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AUDIO - DUwHF #289 - Jason Barney
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VIDEO - DUwHF #289 - Jason Barney
It’s Howard’s second visit to Superstition Springs Endodontics in Mesa, Arizona. Howard and Jason talk about everything endo - from file systems, to warranties, to pain medication, antibiotics, and more.
Dr. Jason Barney was raised in Spanish Fork, Utah. He is fluent in Spanish, having served a church mission for 2 years in Santiago, Chile. Dr. Barney completed undergraduate work at Brigham Young University in 2000 then attended dental school at Ohio State University. Upon graduation in 2005, he practiced general dentistry in Grand Junction, Colorado. He returned to the Midwest for his specialty training in endodontics at Indiana University. During his residency, he had extensive training in non-surgical and surgical microscopic endodontics. He also has experience with newer techniques such as pulpal regeneration and use of CBCT in endodontics. Since graduation in 2010, he has worked in private practice in Indianapolis, Indiana.
Dr. Barney played collegiate baseball, enjoys running, hiking, mountain biking, basketball, and being a spectator and/or coach for his children’s sporting activities.
Howard: It is a huge honor to be back in my favorite endodontic office in the world. What is it? Superstition Springs Endo? I'm with with Jason Barney, who's an endodontist. He went to Ohio State and he went to his endo program in Indiana. Are you a Hoosier or a Buckeye?
Jason: I'd probably say a Buckeye.
Howard: A Buckeye?
Jason: It's easier to be a Buckeye right now.
Howard: They finally figured out what a Hoosier really was.
Jason: What's a Hoosier?
Howard: It's not even a joke. There was a lady was doing the history of railroad companies. Railroads used to lay like 5, 6, 7 miles a day, they moved too fast to introduce everybody. when someone's running into town, they'd say "Well, who are you?"
There was a man named Hoosier that laid a railroad across Indiana. It would have been common for all of his employees say, "Yeah, I'm one of Hoosier's men." So, what's a Hoosier? This was on National Public Radio. It was interesting book on the railroad industry. I liked it because it really underscores the value of standards, because everybody was laying railroads different sizes.
When it went bankrupt, if you're trained in 5th [wheel 00:01:17] tracks, it was useless and it was later on when governments started realizing that "If we impose a standard, it is really value adding, it makes everything lower costs because trains can fit on every track."
Imagine if everybody's electricity had a different deal and by creating standards, then you can mass produce a toaster because every plug in is going to be standardized 110 or 120, so it was a really interesting book, but on Dentaltown, we got 51 categories and the top categories, of the most activity, always your field, endo or implants or practice management and of all my friends I know of in the backyard here in Phoenix, half of my friends would rather be beat with a stick than do a molar root canal.
They will do single canals, like my friend Bob Savage says, "I would rather just be shot. If I have to do molar endo, just shoot my now." Why do dentists hate molar endo and why did a guy like you decide you want to commit your life to something that half the dentists would rather be beaten with a stick than do?
Jason: Well, it is interesting ...
Howard: What went wrong in your childhood to make you want to do it?
Jason: Well, I was a general dentist for a few years on the western slope in Colorado and I think that what got me interested in endo was the magnification part, because I knew I enjoyed practicing with loupes and I saw some cases on Dentaltown.
People started to post videos of their scopes, what they were seeing when they were doing the root canals through their microscope and I thought "Wow, that pretty much just changes everything, because I could see all this, what could I do with dentistry?" so, to some degree, I was interested in it early on when I had seen those photographs, then we had a prosthodontist come to town.
He was just out of Iowa, I can't even remember his name and I don't know if he stayed, but he had scopes in his practice. He put up two globals in the practice and I thought "Well, if a prosthodontist is using scopes, there has got to be something to it.", because I knew he wasn't doing endo. I think that that kind of triggered things and I started to look in and I thought "Well, what is endo?"
I was doing single canals, I was doing, occasionally, a molar and I would get in trouble and you would realize "Yeah, if I am really going to feel comfortable, I either have to bag it and not do them or I got to get training.", and it just ... That education bug that you have in you, "I am going to go back to school."
That is when I applied to go and started it and that is kind of what triggered it, thinking that I was going to learn all of this, as we were talking earlier about how you really get your education. It is ironic, because so much of our education says "This is how it is supposed to be", in dental school you are taught all of this stuff, even in residency, but when you get there, you realize "One, I don't know if they even know everything and what they are teaching is accurate because they are not out in the trenches getting the cases, showing those cases", and then when you get there, you realize that and then you realize "Well, I don't know everything even after I get all of this education."
So much of what we do is clinically based and how do you get that once you are right there doing it? Anyway, I think that that is how ... The long answer to your question, but, yeah.
Howard: What percent of the ... As an endodontist ... Most everyone you talk to is going to be is going to be general dentists.
Howard: Do you mostly only get molars? Do people actually send incisors to the [crosstalk 00:05:09]
Jason: Well, obviously we get a lot re-treatments and that is going to be ... Are we good? That is going to be ... We will get from anteriors to bicuspids, but no, we have some that will send them in. I think it depends on the person and the general dentist.
I think some of them, they have realized "Hey, I can get this person to get the headache out if they are in pain or having swelling and just get them to someone who treats it daily and I don't have to worry about it. Get them back and whether they are going to be crowned or just a restoration." I think we still get occasional anteriors and bicuspids, we do those a lot. Yeah, the majority of them are going to be molars and things like that.
Howard: What percent of your workload is just re-treats?
Jason: I would say a third of what we do here at Superstition Springs is re-treatments.
Howard: Why do you think they are being re-treated? Is it missed anatomy, was it ... Are there some bugs that are far worse than others?
Jason: Yeah. You know, it is interesting, I think as we talk about bugs, I really believe in endo we don't understand what causes something to go back into a refractory case where it is stable and it starts to hurt after it has been done, because you can see a perfectly, nicely done endodontic root canal and as we ... On an x-ray, and yet you have no reason why it is not working, and yet the patient is complaining. I think that just lends itself to the fact that our obvious model is a little flawed to some degree in what causes a tooth to go and not go and I think it is a lot more multi-factorial in the sense that whatever our bodies are doing and whether they can handle what is going on has something to do with it, but we don't really know.
Yeah, some bugs probably become more comfortable in an area and that is what causes them to go and things like that, but I think that that will become more and more of an issue as we get more, I guess, evidence on what is causing these cases to need to be re-treated.
Howard: Imagine what we will know 100 years from now when they are telling us that every three months you identify a new species of bacteria in a cavity.
Jason: Yeah, I know.
Howard: Just in dental decay.
Jason: I know.
Howard: Every three months, they find a new species.
Jason: Yeah, and what causes those to be more aggressive than others, I don't know. Again, I think it is very misunderstood in that and that is why I think it is important that you look at the evidence behind cases because I was told "Oh, you can't do this, you should do this", and there are so many different ways whether you one step, two step, multi-step a case and I think it is difficult because we don't have that information.
I think that is something that comes, unfortunately for the endodontic resident or the dentals, the dentist or the young endodontist, you have to have cases under your belt to see that and even then, it becomes a very difficult thing to put your finger on and say "Well, this is the steps you do.", but to answer your question, "Is it missed canals?" Yeah, but I could show you 100 cases, probably, in our own practice where a missed canal hasn't done anything, so what does that say to the model? I think it is a little different.
Howard: I remember when I opened up in a ... In '87, you would see all of these elderly people with silver points and there is no way it could have worked.
Howard: They were in there for 25 years.
Jason: If not longer. That is what I say. Obviously, I am a little bit biased because what I see here at my practices is the bad ones because they are hurting, otherwise they wouldn't be here, but how many of them are out there just walking around our communities without problems? Probably a lot.
Howard: My first endo lecture in '83, the endodontist said "Endodontics is like Stevie Wonder picking a lock."
Howard: You opened up with what turned you on was magnification thing, so is it no longer Stevie Wonder picking a lock?
Jason: No, not at all. Obviously there is some feel to some cases where visibility is difficult with a person who can't open their mouth or that, but for the most part, I start under the scope and I end under the scope. I am never not working without looking through the scope, so that changes that to where I know where the canals are, which can be a great thing and then sometimes it can be a bad thing because you think "Well, there should be a canal here.", so then you start really looking and there is not.
Once you remove tooth structure, it is gone, it is not coming back, so I think it is that balance of understanding of how aggressive do I get of looking for canals and how aggressive ... Or how conservative do I get where I say "Eh, I am not going to go after too much because I could cause damage to that tooth?"
Howard: You said your microscope is a global?
Jason: Yeah, we use ...
Howard: That is out of St. Louis?
Jason: Yeah, I am not for sure. I would have ... I think it is actually. Yeah.
Howard: Do you know how much that costs and is your mounted on the ceiling, do you wheel it from room to room.
Jason: Yeah, ours is mounted from the ceiling, it can be mounted from the wall, they can be wheeled. Usually a microscope ... It varies. I think you can get them as low down as ... I want to say $15,000, but then it can go up as much as $50,000 for one scope.
Ours is what we call a five step, which means there is five levels of magnification on there. If you were to ask me what they are, I wouldn't be able to tell you. I know I usually function under what is a .6 an a 1, which is ... Well, it is a lot stronger than my 2.5 loupes that I have, the .6 is much stronger than that, so I don't know. It is a little different going from that because I don't know what the magnifications are.
Howard: How do you rationalize this? Could a general dentist ... Half of my friends won't do a molar, but the other half that are doing it, do you think you could do the quality of endo you are doing without a scope?
Jason: No, I don't think I could. I really don't, which is why I think the scope kind of changes ... Well, it changes everything. It changed not only what I saw as an endodontist ... Like I said, I feel pretty competent in my general dentistry skills. I mean, I did it for three years and did plenty of ... I don't know if I dare jump into any of that without a scope.
I would daresay if you were to say "Okay, you can't be an endodontist, you got to be a general dentist.", it would all be done under the scope, because I feel like what I can get out with decay. That is another thing that I think my general dentists kind of like when they send me cases is ... I remember when I was a GP sending out my big, decayed molars to my endodontists and they would come back with the decay and it is still there and a root canal done. I thought "Well, that is fine. I will take the decay out", but my cases don't go back that way.
I usually, well not usually, all the decay is gone that I can excavate under the scope, and ready to be restored back to my GP, because I think that I understand how big it is to use a scope with that. Going back to your question, yeah, I don't think it would be ... I would have a hard time doing a root canal without my scope.
Howard: You know the [crosstalk 00:12:39] other people excited about the scopes are the ergonomic people because they look at me, I am 53, I can completely trash my neck, I just was always hanging my head over, now I have to do yoga three times a week just to get my neck pain and you guys are looking in like a submarine, so you are saving your neck.
Jason: Well, I think it ... Yeah, the ergonomics of it, and with your posture, there is a lot of positives with a scope and that, obviously, is nice. We still have the same problems because you will catch yourself even leaning there, but yeah, compare to that there is no question.
Howard: I want you to talk to the general dentists because marketing is huge in Dentaltown, there is a lot of advertising, there is so many file systems. When you go to the dental conventions, you probably can't even count them all. There has got to be, what, 25 or more?
Jason: Yeah, I don't even know. [crosstalk 00:13:32]
Howard: Now we see so many of them like the one file, now there is one file. Can you do a root canal with one file?
Jason: Well, I mean I think you could if you understood what you were doing. I try to limit the amount of files I use, not just because financially it makes more sense, but two, again, the more you take a file into that canal, I think you are removing two structures that could potentially damage that tooth.
I remember when I got into my endodontic program, I was like "Okay, what is the recipe? Do I do an 0420 and then just go up the ladder?" I thought that that was how it was, but in all reality that if far from the case. It has much more to do with how do I effectively clean, but even then we know we are not cleaning everything, but how do I get out nerve tissue, if that is my goal, because if a patient comes in with an irreversible pulpitis, I want the nerve tissue gone because I know that is going to give him or her the most relief and how do I get to that point?
I think the file systems, if you are smart enough in the sense of "What is my file doing?" I try to get away with ... I don't real aggressive files, I still use the old tried and true pro-file system ...
Howard: Tulsa Dental Program?
Jason: Yeah, which is a landed system, doesn't cause a lot of damage to the tooth, it is definitely takes a little longer to get down, but I it is used as a final file where I have used and F1, from the S1, S2. I don't use the S1, S2, but the F1, if I can get a hand file 20 down, I know the F1 is probably going to go and then I will get that down and then I will overlie that F1 with just a 3504 file and then I fill with a 3504.
I am really only using to files on my cases that I can get a hand file 20 down. With that said, not all of my cases, I can get a hand file of 20 down, so real easy and so then I will incorporate something like the Pathfinder series, which is the real small ones.
Howard: Who makes the Pathfinder?
Jason: I think it is Tulsa. Yeah, or any type of O2 type of file that you can start out with a 10, 15, 20, and get to length. That makes it a little bit easier, and them maybe you can get your hand files down. There is no question that for general dentists out there that there is probably some sort of rotary system that you could use through the whole case and not even go to hand files, but to me, I don't see the need for that.
Again, we are talking about a lot of money when you start going through ... If you are using five to six files per case, rotaries, we don't ... I don't know, I don't like .... I don't think that you need to do that. Seems to be overkill and you are just spending money you don't need to be spending.
Howard: What would you say ... Sometimes dentists in Oklahoma tell me that they are the state where Ben Johnson in Tulsa, Oklahoma ...
Howard: They invented rotary endo file. I was in Tennessee last week and they were saying "No, it is our state. It is John McSpadden[crosstalk 00:16:40] in Chattanooga, Tennessee. Who do you think has bragging rights to start endo file? Oklahoma or Tennessee?
Jason: I met Ben Johnson once in a residency and it was one of the most fascinating lectures we had when he came because all he talked about was hunting lions, which was actually quite fun.
Howard: Hunting lions like Cecil the lion?
Jason: Oh, yeah. He went out. I remember he told us this story that, literally, he had a guy find it and he flew out and went and killed a lion and I felt like I was talking to Ernest Hemingway. It was actually kind of fun.
Howard: He is lucky that he wasn't the last guy to [crosstalk 00:17:16]
Jason: I don't know who has bragging rights. I think that McSpadden is down there in Chattanooga and he might be able to give enough arguments on it. Dr. Carlson here, I think, had met Dr. McSpadden and I have never met him.
Howard: Do you know what I like most about those guys? When I got out of school in '87, I was so frustrated in molar endo, I called John McSpadden one time in Chattanooga, Tennessee and he said "You know, I wish you were here an I could show you.", and I said "I can afford a plane ticket, but I can't afford your course or your hotel or whatever." "Well, just fly out and stay with me."
Jason: That's awesome.
Howard: He let me come stay at his house and then I was calling Ben Johnson with another question and he said the exact same thing and I said "I can afford a plane ticket, but I can't afford a hotel or whatever.", and Ben said "Well, just fly here and stay with me."
Both of those guys let me sleep in their house and spend the whole day with me in their office. That is how much they love their profession. It is like "Oh, man."
Jason: Yeah, I love when Dr. Johnson came in and spoke to us. It was almost ... Like I said, I felt like I was talking to a celebrity and it was fun. I think, talking about Dr. McSpadden, I still use the McSpadden compactor a lot of times, which is that reverse hedstrom type of file that will push Gutta Percha.
Sometimes if you got a Percha case where ... Especially like on a number eight, if it has got a large canal that has got to be obturated, you can take that McSpadden down with the gutta, so you backfill and if you have void, you just take it down a couple passes and it pushes very nicely and compacts. Yeah, it is a great instrument.
Howard: Let me just ask you some of the things that are confusing. Some dentists say that when they are doing a root canal, they want to keep going back with their 6 or 8 or 10 file, not going out the apex, and make sure they have [patency 00:19:01] out the end. Then other people scream and holler and say "You are pushing infection out of the apex, that is why you have post operative discomfort. Don't do that."
Same with sealer. Some people, they want to see a puff of sealer out the end and other people are saying "Yeah, that is why your patient needs Vicodin and that is why they were sore for a week." What is our thoughts on pa ... Are you pushing [crosstalk 00:19:22] the apex?
Jason: I don't think it is bad, I think you are going to get some inflammatory response whether you push anything past the apex or not. I was ... I had one professor in my endo residency that believed in the dentinal chip packing, so you kind of reverse your file and push it and then kind of create something to push against. I don't think there is anything wrong with that.
The bottom line is that it goes back to what I said before. I don't feel we know exactly what is better or best, it is jut a matter of what is working in your hands and you have the cases to support it, because like you said before, we can show plenty of silver point cases that went 30+ years, and yet we don't know why.
I have been reading a fascinating book that talks about how sometimes the evidence isn't in being able to show all of these cases, the evidence is in the cases that don't make any sense. Why is that working, so I think, just to some degree ... We had John Khademi, who is a pretty incredible endodontist out of Durango, come and speak to us here for are Endodontic Association just for Arizona.
The cases he was showing ... Again, it goes back to the whole "They shouldn't be working based on the model that I was taught, and yet they are working just fine." I think there is a balance between ... I think what we do know is that the more aggressive we are in taking a way tooth structure, we have problems.
As we all know with those big silver filings, I look at the ones that were placed, even though I have nothing against those because they actually work. They stay sealed, but eventually they start to wear and they break and then you know you are moving into a little bit more ... A crown, things like like and so being conservative is probably a better step than not. As for pushing stuff past the apex, I don't get too uptight about that. My goal is to be [patent 00:21:24] and I that is what I have always done, that is what most of the endodontists trained me do it, only a few believed in the packing.
Howard: This is on Dentistry Uncensored, so I always like to ask the most controversial questions[crosstalk 00:21:38] Some people say "Okay, root canals area painful, I always give a standard script for Vicodin or Percoset", and ever year of the top 10 most prescribed pills in the United States, going back 20 years, Hydrocodone is always number one. Other people scream and yell that this is the cause of addiction, you should never do narcotics, yadda, yadda, yadda. If you do a hundred molars, what percent would get a pain prescription afterwards and what would that be?
Jason: Yeah, I think this is a good question because I think we fight with this because there are some people who believe we are the ones that are contributing to this addiction. The problem is how do you viably say "Well, this person deserves the pain medication and this person doesn't." I thin that is hard to do.
Most of the patients that come into my practice are in a lot of pain, so to have them ... Yeah, we are trying to fix them, but for the short term, most of my patients are getting some sort of pain management, whether that is 600 to 800 milligram Ibuprofen prescription strength on top of something like a Vicodin or, in some cases, Oxycodone and that.
Howard: Oxycodone, you mean Percoset, not Oxycontin?
Jason: Yeah, Percoset. Especially our ...
Howard: What percent would you give a narcotic?
Jason: I would say ... They come in in pain, they leaving with it, so it is close in my case to 85-90%. Second treatment is where they come in and they are asymptomatic, so if I have patients who come in and they are not hurting because we have had them on ... They have already been through the bad part and we are now just obturating, they are not leaving with anything.
If they come in asymptomatic and they noticed that there was an infection on an x-ray or we noticed that they have a sinus tract that is draining, those cases are usually not going to have whole lot of post operative discomfort, so usually those patients don't.
Howard: Okay, I want to go into another area that is incredibly controversial as well. I think anybody would agree on this. There is a post, some people say ... On molars. Sorry I said molars, but posts.
Jason: Just a post.
Howard: Many people on Dentaltown believe that the only function of a post is to fracture a root. It has no other function.
Jason: Are we talking metal posts?
Howard: Yeah, metal posts. Some people say the post needs to be there to hold the build up. Some people say post should only be fiberglass, so let's talk posts. Is the only purpose of a post to fracture the root?
Jason: You know, I have seen plenty of them that is for sure. We get a lot of fractured roots from post placement. I will say this though, I am a proponent of ... Especially on an anterior case because there is some research, again I am not a big research guy so I don't even like saying it, but I listen to ... There was a ... I am going to brutalize their names, but Dr. Rick Schwartz, out of Texas, did a paper.
He is an endodontist who with a ... Think it is Margaray, is her name and she is out of some ... In Europe, and they did it on fiber posts and there is some evidence out there that fiber posts may actually strengthen the root and give some sort of, I don't want to say strengthen it, but maybe having fiber posts placed, almost like having rebars placed in when a building is being built, to hold and strengthen it and there might be some evidence of that because, obviously, fiber posts have a little bit of movement, such as Dentin, so maybe there is a benefit for that.
I think that that is something that is very controversial on many levels, but as for metal posts and again, we are going back to "Are we moving too much structure to put a metal post in?", because if you are moving too structure to put a metal post in, then I don't think it needs to be there. It should be a passive fit, cemented, you know what I mean, and in that case, the fiber posts seem to be well placed.
I don't place a whole lot of metal posts because I don't think I was trained very well to do it. Now cast post and cores, I have seen some of those go a long time, so what is making those things last? Maybe it is that passive fit? I don't know, but if a fiber ... If a post is being placed by me, it it has been asked by a genera dentist, it is a fiber post that gets placed.
Howard: What brand?
Jason: Oh, I could show you, I don't know. I think it is the ParaPost brand, I believe it might be, but it is a tapered, it is a tapered.
Howard: [crosstalk 00:26:19] something that I always think is extremely strange. You will see someone with a lot of worn down teeth, so to treat the worn dentition, the dentist will prepared each tooth for a crown and it is like "Does this make any sense?" "You have so much wear that I am going I am going to stick your tooth under a pencil sharpener."
Howard: "Then to make your tooth stronger, I am going to bore it out so I can put in this big old strong metal post."
Jason: It doesn't make sense.
Howard: Of course, that doesn't make any sense.
Jason: I don't think it does and that is not where they are needed. I think they are needed in a case like ... Well, a good example is a patient comes in, I am dealing with this because my boy just got hit with a baseball so he is dealing with a lot of trauma. What if he got hit when he was, let's say eight years old and number eight got knocked and it is an immature tooth and we are trying to get some dentin growth because we know that canal is wide open, so let's say later on in life it stunts it is always going to be a wide open canal.
A fiber post, and it is interesting because the ray paper I am talking about that she did, she is not placing just one post, she is literally placing one big post in the middle and then accessory fiber posts on the outside of it.
First of all, she is backfilling with the duel type cured composite, like we have RelyX product here, but it just has to be duel cured, but you backfill with the Centrix tip, you place your main post and then accessory posts around it to support it, because, again, going back to like she talks about in the paper, and this is way over my head, but the C factor, you are going to have less of it because of the feel that comes from those posts.
Howard: Explain the C factor.
Jason: Well, I think it is the shrinkage, so if you have one metal post ... Not metal, excuse me, but one fiber post and the rest of it is that duel cured composite, you are going to get some shrinkage on that. Whereas, if you have less of the actual duel cured composite in there, it is not going to as much because the fill is going to be those fiber posts that are already solid with some give.
Anyway, that is a case, let's say number eight immature tooth, you have a wide open canal, those cases, when I see them, when I finalize the treatment on them, they are getting a fiber post with accessory posts around it and then backfilled and that is how I do it.
Howard: Now I am going to get you in real trouble.
Jason: Yeah, get me in trouble.
Howard: A lot of dentists out there, probably half of them, say that when you do a MOD Amalgam, it will literally last 35, 40 years. The other half will never do an amalgam, they are metal free. They say all of those amalgams fracture the teeth, they only do composites. The amalgam people say "Yeah, your composites have recurrent decay and six and a half years, that is all they last.", and they say "And you have recurring decay and endodontists love posterior composites, because t is double their business." Then the composites will say "Oh, no! The endodontists make a living by all the teeth fractured by amalgams."
Are you pro composite, pro amalgam, pro both? Where ...
Howard: Who made you more money, the guys placing all of the MOD amalgams or the guys placing all of the MOD composites?
Jason: I would say it is even because I will get plenty of cases with the MOD composites and they are still very sensitive to hot, cold and that is not getting better and we get plenty of broken teeth. The bottom line is what lasts and nothing lasts in dentistry.
We can go back and as great as the amalgams are as it pertains to that, I do think they are durable, they do have their negatives. They break teeth, it seems to be that, at the time, much more tooth was removed to get them in there and there may be something to the composites in the sense that if you can, if there is a term, minimally invasive, you can take away less tooth structure to get those to work, then that is great, and I think we are seeing that is why a lot of people are jumping on board is because you can be a little more conservative, again a term, and place those. Equally, we see, I would daresay, we are seeing them both. I would.
Howard: You would say that you are neither pro composite or pro amalgam?
Jason: No, I place both, I place both.
Howard: Do you place amalgam [crosstalk 00:30:44]
Jason: Yep, there is a reason.
Howard: We were joking about how a dentist will bore out a tooth and string it with a post, a face has worn dentition so they will file down. There are so many dentists out there that you are talking to right now that they have this deal where every root canal tooth needs a crown and then I am seeing these lower incisors and after a root canal ... When they are done prepping a lower incisor for a crown, the only thing that is sticking out is the Gutta Percha.
Jason: Yeah, you might as well [crosstalk 00:31:12]
Howard: Yeah, talk about when ... When does a root canal need a crown and when does it clearly not need a crown?
Jason: I think it is the ... Well, my thoughts on it, obviously a posterior tooth that has ... Again, when are we doing a root canal on as posterior tooth when the only thing there is the axis opening? Usually there is an MO on it or a DO or a MOD of some sort or it has already had a crown, but if you ... Like an anterior tooth where a patient gets hit, and it dies and a root canal need to be done because it has become infected, I don't think those teeth need crowns. You can do your access opening pretty small on the back side and it is going to have one composite and it is going to be right off the incisor ledge and it is going to be little. That crown doesn't need to be done.
Even to some degree, I have seen some molars that have become infected and root canals and they were so minimally restored that I don't know if a crown was needed on those because two structures being taken away, lot of it, just to put that crown on there. For the most part, I think the more restored a tooth is, meaning it has already got existing restorations on it, the crown is needed and the reason why the crown is needed is it does seem to do do a little better job of sealing of root canals, which is really, ultimately, why a crown works well and why we recommend it.
It is not because it is strengthening the tooth, it is because it is covering a little better than some of those restorations are going to do and there is a chance of leakage. That is my opinion, but whether that is ...
Howard: Okay, I see this posted on Dentaltown all the time, since 1998. It is confusing, they stop and they take a picture, they took out a MOD because of recurrent decay and they got it all cleaned out and they are getting to fill it and they see a black line on the bottom of the floor and they weren't expecting it. There wasn't pain, the black line ... What do you do when you are placing a filling, you remove the decay and there is a black line on the floor?
Jason: Well, I think at that point the patient is numb, but what I was going to say is if you are suspecting crack, I think it is important to get pulp testing done on that tooth, which can easily be done by a general dentists and figure out what is the status of that pulp and what I mean by that is I do believe if a tooth ... If you are suspecting possible crack and it is testing with ... Even a hypersensitivity to cold, there is a good chance you may set that off, so those are the ones that you want, at least baseline testing before, but as you said, the patient is asymptomatic, you take out the cavity and there is this crack.
Well, obviously, restoring it and I think having a conversation with your patient "Look, we noticed a crack. If we get any of these symptoms, possible cold sensitivity that lingers, or bit sensitivity, we need to be pretty aware of that and track it that way." Again, is there any out there that says "This is the best thing to put on top of it, do I do an amalgam, do I do a ..." I don't think that the research is there to say that this is what you should do.
Howard: So you would take a picture ... Show the picture and discuss it?
Howard: Let's say that you do the filling and it is sensitive to cold and it lingers and it is sensitive to bite and it has that fracture. Is that an extraction ...
Jason: No, I don't think so. We as endodontists, I wouldn't just automatically commit that to an extraction. Now, where it becomes a problem, is if the endodontist goes in, because we are talking about it going across the pulp chamber, the roof basically. Now if it is dropping down in the pulpal floor, but you are only going to know that if you open it up and start a root canal to look at that, or going down a canal system, then that changes, I think, your success rates.
That way that I look at those teeth are, again, you look at the symptoms. If it is vital before it started and it has now become hypersensitive to cold, so you now labeling it as an irreversible pulpitis, let's say, and you open it up and it just stays on the pupal roof, there is nothing wrong with the root canal and the success rates on those.
Howard: Okay, address this referral issue. I am looking at this patient, they are in pain, and it turns out it is a root canal that has failed.
Howard: How can I be more clear? Do I send this to an endodontist for a re-treat or an oral surgeon for an extraction and an implant? How are you assessing this because you don't want to waste your patient's money.
Jason: Yeah, absolutely.
Howard: Someone already did a root canal and it didn't work. Do I sent it back to them and say "Hey, try again"? Or do I just say "Pull this baby, go titanium?"
Jason: Well, again, there is a lot of factors that go into making that decision.
Howard: I didn't say any of my questions were good.
Jason: Yeah, right. I am going to get into more trouble trying to answer these. Being evaluated, I think it minimal. We have, here at our office, we have 3 Dimensional Scanning. Most of our re-treatment get scanned. Not all, but most, and they get scanned for different reasons.
One, they get scanned to verify that we are not dealing with a potential crack and I am not saying that through scanning we see cracks, because that is a big marketing scheme that these scanners are trying to say "Oh, yeah. You can tell if it is cracked." I don't ... What I see is the bone and I see the response of the bone around it and if I see a tooth that has beautiful bone from basically to the mid-root to all the way occlusaly, there is a good chance, and yet you have a radial lucency at the apex, there is a good chance that is just endodontically related and a re-treatment can help fix or help prepare that.
That is one factor. I think scanning has helped us make our decisions a little bit easier. Costs on scans are down to where I don't feel like are having to spend a lot of money to be able to get that information and two, one of the things that we do, and I would say for endodontists, this is probably going to be controversial, but let's say you are on the fence where you don't know will this go the distance, it is better to go with an implant?
By no means am I an implant ... Am I afraid of implants. If anything, I am probably a little more ... Because I saw the benefits of implants when I was in practice as a general dentist, but I would daresay that when you see a case that is questionable, we will open those cases up and place calcium hydroxide and evaluate. Do symptoms improve? Do we see improvement of if it has a radial lucency. Do we see bone being repaired, do we see some osteos healing occurring, symptoms are going away, if there was a sinus tract, all these things and at that point we can commit to saying "Hey, look. We are going to keep this tooth."
For a patient of mine to jump into that, they really are not investing a ton because if it does not work, we are not doing the root canal. Yes their op time, so if that is a problem, so I think there are ways around it if you are really worried, but to answer your question, it is not just to "You should go to an implant or you should just save the tooth", because a lot of those we don't save, a lot of them become implants.
Howard: Some people, it looks like data can be shown by insurance companies as implant placement goes up, the numbers of apicoectomies in the United States is going down.
Jason: Oh, yeah. I would ...
Howard: Is that one on one? Is that implants putting downward pressures on apicoectomy retro fills?
Jason: Probably. I would say that that is definitely something that is happening. I think you could even argue that root canals will even go down because as more and more dentists decide to place the implant, to that person it may be easier to go to the implant. It may not be the right answer, or the right ... But it is an option that is being done.
The other thing is, I think with apicoectomies, we used it as kind of this last ditch effort to save the tooth. I look at an apico as if I know it has got a high success rate after going to an apico, then that is when I will push it, but if I look at that and say "This is possibly a fracture,", there is no way I am attempting an apico on it. If I suspect a crack or a fracture, it is almost guaranteed that tooth is coming out.
Howard: Are you pulling them and placing [crosstalk 00:40:00]
Jason: I don't do that. I think it would be fun to do, but I just figure my specialty is doing the root canal and making a decision of whether I can save that tooth for a long period and if it is not then it goes back to the general dentist usually. I usually will call them and say "Hey, look. This needs to come out. Would you want to do it or would you want me to send them to somebody else?"
Howard: I want to switch to warranty. Some consumers think that everything should have a warranty that should last five years, or a period of time. Is there a length of time that you think a root canal should last or the patient should get some of their money back?
Jason: Good question. We are pretty fair here. I have seen the extremes where if it goes two years and it doesn't work, they are not getting their money back. We usually still bill out an incomplete. If it doesn't last ten years and it is not working, we are usually pretty fair to that patient.
Howard: Ten years? What do you mean?
Jason: Like if they come back and it is not working and let's say I have to go back in it. I usually don't charge them to go back in it.
Howard: For ten years? Are you serious? I never heard of that.
Jason: Yeah, because a lot of times I feel like it is my responsibility to keep that tooth for ...
Howard: Well, a lot of dentists on Dentaltown say "I don't know if I trust my dentist. He will do a root canal, it will fail in six months and he says 'Well, you know. I did my best, I tried, it is all I can do. It is not my fault'" and they are like "Well, maybe if you had to warranty it for three to five years, them maybe then endodontist wouldn't have done the root canal."
What do you, specifically, do if you do a root canal on Fred and six months later it has got to be pulled?
Jason: It is billed as an incomplete, which obviously has a fee associated, which if you look at the incomplete fees on insur ... You talk insurance because that is what we see, it is usually around $250, $300. Around a third of what a root canal maybe is, that is kind of the give or take, so that is usually what is billed for that first and then reimbursement back the insurance company or if the patients pay out of pocket, it is back to that patient.
Howard: So you do believe in warranty. I never head of anybody with a ten year warranty.
Jason: Yeah, we do it ... We are pretty ... Like I said ... I don't know, I came to this practice and I knew Dr. Carlson and Dr. Hales prior to it and I knew that they were pretty neat guys, and that is kind of what they have done. We try to keep ...
Howard: Your website has amazing cases on there, what is the name of it?[crosstalk 00:42:43]
Jason: There is the Endo Blog.
Howard: What is the www on that?
Jason: It is theendoblog.com
Jason: Yeah, and that is run by Dr. Hales.
Howard: That site is run by Dr. Hales? Tell them about that site.
Jason: He started that probably about ten ... Well, not quite ten years ago. Probably seven or eight years ago and he just started posting cases he was doing and it gets a lot of ... A lot of people go to it for information and he will just post cases here and there and people comment on them and he gets a lot of followers from that.
I don't post a lot on it because I usually just give my case to him and let him do it if it is an important case. Yeah, it is neat. He has got some good stuff on there and some stuff that is controversial.
Howard: I am trying to get you in as much trouble as I can and this one is going to be a doozy. Ben Johnson show the best lateral condensation root canal ever done. I think some guy got literally like 50 accessory cones and he magnifies that, showing it and it just all spaces and [crosstalk 00:43:47]
Then he talks about his percha carriers ...
Jason: The Thermofills.
Howard: The Thermofills, and how that is just better. Some people say that ... Our friend Joe Dubkin, who passed away ...
Jason: Yeah, from Scottsdale.
Howard: ... he said "Three dimensional endo, you got to be a squirter. If you are not using a hot gutta percha gun, if you are not a squirter you are not doing it right." There is a lateral condensation, there is vertical condensation, there are squirters with obtura, there is gutta percha on a cone, how is a dentist supposed to make sense of this? What are you obturating with?
Then some of other people, who are to endodontists, say "My endodontist doesn't like those carrier based kind of perchas because if it is a re-treat, he can get out and get a percher real easy, but if she has got to go get the carrier out ..." Some endodontists say that takes them twice as much time and sometimes they can't even get them out.
Jason: It can happen.
Howard: What should I obturate with and can you get carrier gutta percha like a Thermofill? Does that make it significantly harder to re-treat?
Jason: No, not necessarily. I mean, when I was first starting it did. I used to complain all the time and I remember I was at a course with Joe Buchanan, who I think was kind of the one who was in with ... Worked a lot with the Thermofills, but I remember he was saying "If you can't get these out, you are incompetent.", and I thought "Wow, what a jerk.", then I realized it is true because you can't ...
Howard: Joe Buchanan or Steve Buchanan.
Jason: Steve Buchanan.
Howard: Steve Buchanan, okay.
Jason: Yeah, Steve Buchanan and I knew that he was probably right because I can get them out pretty easily. Some I can't and I think it has something to do with the way I am getting down the canal system. They key is if you can get past them with a file, you are getting them out because now you are [patent 00:45:35] and you know you haven't ledged yourself out.
It is the ones where I think you ledge yourself and then you can't get past them that I think you are in trouble, so I think it is a general dentist trying to do a re-treatment and they are working on it, the key is don't get real aggressive with file sizes trying to pull them out, I think you got to get past them with a file, even a 10.
If you are painting with a ten, that thing is coming out because then you know you can always get a 10, 15, 20 and eventually that thing will pop out as you start taking rotaries down it. As for your question, what is the right way to obturate? I don't think we know. I really don't. I am a single cone, place it. If I take it to a 3004, I will place it and then using a system bead, heat it and then back fill with obtura. What Dubkin said is true, I think the only way to get 3 Dimensional is to squirt because that is the way you get it out, to gt that stuff in there.
As for Thermofills? Everyone bags on Thermofills and yet they work in so many cases, especially those skinny cases where you know you can't be taking it to a 3006, but you are at 2504 because of a significant curve. How are you going to get anything down that and Thermofill seems to work in those cases. I am not really a negative when it comes to that. We re-treat everything. I have seen nice cases that they use single cone or ... So to say one say is better than another is not right.
Howard: You miss Joey D?
Jason: Yeah, that was kind of a bad deal.
Howard: You know it is funny, I went to Creighton with him and he is the only ... I would almost ... 100% on endodontist, but almost all dentist. He was the only guy who his whole life he only had one mode and it was dentistry. The guy, if you talk to him at six in the morning or seven at night, it didn't matter if it was Monday or Sunday, he was doing something with endo. The guy just ate, lived and breathed and died in his sleep. It was just an amazing man.
We talk about pain meds afterwards.
Howard: What about antibiotics? If you did 100 molars, do you just shotgun everybody with a Pen VK?
Jason: No, I don't. I am usually pretty conservative with the antibiotic. They got to have some sort of systemic type of thing where we are getting quite a bit of swelling, obviously fever, things like that. I think that, to patients, they feel like maybe when you are giving them an antibiotic you are helping them out a little bit, that you really care about them.
I usually have a pretty good conversation that I think it is better where you say "Look, there is not a lot of research that says if we put you on an antibiotic, it is going to really help you." Especially on a case where there are no systemic factors. There is no swelling and usually just anti-inflammatories and, if needed, a pain medication is enough.
Howard: What do you say about this? There is a million dollars settlement in Kansas. A person had an extraction, it was a canine, and after the extraction, they didn't give an antibiotic and the infection when back to the brain and they died.
Some people believe ... What do you call ... Some call it the Bermuda Triangle, canine to canine maxilla, they are saying that the veins that go back into the [crosstalk 00:49:01] Some dentists believe that all extractions, all root canals, canine to canine on the Maxilla, have to have an antibiotic afterwards. Again, this case in Kansas settled for one million dollars, the patient died like three days later in the hospital. Do you agree with that? Just because the lawyer sued for something doesn't mean it is right.
Jason: I was not taught that, just to prophylactically give an antibiotic from canine to canine. I wasn't taught that. I was taught to go off of more of the regulation ... Not regulation, but if there are systemic factors, swelling, fever, things like that, that is when an antibiotic can be considered.
A case like that is going to open, I hadn't heard that, but that could open ... Because, again, sometimes we treat based off of things we don't want to deal with and that is unfortunate because I think what is a bigger problem is resistance that we are seeing more and more of in antibiotics, to the microbiologists is a scary thing because bacteria, they are going to live. They are going to live wherever and to get rid of them, we are not getting rid of them, you know?
Howard: Back to Kansas, there was another million dollar lawsuit. A person had [Sargenny 00:50:13], it went out the apex, it pickled the inferior [inaudible 00:50:16] of the nerve. They got the full amount, they got the full one million dollars. Do you still see [Sargenny 00:50:23] or is that [crosstalk 00:50:24]
Jason: I haven't seen it for a long time, I haven't. [crosstalk 00:50:26] Yeah, I honestly haven't. I have seen it before, but, again, that was in my residency, I saw a couple a cases, but maybe Dr. Carlson could speak more to this, but I have not seen [Sargenny 00:50:39] for a long time.
What is ironic is [Sargenny 00:50:43] can do that, but so can calcium hydroxide going out, it can cause a lot of problems. I have seen that placed into the inferior avelolar canal and that causes numbness and things. I have seen gutta percha with sealer do it. [Sargenny 00:50:56], I think the AAE came out pretty hard against it, but it would be interesting to see, and I go back to this all the time, how many cases of [Sargenny 00:51:05] worked and are out there and no one knows about them.
Howard: A lot of endodontists will say, when you ask them an obturation question, "I don't care what you put in. Root canal is about taking out the infection. Not about how you obturate putting in." As far as taking out the infection, in marketing we see people talking about instead of just using bleach, now warm bleach. There are agitators for bleach, ultra sonic vibrations. Any of those got your attention? Any of those you think are worth the money or do you think it is [crosstalk 00:51:42]
Jason: I think it is more about trying to ... No, I don't in the sense of everything has got the endo vac. I remember I used endovac for six months on my residency and it seemed ... It took longer to use, and I thought I was doing a much better job of cleaning, I don't think it really does.
I think that one of the things I use, and I think I use it not because I feel like I am getting better success rates, it makes my job a little bit easier, is I do use just sonic with the endo activator because I can get calcium hydroxide in places, at least get it down the canal system, so I will use the endo activator and it is fairly safe because it is a plastic tip so you have minimal risk of breaking it, so I will use that to place calcium hydroxide, but I don't think it increases my success.
Howard: I am just trying my hardest to get you in trouble, I am just going to throw you something else. There is an endo system called SafeSider by a Barry Musikant and his whole big deal was that his don't break. I think they are going ...
Jason: Yeah, the reciprocation.
Howard: The reciprocation, and his claim to fame is that the nickel titanium is going all the way around and so he calls them SafeSiders. Some people say "I am going to hand file the rest of my life, because I don't want the file to break." Is file breakage a problem, is it a problem with you? Do you get a lot of molars sent where the file is broke and you got to try to get out the file?
Jason: Yeah, but I am not a big ... I was taught to get files out and actually had an endodontist who would come and he was ... His hands ... He was really good, but it is hard to get those files out and what I will say is, where I kind of draw the line is if I am going to have to remove a ton of tooth structure to get a file out, I am not going after it because I have seen, at least in my hands, too many cases where perforations were done because I am trying to get out a file that may or may not cause problems.
The flip side is if a patient comes in and you are re-treating a case and they have already got an abscess and it is symptomatic. A symptomatic abscess and it becomes more of a problem and those are the cases where possibly apicos, or you can consider. I still, usually, re-treat with calcium hydroxide on those case and get past that file in some way. If not, then you go to apico.
Yeah, I am not a big file removal guy saying "You got to take them all out or if they break, you are in so much trouble you might as well start paying money back.", because I am not. I have seen too many cases where it didn't do anything if a file breaks, as long as you are pretty up front with your patient, it is a part of treatment.
There are ways to prevent file breakage. I think that single use becomes something you may want to consider with the rotary files, as well as hand filing. If you are down with a 20 hand file, for the most part you can almost guarantee, not guarantee, but you are going to have less of a chance of breaking with a rotary because you are already ...
Howard: Do you only use your files one time?
Jason: Yeah, for the most part we do. Some, like a 4006, if you used it, a lot of times they are not engaging much, so we kind of make that call. Like my F1 that I use, that is usually a single use because that gets USED. It gets used in my case because it does a lot, the majority of my ... I hate to even use the word cleaning, but it is cutting some and those are the ones. My hand files, I hand file everything up to a 20 and then Hedstrom 20, usually is down, so the canal system is pretty open before I introduce rotary to it.
Howard: I only got you for four more minutes, so switch to irrigants. What irrigants do you almost always use on all of your endos?
Jason: Obviously, I use full concentration sodium hypocholoride.
Howard: You don't dilute it?
Jason: I don't dilute it, and then I use EDTA as a final, well not a final, but I usually will EDTA and then I use a drying solution, it will be alcohol as a drying solution, at the end. Through the whole procedure ...
Howard: Rubbing alcohol from rotarings.
Jason: Yeah, might even be Everclear. Just down in ... Yeah, just dries it out and gives me a ... It is not usually to clean, it is just to dry the system out and then I paper point the alcohol out.
Howard: You are not using chlorhexine?
Jason: I don't use that, I don't think it does ... I don't know if there is much benefit for it. Some people really like it. I shouldn't say I never use it because sometimes on your open apicy cases, you got to be very careful because you can get an accident with sodium hypochloride. Yes, it is used in cases like that, 2% chlorhexine
Howard: Another diagnosing term ... I am just trying to go off all the questions I can remember from the Endo thread. How are you thinking ... What goes through your mind when you are thinking "I can do this in one appointment." "You know what? I should put some intermediate [crosstalk 00:57:04]calcium hydroxide and let this thing heal for what?" What is going trough your mind?
Jason: What I will say is if I knew that we would be in business, because we could figure out how to do all endo. That is the hardest part and don't have answers for that. What I will say is, because I was always taught if it is necrotic and it needs to be two stepped or multi stepped. That is what we were taught. Yet I have seen cases here that is necrotic and it has been one stepped and worked.
What I will say is I think symptoms play a part in my diagnosis, so if I see a patient who is symptomatic, a lot of times they are going to get calcium hydroxide to try to calm them down. The second thing is if they are asymptomatic with a sinus tract, I usually will one step those because I think ... Again, I don't ... I am going off of my cases how many times I have problems with this. Those seem to work, but the other thing is if I see a case where I look at the root canal and I think "You know, whoever did this root canal did a pretty good job and it is not working. Why is it not working?"
If I am going to go into those, sometimes, well not sometimes, but most of the times those are getting calcium hydroxide because I want to make sure that we get healing from that case. To answer your question, it is tough to say because I don't think we know and there are some endodontists out there that I think have a pretty good bead on what ones do and don't work and as more and more as the cases kind of show up, like I said, that Dr. Khademi out of Durango, I think he has plenty of cases where he is showing this stuff and as those start to come out, maybe we will have more of a grasp on it, but I don't think we do. To say we have got it figured out would be ...
Howard: I think the most dead giveaway of that you have an amazing mind is so many doctors, they just stand with their party line. They just know, know, know. You and I know that if you got back every 100 years back in time and find out 100 years later that half of what we know ...
Jason: We didn't really know.
Howard: ... we didn't really know and we know what we know, but we don't know what we don't know. You are just so aware that we don't know everything about molar endo in 2015 or 2016.
Jason: Yeah, I agree. That is why I think you have to have an open mind and you can't be so critical of everything out there. I learned this very early in my career where I got very critical of a general dentist who sent me a molar endo and I said "Well, why were you doing it?", because he could do it and yet at the time I thought he shouldn't have been doing it and I was wrong. I think that you just have to be very careful, both as a specialist ... As a matter of fact, just becoming a specialist doesn't make you any more of an expert on it than your general dentist.
Sometimes the general dentists understand it better because they realize it is the restoration and the restoring of the tooth that is more important than the actual root canal because if you can't restore it, it is never going to go.
Howard: I am a big fan of Regina Herzlinger of the PhD medical economist at Harvard and she wrote a book that had a huge impact on me called "The Focus Factory." She did all this research showing, like when you go to a hernia, you can totally track that the people who do the most have the highest success rate. As you start going down, cut that number in half, the failure rate starts going up high and Regina Herzlinger, called the "The Focus Factory", when I read that, it really made me realize that being a dentist in the old ranch days where you make your own bread and butter.
To be a jack of all trades in dentistry in 2016, isn't going to happen. How can you master sleep medicine and ortho and endo and perio and implants? Even with the implants, bone grafting is almost a specialty.
Jason: Yeah, the headaches that can come if you ...
Howard: You just can't be all things to all people and Regina Herzlinger's book, read it if you haven't see it. It is an old one, it has been out a few years, "The Focus Factory", but she has the data and I thought the hernia repair was the most amazing and she also ... The other variable is not only the volume that you do, but the amount of time. If you repair a hernia in five minutes, you almost have a total success rate. By the time it takes you ten minutes to do it, you have like a 5% failure rate and by the time it takes you a half hour to do it, it is 20%.
Think about pulling four wisdom teeth. For an oral surgeon to go in there and pull, surgery time, all four of them probably 10 to 15 minutes. General dentists probably spend an hour getting one out. Guess who is doing the higher quality, the people who know what they are doing the most, have all the instruments, all the knowledge and they have the quickest times and the faster you do it, the higher the success rate, so the speed at which you do it, the volume at which you do it is highly associated with how well you do it.
Howard: Hey man, seriously, thank you so much for spending an hour with me.
Jason: Yeah, it was fun.
Howard: You didn't have to do it, thank you so much and [crosstalk 01:02:06] am sure they all enjoyed it. Thank you very much.
Jason: Yep, thank you.
Howard: Alright, bye-bye.