with butt joints and you do a root canal on it as that crown gonna fall off you can put a post in those but post doesn't strengthen the tooth it offers resistance form not retention the postal brake and the crown will still come off because there's nothing because I put posts in those 14 teeth and the crown still broke off because there was nothing to retain them there was no chamfer just the butt joint with resin cement was a whole new thing we're going to start seeing.

Howard: Whenever I hear the word post it triggers one response I have done podcasts in Tokyo London Paris where the dentist told me that well the government only gives us $100 us for a molar root canal so we have to put a post in every root because we will pick up another $80.

Bill: That's just go to weaken the tooth even more.

Howard: but they can't do a root canal for $100

Bill: Why, I have no clue

Howard: Yeah you can't I mean those are three high overhead places on the planet Tokyo Paris.

Bill: Majority of teeth that have root canals don't need posts and build ups if they enough to get a Pharaoh you need a Pharaoh for a crown to be retained very well if you're gonna do a root canal.

Howard: You know where the Pharaoh came from where barrel making the barrels kept popping and they found out that just a little 2-inch ferrule around the barrel they could stack those barrels 10 high so all that Farrell knowledge who came from barrels barrel.

Bill: I'm not opposed to CEREC Crown's I'm not opposed to all I think it's great technology I think it's gonna be wonderful but my concern is when I do a root canal on those teeth after they've been prepped if they've been over prepped I'm sure they're a lot of dentists out there that are probably gonna over prep and have bigger shoulders and if those need workouts how those crowns gonna start following off.

Howard: So final question it's the eve of Thanksgiving what are you most thankful for?

Bill: I'm most thankful that I have a wonderful wife that we have a great life and then my mother died peacefully.

Howard: At 101

Bill: At 101

Howard: and what were your final thoughts on mom?

Bill: She was just a great lady and I'll miss her although she didn't know who I was for the last year of her life I'll still miss seeing her every Sunday.

Howard: and where was she born raised?

Bill: South Bend Indiana hootachit country.

Howard: So you're a Hoosier?

Bill: I'm a Hoosier

Howard: Now did mom move out here or how did you get from Indiana?

Bill: Mom moved here because she was in her 80s I think and she fell asleep at the wheel of her car and and broke her foot and we told her that we weren't gonna run the Florida because she was living in Florida they retired to Florida so that we were not going to fly to Florida every time she had a problem she had to move here so she moved here.

Howard: and that's why they call Arizona the Florida of the West.

Bill: Right, she lived here for over 20 almost 20-some years

Howard: and I'll just say on the final thought we are the Florida the West in every way I mean Florida and Arizona are just the same but when I get out of school my biggest diagnostic errors were with people that I thought were gonna live much longer I thought well I'll just patch this to through this I mean this guy's all do that oh my god and it'd be like and there he is 20 years later still coming in and you just my gosh I mean I don't even know if I'd patch to you that a hundred when wouldn't would you quit doing definitive treatment on your mother?

Bill: My mother had very little treatment she still had all of her teeth.

Howard: She what?

Bill: She still had all of her teeth that's the way but she I didn't I did not work on my mother unless she needed a root canal she went to a general dentist that I sent her to and she stayed with him until she went into the nursing home then she went to where she was in complete nursing care otherwise she went regularly for cleanings and stuff the general dentist I did not do any I don't do dentistry I'm family I had learned that by doing root canals on my wife and having her wisdom tooth fail. So I can tell you that the first root canal you know my wife was her third molar and the first dry socket that I gave my wife was whatI extracted that tooth and that was the last time I worked on my wife I did two other root canals on her but I don't do dentistry I'm family.

Howard: Well thank you I'm so thankful that on the eve of Thanksgiving that you came down here to

Bill: Thank you

Howard: Ahwatukee and let me a podcast you I will send you that video.

Bill: Please do

Howard: I'll do it right now before I leave and thank you shout out to Jack Dillonberg for arm-twisting him to make the drive down here to Phoenix thank you so much for coming on the show it was an honor.

Bill: Thank you

Howard: and thank you for fixing my first failed root canal.

Bill: You're very welcome