Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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890 Endodontic Excellence with Mark A. Limosani, DMD : Dentistry Uncensored with Howard Farran

890 Endodontic Excellence with Mark A. Limosani, DMD : Dentistry Uncensored with Howard Farran

11/29/2017 1:18:15 PM   |   Comments: 1   |   Views: 492

890 Endodontic Excellence with Mark A. Limosani, DMD : Dentistry Uncensored with Howard Farran

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890 Endodontic Excellence with Mark A. Limosani, DMD : Dentistry Uncensored with Howard Farran


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VIDEO - DUwHF #890 - Mark Limosani



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AUDIO - DUwHF #890 - Mark Limosani



Dr. Mark Anthony Limosani received his D.M.D. degree from the University of Montreal in 2007. Since then, he completed a one-year multi-disciplinary residency at the Queen Elizabeth Oral Health Center, a McGill University a liated program. Following one year of private practice and many hours of continuing education, he then followed his dream and attended the special- ty program in Endodontics at Nova Southeastern University where he also received his Masters Degree in Dental Science. He won the "Robert A. Uchin Endodontic Award" for his presentation during Nova's endodontic alumni day. 

Dr. Limosani has lectured locally and internationally on many topics in endodontics including: dental traumatology, the restoration of endontically treated teeth, restoratively minded endodontics, diagnosis and treatment planning and cone beam computed tomography (CBCT) use in endodontics.

Howard: It is just a huge honor today to be podcast interviewing Mark Anthony Limosani. Are you married to Jennifer Lopez?

Mark: No. That's - no. Don't look at what you see on E Entertainment. That's past news.

Howard: You're a different Mark Anthony who received his DMD degree from the University of Montreal in 2007. Since then he completed a one year multidisciplinary residency at the Queen Elizabeth Oral Health Center, a McGill University program following one year private practice and many hours of continuing education. He then followed his dream and attended the specialty program in Endodontics at Nova Southeastern University where he's also received his Master's Degree in Dental Science. He won the Robbert A. Uchin Endodontic Award for his presentation during Nova's Endodontic Alumni Day. Dr. Limosani has lectured locally and internationally on many topics in Endodontics including dental traumatology, the restoration Endodontically treated teeth, restoratively minded Endodontics, diagnosis and treatment planning and Cone Beam Computed Tomography CBCT using Endodontics. Thank you so much for coming on the show today buddy.

Mark: Thanks for having me. I really appreciate you - I'm honored to be speaking with you. So it's great.

Howard: So your practice is in Aventura, Florida?

Mark: I actually live in ( Aman 00:01:24). My practice is in Weston. It's a suburb of Fort Lauderdale so to speak.

Howard: Okay. Well there's a thread on Dentaltown talking about the difference how we were trained in Endodontics thirty years ago versus today. What's hot and what's not in Endodontics? What do you think is different today in Endodontics and ten years ago?

Mark: There's been so many changes in the field the use of microscopes has made basically a specialty that was more tactically oriented to something that's much more visual, very dynamic. Now, use of ultrasonics then came CBCT. There's just such a wide range of changes that occurred in the specialty. More recently the more [00:02:14] inaudible [0.3] denton conservation approach that's really the new wave, keeping things more conservative and focusing on salvaging more tooth structure.

Howard: I think I almost want to start off with this first before we even talk about Endo. But one thing that scares me about Endo, it seems like half the graduating class walks out of school. We just had six thousand new American Dentists minted three months ago and another six thousand are going to start dental school this week. And it seems like half the students who come out of dental school already hate Endo. What would you say to someone who graduated and they already hate it.

Mark: I think you have to find your - You have to find what it is in dentistry that you enjoy doing. I like the minutiae of Endodontics. I like the precision of it. I found a very good mentor that was up to date with all the technology and I just pursued it. And became really - I really enjoyed the clinical practice. That whole aspect of Endo is something that I wasn't really familiar with straight out to dental school. So if it's something that you hate just come to finding courses or finding mentors that are passionate about it. And soon enough you'll find a liking to it. I find that Endodontics is this branch of dentistry that has this whole different kind of concept with the tactile aspect of it. So some people take a liking to it other people hate it. It's one of those things.

Howard: Yeah I always think you hate everything if you're losing at it and getting beat up by it, so if you really hate something you need to do it until you master it and then you might love it...

Mark: Yup.

Howard: ...after you master it. This is dentistry uncensored so I like talking about all the controversial things. I don't want to talk about anything anyone agrees on. Let's [00:04:06] inaudible [0.3] a standard of care because you know when you do a molar root canal and you're a General Dentist it's going to be judged by the standard of care and that's going to be your local Endodontist. Is microscopes and CBCTs, is that bordering on standard of care, or...?

Mark: I would say with microscopes and CBCT, I would say to be able to practice at the highest level of proficiency in this day and age both microscopes and CBCT are pretty much invaluable. That being said there is a significant amount of time that was spent in dentistry in which these technologies did not exist and root canal therapy still remained very successful. So I don't think it would be fair to practitioners to say that that would be the standard of care because root canal therapy was practiced without those technologies. I, in my personal experience in my practice at and the level of care that I espouse to provide, those technologies are indispensable. But I wouldn't say that you know if every root canal had to be performed with both CBCT and microscopes they would be something that would be commonplace everywhere. So I'm a bit more realistic in my thoughts.

Howard: I'm really starting to have different views about - whenever you talk to a Rhinologist, an Ear, Nose and Throat, they're starting to tell me a lot that people who think they've had allergies for ten or twenty years actually have a failing root canal leaking into their sinus and I've seen videotapes of these, of study club presentations. Do you think that if someone has an existing maxillary and root canal on the second bicuspid in the molars that the health history should say, "Do you have sinus problems?" and really start looking at it in a whole different way, is this thing is something failing and chronically leaking and sinus_

Mark: That's a brilliant question. And I do see maxillary sinusitis of dental origin quite frequently. I think that the key would be to create an inner working relationship between both root canal specialists and ENTs, or the dental community and the ENT community to kind of get on the same page and create that dialogue seeing as though there is so much of interchange and that possibility being there. I think that it would be a question of fostering that communication in study clubs and really examining those relationships. I think a thorough medical history always should be taken regardless of whether or not we're dealing with a maxillary sinus issue. But just to kind of open the minds of people to start thinking along that train of thought I think is important and very pertinent.

Howard: I want to ask another controversial question. You know if you're a dentist like me, I have seven restorations in my mouth and they're all gold because gold is perfect. It's soft, it's malleable and the consumer wanted porcelain so we went to PFM but now it's all gone to zirconia and some people are thinking, "Well you know you used to traumatically bite something the weakest spot was the porcelain off the metal and that would chip," but now that you've replaced the PFM with zirconia that's not going to give some people are thinking that what's going to give is the Endodontically treated tooth underneath it. Do you think zirconia will lead to more long term root fractures than say porcelain fused to metal?

Mark: That's actually a great question. I would say looks like [00:07:55] were [0.1] restorative failure would be the additional preparation that would be required to accommodate the materials. So if zirconia would require a deep chamfer as opposed to more of a feather edged type margin that was required in gold, more specifically on the lower second molar then necessarily, that additional preparation could lead to tooth loss. From my perspective and speaking to this wave of Endodontics that's moving towards more of a minimally invasive approach I try and keep my access as conservative as possible. I try and limit the shaping of the canals in the coronal and midridge portion and I'm leveraging the new technology in metallurgy that allows pre bending files before placing them in canals and is more mindful of that danger zone in the middle and mid root and coronal portion, coronal thirds of that root space. Switching from zirconia to - from gold to zirconia in the lower second molar region, those are teeth that have more of a propensity of cracking and if you're restoring those cases I think that those teeth have more of a propensity to be restored in patients that suffer from bruxism and they're due to some form of a power functional habit so I think we're kind of segmenting a portion of the population and that tends to have Endodontic failures that are related to cracked teeth. So it's kind of a chicken and the egg you know is due to the material or due to the case, the way it started?

Howard: You know when I got out of school thirty years ago in 1987 it was all hand files. And I looked at all the root canals that were prepped, you know shaped and cleaned thirty years ago to now it seems like when Rotary came out especially when the 0 4 Taper came out it seems like the preparations thirty years ago removed half as much tooth structure. As it went to Rotary, it seemed like when Rotary came out it was like switching from a table saw to a chainsaw.

Mark: Yup.

Howard: There is just - you see it all the time when you take x-rays of new patients, I mean these these root canals. But you're saying that you start to see the pendulum swing back where people are starting to say yes. So what is too big of a taper, what is too big of a file? Do you think filing out molar to an 0 4 Taper is just too aggressive?

Mark: So I'm going to say that it would be more the constant 0 6 Taper that would create that extra funneling. I think the inappropriate use of Gates Gliddens or Peeso Reamers really leads to that over preparation. I would say that what happened is, is that shift in technology led clinicians to adapt their clinical technique to the technologies available. Meaning, if I have a rotary instruments and I want to use them and I don't want to break them then I have to over flare the canal to prevent them from breaking. Well now that we have Rotary files that are heat treated, we definitely can do things a lot more conservatively. And I think that any Rotary system that is mindful of that paracervical denton, that area within the mid root or coronal aspect of the tooth and keeping that area more sacred and using techniques to access the root canal system. Sorry about that. Techniques to access the root canal system that are much more conservative that allows us to save teeth and save more denton. And I can't be credited for this concept. I think there are people way before me namely doctors John Kadomi and David Clark that were visionaries in starting that shift. And guys like me younger guys have taken it on and really seen how far we can push the envelope with regard to that more conservative approach.

Howard: So you know everybody wants to know they're listening to you right now saying, "Well, you're an Endodontist. You lecture internationally. What system do you use?"

Mark: Actually I primarily work with V Tapers. I've just come to the conclusion that their whole model is more driven on that minimally invasive more conservation of root structure approach and in the coronal third of the root the mid root aspect of the tooth they do provide me shapes that are a lot more conservative so I've gravitated towards that approach. In addition to that they're heat treated. So for those reasons I've espoused using that system. There are other systems that have that philosophy in mind. But it's just that's what works well in my hands. I like the tactile feedback that I get from those files.

Howard: And what is that website you said, V Tapers?

Mark: Yeah that's the - through SS White, V2 Tapers.

Howard: Oh, okay. It's SS White.

Mark: Yeah.

Howard: Okay let me see. Okay there we go. And what's the "SS" stand for?

Mark: That's a good question. I don't know. Actually can you enlighten me?

Howard: You don't know what the "SS" in White but you know what the "V" on the V Taper stands for.

Mark: Because it's not a constant taper.

Howard: So the V Taper is basically it's not continuing the flare the whole way up the file.

Mark: Correct. So you have that you have that more tapered approach in the apical third to prevent the extrusion of materials and allow for that vertical compaction of gutta percha. But in the mid root and coronal portion it's a lot more conservative so that you have the best of both worlds.

Howard: So SS Taper is - if you follow me on Twitter. They're all commuting to work right now so they can't take notes. So they follow me @howardfarran and I just retweeted @sswhite1844. I thought SS White was out of Colorado but it says on their twitter that they're out of Lakewood, New Jersey.

Mark: Interesting.

Howard: I wonder which one's correct. So do you use everything from SS White on this V Taper system that I mean is that your files your gutta percha, cement?

Mark: That's actually a great question. I mean with regards to sealer I use AH Plus. With regards to the gutta percha I sometimes use the SS White gutta percha. Generally speaking I use non standardized medium fine cones. As an Endodontist I've molded my techniques to the case. So because of the fact that I'm not getting these more standard more cut and dry cases I'm always having to play with the systems and play with the different materials in order to accomplish my goals. So I do tend to use their products but not exclusively in terms of the gutta percha. I do happen to use other products exclusively in terms of the files, the Rotary files, but that just kind of fell that way.

Howard: So you're basically promoting more minimally invasive preps so you don't want the flare to go all the way from the end of the file to the top because then when you get up in the coronal third it looks like it's been blown out with a Gates Glidden or something.

Mark: Exactly. More specifically because I don't believe it's necessary. I don't believe it's necessary to remove all that additional tooth structure. And specifically because of the fact that, as you noticed, hand filing was a lot more conservative and teeth lasted. I mean the whole concept and again I don't credit myself, I credit John Kadomi, Doctor John Kadomi to enlighten me on that is if you look at the cases that tend to have that long lasting appearance most of them have very, very little very conservative preparation. Those that don't go the distance or those that end up in perio oral surgery offices to be extracted and replaced tend to be the ones that are over flared and that have lost a lot of tooth structure. So that's where that movement to take a more conservative approach really stemmed from.

Howard: And he's in Durango Colorado, John Kadomi's in Durango, Colorado right?

Mark: Yeah that's right.

Howard: Yeah, and one of my classmates practices right across the street from him. He's an amazing person. So you said you use AH 26. There's a lot of people asking on Dentaltown about these new bio ceramic sealers.

Mark: That's a great question. I do use BC sealer for - I actually use BC sealer and putty for surgical cases. I'll use it in cases of open apices, sometimes BC sealer or sometimes MTA [00:16:34] inaudible [1.1] that just using it on every routine case. There's a big cost involved and I haven't really seen the true benefit of adding that cost without necessarily seeing outcomes, better outcomes just because of a change in sealer. And I have seen instances where clinicians adopt a new material to fix a problem that really isn't broken. Kind of like resilon and then you end up using a product for X number of cases and you end up with obturation based failures and then you start questioning all of the cases that you did using that method. So I like being progressive in my approach but I don't like changing what's not broken.

Howard: So MTA, that's the Mineral Trioxide Aggregate developed by, I could never see his name right. Doctor -

Mark: Torabinejad.

Howard: Mahmoud Torabinejad.

Mark: That's right.

Howard: DMD, MSD, PhD, Professor and Director of Advanced Specialty Educations at Endodontics Loma Linda University. But what is so funny about that is it's so expensive in a dental office but it's just Portland cement when your pool guy comes. Is it pretty much Portland cement that you're Pool guy's using?.

Mark: It's basically medical grade Portland cement. And I know that there are some standards that you have to go through to be able to place materials in the body and leave them in the body. So I can understand the rigors that go into having to develop and Endodontic material. But yeah at it's rawest form it is basically Portland cement. And God bless Dr. Torabinejad to have come up to that conclusion that you can use Portland cement in specific cases in Endodontics.

Howard: Yeah that is amazing. And it's the same thing with - there's all these people who want to do a lot of stuff with superglue but you can't invest a million dollars going through the FDA program when you're going to have something that you can go buy at Wal-Mart for ninety nine cents.

Mark: Yeah.

Howard: It's tough that way. I want to ask you another question. You can kind of divide all root canal providers into either apical barbarians where they want to get [00:19:00] inaudible [0.7] sealer at the end and then the other side is the pulp lovers who want to leave a half millimeter of tissue again. Would you say you're an apical barbarian or a pulp lover?

Mark: Look, the way I see it is, if I'm not to be apex and if I can't go beyond the apex then I don't know where I am. So I use electronic apex locators exclusively in order to determine my length and if I'm not out then I don't know where I am. So I like to fill - I basically fit my cone and it depends. I'll fit my cone to 00 right at the AL apex locator read - right there, if I have a very conservative preparation. If I'm dealing with a distal canal palatal canal and it's a little bit on the wider side than I'll fit the cone to point five. But I don't tend to like my cases to look short. That's the aesthetics of Endodontics. I would much prefer my cases to be to length and a little pulp doesn't bother me.

Howard: When you lecture on dental traumatology, what does that all encompass?

Mark: That is such a broad topic; there is so much to talk about. I've got kids that come to the office and it's from an avulsion to a pogo stick action, the less foreign intrusions to a complicated crown fracture. I mean it's everything under the sun but the impressive thing is so much of it has major implications in that child's future. You're talking about going to high school with a missing tooth or a flipper or - it has a very big implication on the kid's ego and not to mention the expense that they're going to have to incur later on in life to be able to cosmetically and functionally repair the defect that's created. So I think that having more knowledge in terms of how to manage trauma is crucial and it actually has a very big impact in these kids' lives.

Howard: What is the success rate these days of a reimplantation when a kid avulses a permanent anterior tooth?

Mark: It really depends on how fast it was reimplanted in the mouth and if it wasn't reimplanted in the mouth within thirty minutes what medium was it stored in? Was it stored in milk, saliva, water, orange juice? That all has a huge impact. If it was stored in dirt or if it wasn't reimplanted in a reasonable time that if the apex is open then you probably have a better chance of having a better long term prognosis. But there are so many variables that have a great influence on the success rate of a reimplanted tooth. But in any event, you do everything you can to try and say the tooth, and if in certain instances you can't save it then you move on to other options.

Howard: You got a very young audience you're talking to you right now. Most of these probably quarter of them in dental school. The rest are almost all under thirty. How should she wrap her mind around a tooth if she can't decide to salvage, root canal, build up crown versus extraction implant?

Mark: I think ultimately it's the patient's decision. I think that our goal is to really educate the patient of their options. I think that there is no standard root canal, post or crown. It really depends on how much to tooth structures is left, what else is going on in the mouth, what's the occlusion like? What do the patients want to use? I mean to extract it to another place that I think is a shame. I think it has major orthodontic implications. I really look at the patient, provide them my honest opinion and then ultimately they make the decision. But the amount of tooth structure remaining and the patient's desire to save their teeth is high up in the discussion.

Howard: I'm so glad to have you on the show. I personally think they're fed a lot of information from implant manufacturers that's not true about their success rate and then compare it to a less rosier picture of a re-treat. How how's she supposed to - I mean you keep hearing these numbers from implant companies that have like at ninety eight point nine success rate or a ninety nine point four and it's just not true.

Mark: Yeah. I would say that one thing that's never considered is the strategic position of that specific tooth in the overall scheme. Meaning if that patient is moving towards partial or total edentulism and you go stick an implant in let's say the premolar region when in fact when it comes to an All-On-4 case or it comes to a more advanced prosthetic treatment or rehabilitation it would have been more appropriate to have it in the molar position. You got to take that into consideration. So I think that saving teeth within reason if the patient's aware, willing to commit the time, money and effort into doing so, should not be a lost art. I think that the more we remove teeth prematurely the more we lose our ability to know how to save teeth. And that doesn't just go for Endodontics. It goes across the specialty: Periodontics and restorative dentistry. If the young dentist isn't being taught how to save a tooth, then obviously if all you have is a hammer then everything looks like a nail. So I think that they should be taught on certain techniques to be able to save teeth like they were done in the past when implants were not as commonplace.

Howard: There are approximately four thousand Endodontists in the United States. What percent of the four thousand Endodontists in the United States - what percent of their cases do you think are re-treats versus initial treatment?

Mark: That is such a great question. I really think it depends on the location. In more of a major metropolitan suburban area I would say that that's probably more of a higher range, maybe in the thirty, forty. I mean there are some practices that are pretty much exclusively re-treatment based, but there are some practices that are exclusively surgical re-treatments or surgical approaches. But I think the more you move out into more areas where there's more quote unquote "sophisticated dentistry" then the re-treatment is going to be a part of the treatment plan. In other areas that might not be as much of an option. But speaking from my practice's perspective of...

Howard: I always like to spot controversy in dentistry and it seems like every single dentist thinks their composites lasts longer than amalgam but then when you look at the big picture of the data, the amalgams last twice as long as the composites. But when you start talking to them they say, "Well Endodontists love amalgams because they fracture the teeth," and it's like - what do you think is more likely to drive an M.O.D. restoration and a molar to an Endodontist someday needing a root canal? An M.O.D. amalgam or an M.O.D. composite?

Mark: That's a great question. I really think that the patient has the biggest influence on that. Depends on what their habits are, depends on where their hygiene is, and it depends on parafunctional habits and what their habits are. I think that if they have any propensity to bruxism or any parafunctional habit or their occlusion is more hostile, then amalgam could lead to more fracturing and so on and so forth. However, if they have a mouth that's more hostile in terms of caries then they're more prone to recurrent caries or they're hyper salivator or and just execution of treatment on them is a lot more complex, then composites are probably not the more appropriate material. So man, it really depends on the patient. You have to take a patient centered approach. We work in a mechanical world but that's constantly changing. It's like you're playing football but one day it's snowing one day it's raining one day - So what shoes are you going to wear? Where you're going to wear the shoes that are appropriate for that day. That's the way dentistry works. In my opinion.

Howard: Yeah it is surprising to me though. I think at least half the dentists in the United States they don't even have amalgam and in their armamentarium any...

Mark: That's crazy.

Howard: Anymore. Do you still have it in your armamentarium?

Mark: Absolutely. Absolutely. If I'm dealing with any case that's in close proximity to the alveolar - to the marginal ridge, any instance where it would be a larger core buildup and I know that a crown is planned I think an amalgam is a great material. I wouldn't see how - I think that a lot of teeth would end up extracted prematurely if amalgam is not being used in some cases. What I see that composite has brought a whole another facet a much more conservative approach we can be a little bit more proactive and still remain conservative. Absolutely. But I do think that amalgam still has its place.

Howard: I've got another good controversial one for you. There's a lot of dentists that I've heard say over breakfast, lunch or dinner over the years or on Dentaltown saying, "The only purpose of a post is to fracture the truth."

Mark: Not true. So I think that in instances in anterior teeth, in premolar teeth, more specifically - what are your choices to obturate the roots? The mid root or the mid to apical portion of the root canal system. Gutta percha? Filling it with dual composite resin? Filling it with some other bioceramic material? Or placing some form of a material that mimics the flexion of the natural roots and that would be a fiber post. So I'm all for placing fiber posts so long as it doesn't incur much more additional preparation to the root canal space. So I'm thinking even when performing root canal therapy through a crown for a premolar and an anterior tooth it's very appropriate to place fiber posts - passively fitting fiber posts with no additional preparation of the root structure.

Howard: What do you think is more predictable? I know these are general- I know these questions are so hard to answer because...

Mark: Nope.

Howard: depends on the specific case but I've got to talk generalizations.

Mark: Sure.

Howard: What is more predictable, a pulp cap if you run into the pulp and sealing it right there or going through and doing the whole root canal and sealing it at the apex? How should you decide to pulp cap or Endodontic treatment?

Mark: So I would say, and I'm going to be reverting to this again and again. But it really depends on the lifestyle of the patient; their age. I think a younger patient, definitely if the apices are open, we're moving more towards any form of pulp preservation and even with regards to teens and younger patients I think it would be more valuable to use more biocompatible materials in a order to cap the pulp. As we get older in age the value of attempting to save the pulp becomes low. The value of preventing a very uncomfortable and unpredictable experience goes up. So for instance if I have let's say a sixty year old male and they've just had a pulp cap on tooth number thirty. Well, what is the consequence of them going through pulpitis? Missed work. They have to get a flight home, they're in the middle of god knows where, where they have to go get a root canal by someone if they may or may not be qualified, so that's a very negative effect of a pulpitis in that case. Now if you have a thirteen year old kid that has a pulp cap and that that pulp cap lasts another six years until they're nineteen years old. They're right about to go to college. Then, they're much more mature and in addition to that the pulp has had time to recede so [00:31:35] inaudible [0.1] the chamber in order to address the root canal system, you're able to do that a lot more conservatively as well. So it really depends on the age of the patient and their lifestyle. That's my opinion. But I do think pulp caps are appropriate in certain instances and using the appropriate materials is also very important.

Howard: What is your go to pulp cap material?

Mark: MTA in posterior and if I'm working in the anterior we're going to go for some form of bioceramic material, either BC root repair material or biodenton.

Howard: Now when you do use MTA for a pulp cap do you have your own personal pool cleaner man deliver you of fresh batch of porter cement?

Mark: No, I actually buy it from the manufacturer. I get the legit ProRoot MTA. You know, especially when dealing with such a material sensitive procedure, I really want to make sure that I'm using the gold standard, I'm using the best because if it ends up failing I want to know that I gave it the best shot.

Howard: I was just kidding that was just a dumb joke.

Mark: It was a good one.

Howard: I want to ask you some other very controversial question. I mean I don't know if you have seen this or not but there are a lot of dentists in the United States that after every single root canal they've ever done they give them twenty eight tabs of Pen-VK, forty tabs Pen-VK, three or four tabs a day for seven to ten days. I mean have you seen this or is this just my old friends?

Mark: I know that that does tend to be - In my community I wouldn't say that that's routine but I have heard about that. I think that it's just a question of previous habits. I don't think it's necessary. I think it could actually be harmful in some instances. I have had patients that an antibiotic is prescribed, they end up with major diarrhea or any type of G.I. issue and then you're really regretting, or questioning if that was really necessary. So that's not commonplace in my practice. But I won't be able to tell you all the rest of the practices in my community what it is that they do.

Howard: So the same question when I got out of school thirty years ago the media was coming down hard on doctors, oncologists, that, "You're not prescribing enough pain meds. There's people that are dying, in chemotherapy and they're in pain and you did root canals and you pulled their..." And there's this big push to get all these conservative doctors and dentists and physicians to prescribe more opioids. Now the pendulum's all the way to the other side. Now there's a lot of people saying, "You know the problem is so many Endodontists and dentists and oral surgeons are prescribing all these Vicodins," and they call out oral surgeons by name in these articles in big newspapers.

Mark: Wow.

Howard: So the question is how do you get your mind around the opioids. Do you use opioids?

Mark: I would I say use them very, very, very rarely. I would say that most often with a good combination of ibuprofen and Tylenol, that takes care of most post-operative sensitivity. In many instances when I'm dealing with a case of periapical periodontitis, meaning tap on the tooth and it hurts like crazy or the patient's complaining of a deep gnawing ache, and when they touch the tooth it hurts like crazy after procedure was done. I've come to the conclusion that it's more appropriate to prescribe some form of a steroidal anti-inflammatory assuming the medical history allows for cod. I've found that be much more effective in providing them relief rather than narcotics. I do sometimes prescribed narcotics but it's definitely not routine.

Howard: When you were doing your re-treats, what percent of these are failed because they weren't done correctly by the general dentist? And the general dentist does a root canal and it fails later on, what are the usual mistakes? Is it mostly missed anatomy or not getting to the apex or what would you say is the mistakes?

Mark: I would definitely say it's a combination. What I see most frequently is definitely missed anatomy. Missed MB2 is something that I see very, very frequently. I'd go so far as to say as there's some instances that in mid mesial canals or a canal that's located in between the two mesial roots of lower molars can lead to failures. I've had instances where a tooth was treated in re-treat. And that canal was still missed and then upon my third revised treatment I find it and there's resolution of - or there's a bone fail. So it really depends. But that tends to be the most common. Missed anatomy tends to be, I would say the most common when I'm dealing with re-treatments.

Howard: Where would on the top five reasons where would a broken file come in? Is that also very common or is that less common than it was ten years ago?

Mark: So I would say it's less common. I would say that I don't deal with separated instruments as frequently as I possibly would have expected when graduating. I would say that most often those cases - So if it needs to be addressed in the mid root or coronal aspect I'll attempt to bypass or retrieve it nonsurgically. If we're into the apical third I much rather proceed with a surgical approach assuming anatomy is appropriate. But again it goes down to how much tooth structure is going to be remaining after your attempt of removing this separated instrument. And that's how I make my decision. It's about the number of - it's about the amount to tooth structure left. Biology is important but I think we deal with a lot more of a mechanical - we're in much more of a mechanical or a biomechanical field than we are in a strictly biological field and we need to embrace that aspect of what we do.

Howard: We're supposed to be patient centered and not doctor centered. It's supposed to be all about the patient not about the dentist. And I see a lot of dentists sending a patient to the Endodontist saying you do the root canal but I want to do the build up and obviously the crown. But when you look at saliva with a billion bacteria, microorganisms, fungus, viruses and parasites per CC, which is the volume of a nickel, gosh don't you think that having them leave your office temporized and maybe not getting back into the office for a month, do you really think that's the best deal? Don't you think it would be better if the Endodontist always did the build up?

Mark: And that's a great question. Some of my referrals would prefer me to do the build up on all cases. Some referrals are a little bit more selective and they would prefer to do the build up. In those cases, what I tend to do is place an orifice barrier. I'll place a millimeter and a half of resin on the floor of the tooth and then restore with some form of temporary restoration. In some cases I'll have an open discussion with the referral and say, "Listen this is a pretty difficult restorative case and I'm not so confident that we'll be able to maintain that sterility during a temporization phase. Would you be opposed to me placing the core?" And very often they're okay with that. I think it's just a question of having that open discussion rather than making a blanket statement. "I'm placing all restorative at all costs." I think it needs to be discussed and then that relationship is then molded into what what ends up being best for the patient.

Howard: Let's say she just took an x-ray of this tooth and she doesn't have a CBCT and she can't tell if it's internal or external resorption. What would you tell her?

Mark: I would say the value of CBCT when it comes or resorption is tremendous. I think that taking shift shots really only gives us an approximation. We don't truly know exactly the extent of the resorption defect when we're not using CBCT. In my practice CBCT is a must when it comes to resorptions. I really do want to know if this is going to be something that's predictable and if I'm going to attempt it, what's going to be the approach. Non-surgical, surgical, what materials am I thinking that I'm going to be using. So with regards to resorptions that's my take on things.

Howard: It seems like whenever you see two general dentist talking about Endo they only talking about well, "What system to use and what do you obturate with?" They always talk about obturation and even if they ask about files, most of the stuff I read is that files and everything maybe gets out two thirds of what you need to remove and the other one third is irrigation, etcetera. Why do you think dentists always focus on how you obturate what you put back in instead of what you take back out and what advice would you give them on irrigations and new technologies to get? Do you agree it's about forty percent that you probably only removed sixty percent mechanically?

Mark: Absolutely I would say well first off to answer your question with regards to obturation I think that the reason why so much focus is on obturation is because that's the final result that you end up looking at. So it's like if you look at an artist and you look at his painting you're going to say, "Well what paint did you use. How did you recreate this?" Because of the end result. You don't go into the brush in the nuance. So I think that obturation is a reflection of instrumentation. I think that thorough irrigation throughout the procedure, constant irrigation is paramount. And I think that addressing all the anatomy also ends up giving you the look that ended on as look. It just looks more dense because there's more of that internal portion of the tooth that's filled. And what I would - my best piece of advice is: use enhanced magnification and take more advanced continuing education to be able to find all the anatomy and address it. And once you do that the rest comes with it. That's my opinion.

Howard: And what is your go-to irrigation?

Mark: I use sodium hypochlorite throughout the entire procedure.

Howard: But what was strength though? Straight out the bottle or do you dilute it?

Mark: I dilute fifty percent because now straight out of bottles at seven to eight percent. I prefer my solution to be a four percent solution. So I'll dilute it fifty percent. And seventeen percent EDTA to remove the smear layer followed by a sodium hypochlorite wash followed by a ninety percent isopropyl alcohol to dry the canals at the end. Micro suction to remove most of the moisture. Then paper point wicking and then we're ready to fill. In re-treatment cases I've been adopting a two percent chlorhexidine solution right before I place calcium hydroxide after the first visit. So those are the main irrigation techniques that I use.

Howard: That's very interesting. Do you use any ultrasonic devices in the irrigation to try to get the irrigation into more lateral canals, or you see some of these CBCT images of these teeth and it almost looks like a fern is growing. You know?

Mark: Yeah.

Howard: It's not like a tree stump it's - So do you use any ultrasonic agitation? Do you think it is worth it or does that work better getting in all those nooks and crannies?

Mark: So typically what I use is I'll pump a gutta percha cone. Some studies have shown that there is no major difference between pumping your master cone versus sonic or ultrasonic activation. From what I've noticed for instance when there is missed tissue or when we are dealing with a C shaped canal or one of those mesial roots of lower molars or two canals that join, very important to constantly irrigate and flush out such as ultrasonic or sonic activation are helpful but I don't think that replaces finding all the anatomy and being very meticulous about attempting to address it all with small precurved hand files.

Howard: Another question that prominently comes up on Dentaltown with very young dentists is they hear a lot of - some dentists say, "I do all my root canals in one appointment." Then other people say, "Well sometimes you should do it in two appointments." Then some people say that if it has a periapical radiolucency you shouldn't one step it. How does she get her mind around a one step or two step?

Mark: That's actually a great question. I would say that with regard to symptomatic cases are not related to pulpitis, I'm much more inclined to go with a two step model. That just gives you more comfort to know that the patient is then comfortable when we choose to obturate the root canal system. That being said, there are some instances where I'll opt for a one visit approach. But I like the security of a two visit model. I like the ability to be able to ensure that the patient is now comfortable. From a convenience perspective there are some instances that I'll make an exception. It takes me a little bit out of my comfort zone but I do understand that some patients have certain needs and I'll opt for that. For instance if I'm doing a case and we're understanding that he'll have to go under general anesthesia in a hospital setting in order to be able to address his tooth clinically again, in those cases I'll do everything in my power to finish it in one visit. But de facto I would prefer the security of it a two visit model.

Howard: I love how you're talking about the final restoration. That trying to use a final restoration doesn't involve so much reduction. I mean not only not carrying out the taper all the way up but they're not putting a final restoration. Some of these cases you see by the time the flare out of 0 6. And then...

Mark: There's nothing left.

Howard: Put a two millimeter shoulder around it's like - which also leads to my other question. Lot of these young ladies are working with their dad who says every root canal tooth should be crowned. And then they're doing a lower anterior and by the time you get done prepping a lower incisor for a crown looks like a grain of rice. And so we filed the entire tooth down to a grain of rice to save it. What do you think of these one liners like, "Every root canal tooth has to have a crown?"

Mark: So the studies were based on the Farrall effect and based on crowning teeth after Endodontic therapy were really examining teeth that have forces that are compressive forces. So if you're dealing with a tooth like a molar or even a premolar that's dealing with compressive forces then you are more moved to recommend full cuspal coverage. When we're dealing with an anterior tooth that's dealing with more shearing forces, removing more tooth structure in order to place other types of materials and more specifically weakening the tooth at the neck is actually - that definitely does not strengthen the tooth. If anything it would give it more propensity to breaking in the future so I would say with premolars and molars it may be more appropriate to consider some form of cuspal coverage assuming you're more conservative with your axial reduction and when it comes to anteriors and in some instances premolars and many times crowns are not an appropriate route [00:47:59] inaudible. [1.0]

Howard: So another thing that freaks people out early in their career is the tooth is symptomatic, they've got to do a root canal. They take out this big old M.O.D. amalgam that's been in there for forty years and there there's a black line on the floor. And they're just like, "Okay what does this mean, to treat or to extract?"

Mark: That's a great question. I'll say that CBCT has provided us a lot of very good insight when it comes to those cases. Not to be able to see the cracks specifically, but to examine findings that may be correlated to bone loss patterns that would lead us to believe that the attachment is significantly involved and even at that, I always leave the decision to the patient. Aand the way I say it is, "Mrs. Jones, come back to the office. Come to the conclusion that the crack has progressed and now that tooth that you spend the time money and effort on a root canal post-coronal and a crown or a root canal and a crown has to come out would you feel satisfied that you did everything that you could try and save your tooth? Or would you feel regretful and upset at me? If you believe that you'd feel regretful, then the most definitive option because you can't go back, is to remove. And we'll do everything in our possibility to be able to put the cards on your side." The crack is just more of an unpredictable - just gives a much more unpredictable approach. That being said not all cracks are the same. I would say that if I would see a crack that's not extending down the root canal system there would be a better prognosis associated with it. I would say that if we have a crack that's going further the prognosis is more compromised and if we're choosing to save it, definitely want to consider totally flat occlusion. No [00:49:50] inaudible [0.5] of contacts whatsoever and hope that the patient has a more favorable occlusion to be able to be able to maintain that too.

Howard: When you're almost done with your root canal and it's a molar but one of the canals keeps bleeding, what do you use to stop the bleeding and at what point does that bleeding say to you, "I'm going to temporize this and wait?" And how long would that time period be? I know that was twenty questions in one but hopefully...

Mark: That's a fantastic question. In some instances where I really - we want to finish the case for whatever reason - in some instances placing a little bit of ferric sulfate on a paper point and placing it in the canal and then obturating the other canals is enough. In some instances, what you need to increase a little bit of the apical size of that preparation to remove a little bit more of the pulp tissue. I'm noticing that in vital cases with younger patients I'm more inclined to go to a two visit model because they're more ovoid in nature and I'm finding that the use of calcium hydroxide really helps me at that second visit get that nice dry canal, where I'm able to obturate and not have any question with regards to weeping or or anything of that nature. I don't want there to be question...

Howard: Back to obturation. I think that we have to do techniques that can be re-treated. I mean they are re-treatable. It makes it difficult on a long term if you do something and you can't re-treat. Do you think some obturation techniques make it harder to re-treat? I mean, you see a lot of gutta perchas on a cone that leave - gutta percha on carriers. Are there any obturation techniques were as an Endodontist you would say, "That really makes it a lot harder to re-treat and shouldn't be used?"

Mark: I would say Howard, that the difficulty in re-treatment has much more to do with the instrumentation that was performed. Canal was under instrumented and Thermafil or some form of carrier based obturation was placed, then those cases tend to be a little bit more challenging. I would say that if proper cleaning and shaping was performed and that method of obturation was used, those cases are actually not that difficult to remove the carriers from you just have to have the right technique. I tend to use you the Hedstrom that's wound in and I'll use the full crumb or some form of technique to be able to remove that carrier. That being said, instrumentation creates the most frustrations when it comes to re-treatment. Ledges, blockages, or under instrumentation placement of obturation materials that are very hard such as resin based paste makes the obturation much more difficult than a blanket statement of, "Thermafil is Hell." I feel like carrier-based obturations are Hell in cases where the instrumentation was inappropriate.

Howard: A couple more questions. You've been so - I can't believe I got you on your day off to talk to me for an hour but I just got a couple more questions. Sometimes she knows the tooth ache is in this quadrant, but she's just not sure. She's got it narrowed down to two teeth but she's just not sure. What do you advise in those situations when you're not a hundred percent sure because they're in so much pain?

Mark: As an Endodontist or as a general practitioner?

Howard: Well, what advice would you give the general practitioner?

Mark: Well it's very - and this is just my perspective. From a preservation of practice perspective, getting the wrong tooth, from a general general practitioner's perspective, is a lot more harmful I believe than an Endodontist because as the Endodontist, you know you've gone through all the tests, you have that advanced training in Endodontics and if you went through the discussion with the patient, you told the patient that there was some uncertainty and we've made that commitment and it ends up being the wrong tooth, I feel that the patient has less remorse knowing that they went to a specialist rather than having the general dentist having to make up for that. I just feel like that has more negative consequences on a practitioner's practice when they make that call. So that's really my perspective. If you're not a hundred percent certain - and it may sound self interested being an Endodontist to say that, but really looking at a disgruntled patient is really the worst thing that you can have for your practice. So knowing what the patient - knowing that you did everything in your capacity to do right by them I think is invaluable. So for that reason I think a referral to an Endodontist when you're not a hundred percent certain is for that exact reason.

Howard: One of the biggest differences between your generation my generation - I'm old enough to be your dad. I'm fifty five.

Mark: Okay, almost.

Howard: Well when I was born Catholic in Kansas. They start having them at sixteen, so I'm definitely old enough to be your dad. But the Baby Boomers when they went to the dentist you would say - thirty years ago you would give the patient the recommendation. They'd just say, "Well you're the doctor," and we're just more authority. You look at the Ten Commandments the first three is obey God, don't change his name obey, you know. The fourth one honor your parents. But now the millennials are like well, "So what you're an Endodontist I just spent fifteen minutes on Google and I know as much as you do," and we're getting a lot of questions where - if you go to they say the most common cause of all cancers is root canal filled teeth and cavitation sides until a patient gets rid of the root canal teeth. You're hearing this. The Internet started out is to spread all this information to the masses but what it's turned into is spreading massive misinformation.

Mark: Misinformation.

Howard: And so what do you do when a patient comes in and says, "I don't want a root canal," or, "I want my root canal teeth pulled," because they show you all these Google articles and Endodontics' linked to cancer. What verbiage or how do you approach that crazy topic.

Mark: So I'm going to say this. There are a lot of components your question so I want to address them each separately. For one thing with regard to the Millennials are, the way business is done in this day and age or the way interactions are done between us humans in this day and age, transparency is key with any business all while certain practices spread like wildfire. It's of utmost importance to be honest and truthful about why we're making our recommendations and give as much adjunct information as possible. Now with regards to the link between root canal therapy and all types of different illnesses, there is literature out there that disproves that. If we were to think about it if many causes of death were actually related to root canals then it would be more likely that that practice would no longer be provided or that would no longer be a service that would be provided to people in general. So I reason through them. I don't disparage them. I encourage them to provide me with the information that they brought, that brought this thought process to their attention. But I think it's just a question of being very honest and transparent and saying, "You can choose to remove your tooth. There are consequences to removing your tooth. There are consequences to removing many teeth and the potential consequences that you have that are very clear may not be so beneficial with you compared to the potential consequences that are not really founded based on having root canal and the potential health risks associated with that." So I'm just very honest and open and if they appreciate my approach then they'll listen to me and if they don't then then they won't.

Howard: Well that's good advice. I still think one of the hardest aspects of dentistry is dealing with the complicated patient's mind.

Mark: Hey guys. So sorry we got disconnected. Howard I really wanted to thank you for this interview. I hope I gave you guys some good insights about the latest and newest in Endodontics, at least from my perspective. If you guys have any questions don't hesitate to hit me up either on Facebook on Twitter, Instagram or check out my dental group, The Dental Network. I'm more than happy to have you guys over and discuss Endo. Thank you so much. I really appreciate. You guys take care.

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