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AUDIO - HSP #148 - Ken Serota
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VIDEO - HSP #148 - Ken Serota
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Howard and Ken discuss the changes from conventional to minimally invasive procedures, surgery, and the changes in endo.
• Graduated Endo from Harvard Forsyth Dental Center in 1981
• International lecturer, author, has been intensely involved in online CE with ROOTS and NEXUS
• Global clinical director for Dentaltown.com
www.endosolns.com
kendo@endosolns.com
Howard: It is a huge honor today to be interviewing Ken Serota who was the first endodontist rock star on the Internet. He was a big fan of mine. He started Root ZX. I [started doing that 00:00:20] in 98. I think Root ZX was before Dental Town even. What year was Root ZX started?
Ken: It started in 1998.
Howard: We started same year.
Ken: Same time.
Howard: You collected the most famous endodontist, not just [inaudible 00:00:34] it wouldn't be United States. It's like you had endodontist from Russia and India. I don't think there was a country on the map that didn't have someone showing in endodontic case on Roots. That was the single largest endodontic impact on my personal life and I want to thank you for that, Ken Serota. You are a visionary. You are ahead of your time. Some of those cases there were just amazing.
When we go to Dental Town and we look at the 200,000 dentists who had posted 4 million times, biggest hottest topics are root canals, implants, and [practice managing 00:01:14], make a money, lose a money, corporate dentistry, implants, root canals. I want to go right to the killer question. I wanted to open up with this because I thought two older guys could answer this better. I keep seeing new patients for 28 years where they went to a dentist across the street, down the street, and the cavity got deep. Then they went to spoon excavation and they have [die crown 00:01:40]. They tried all these things and the page went back and it's sensitive [inaudible 00:01:44].
Finally, a month later, this patient's had nightmare, they end up in my office. I just kill the damn pulp, do a root canal on the crown. Ken, where do these young dentists cross the line from being a good ethical, moral dentist, and trying to avoid a root canal versus come on, this patient is 30 years old. She's going to be alive when she's 80. You really think this tooth's going to be alive for another half century when you're down there placing dical? If you get too aggressive then they, "Oh, Howard, you just didn't want to do a $250 filling, you wanted to do a $2500 root canal and a crown. Ken, my first question to you is what's the difference between being a conservative dentist and saving the pulp versus just kill the damn thing, do a root canal and put them out of their misery?
Ken: I think you're seeing, as we're seeing now at Dental Town and Nexus, that the world is going back to a more minimalistic approach, bio emulation, this sort of thing. Most recent studies are related to dealing with vital pulp therapy for people like Martin Trope and a variety of other people from around the world are that excavation of carias should be done incrementally, in stages. It allows the pulp the capacity to regenerate in a much different way than it ever did, despite barreling everything out. I think our appreciation of the impact of what air rotors do and the need to have better control, water control, heat, this that and the other.
The advent of lasers in terms of hard and soft tissue removal is going to change a lot of things. I think the reality has hit home that even in doing root canal, there's still a 5% to 10% recidivism rate. No guarantee. I would imagine that the vast majority of restorative gamuts today are going to look to new technologies, new research, and try and change that direction. They may not commit the tooth to full blow prosthetic sophistication, but they will certainly, in the world today, try and do less being more in the sense of incremental removal, laser usage, and you don't have to force to do a root canal now for example. I think there's a whole shift. You're beginning to see a tremendous shift in what was essentially conventional root canal therapy and what is now a bio minimalistic approach both to access and restorative driven endodontics.
It's a huge swing in what people are trying to do. We believe we can preserve pulps in a better way. You're seeing that in terms of even cases that apexes are incomplete. The advent of regenerative endodontic procedures for teeth that haven't fully formed, rather than just committing them to root canal and surgery and this, that, and the other. There's tremendous trends emerging in this day.
Howard: Talk to these general dentists specifically. Do you use carries detection, or is carries detection over detect with an affected dentin versus infected dentin? When you're talking about incrementally removal, instead of just taking a number, 6, 8, round burr and boring it all out, be more specific. How do you do this? Do you recommend carries indicator? How do you remove ...
Ken: Totally.
Howard: Incrementally? What do you pulp cap with? Calcium hydroxide?
Ken: You raised the issue for example of affected versus infected. Even using your spoon excavator to peel away leathery dentin, and then using for the time being [inaudible 00:05:28] enforced glass [inaudible 00:05:33] knowing full well that you're going to go back in. As far as carries detection agents, I mean, absolutely. I think they're invaluable. Today of the systems that are currently out there, the one that I would most strongly advocate based on the research is the canary system by a local Toronto boy who is marketing it: Steve Abrams. [inaudible 00:05:55] whatnot, there've been a number of them out there, but it seems like this canary system has just started to really take off. It's got tremendous science behind it, validating its ability to detect early stage decay and whatnot.
I think you're going to see increasingly ... We're never going to get to Doppler flow or that kind of thing, but I think that type of technology will continue to emerge and carries, in its infancy or earliest stages will be picked up, and will be able to negate that concern.
Howard: For someone who's never heard of the canary system, can you explain any more about that?
Ken: I'm not totally sure how it works. I would imagine that again there has to be some sort of optical capacity for measuring the changes that are occurring on some level. I don't know that I fully understand the mechanics, but I know that from a standpoint of validation, the research that's been done behind the canary system has just been tremendous. They've received tremendous accolades from the scientific community, the research scientific community, in terms of its validity and value, in terms of achieving the end result of early detection of tooth decay.
Howard: You've been an endodontist for decades.
Ken: About a century now, I think.
Howard: What?
Ken: About a century I think. It feels like it.
Howard: A century. What do you think of ... What are the most common mistakes you're seeing general dentists do when you're working ... You're an endodontist, you're working with general dentists. What is the low hanging fruit that someone like you ... You've been doing endo for how long?
Ken: Right now, about 30 odd years. 33 years, I guess. 34.
Howard: Okay, 33 years. 34 years, and a lot of these kids are listening to this 5 years out of school on these podcasts. What are their most common mistakes? What's the low hanging fruit that a guy who's been doing it for 34 years could coach these kids on?
Ken: It's interesting that you mention that because theoretically, I think the first thing that anybody who's going to root canal therapy needs to do today is to look at the work of people like Marco Versiani, Ronald [inaudible 00:08:11] and these are things that you can pick up off the internet. These fellows are using micro CT to essentially show people the enormous complexity that is present at the root canal systems of every conceivable tooth type imaginable. I think that tragically they're so used to looking at flat films and post-treatment white lines that are submitted to insurance companies that we really have lost our ability to understand the labyrinthine complexity of the root canal system. It's just simply staggering that people undertake treatment with a single x-ray or a badly-angulated film or a foreshortened, elongated, or cone cut. Whatever. That's where cone beam is obviously coming in too, and from my perspective, the most invaluable image in the cone beam sequencing is the axial image.
I think from a diagnostic standpoint, if they determine that that tooth is requiring root canal therapy, then I think quite honestly that within the next certainly 5 years the gold standard for endodontic diagnosis has to be CBCT. There's got to be cone beam imagery taken to augment. If you don't do that, at the very least multiple digital films to try and gain a greater appreciation of curvature and anatomy. They really need to understand the complexity of the root canal system above and beyond what is traditional in the while line imagery that everybody associates with the quote, unquote "look."
The other big concern that I have is that at the moment there are 100 [inaudible 00:09:57] systems on the market. Where you have it, especially where you've got these armies of representatives from the companies going out, you're being literally deluged with, "This system works, that system works, we can go to single file. You go to reciprocation, you go to rotary," there is just a tremendous push to try and imprint single file usage onto teeth that are far more complex, that require far more consideration. A single tool can't be used to create a Michelangelo statue. Michelangelo didn't carve the David with one chisel. I think there's a tragic shift in the marketing of endo as 1 file, 1 [inaudible 00:10:52], whatever whatever, and then you're done.
If there's anything that they need to understand, it's the fact that instrumentation requires, not a generic or singular approach. It's an extremely sophisticated approach dependent upon curvature, dependent upon location, position, patient access, this that and the other. Then the biggest problem of course is that most of these young folks haven't addressed the implications of things like biofilm, what people like [inaudible 00:11:27] are doing, [inaudible 00:11:30] people like that have been screaming about for years.
The most underrated, the most under valued aspect of endodontic therapy is the ability to irrigate well. That's why son-endo is coming on strong, that's why PIPS has mattered. That's why everybody who practices endodontics on any level has to understand the implications of passive ultrasonic irrigation. There's no drive for that because they're renewables that cost nothing. In most cases it's sodium hypochloride. You buy a jug of [inaudible 00:12:07] or you buy something that's been modified with sodium hydroxide, and there's no money in it for companies. The tragedy is that's what does the majority of the work, provided you'd given it access to eliminate, and the bride in disinfect the canal system properly.
From my perspective, we're being sold all the tools and all the root filling material, but we're not focusing on the thing that eliminates primary cause of root canal disease in atypical periodontitis. I think if I were a young guy, I would want to have a better understanding of pulpal biology, atypical periodontitis, all the implications of what causes pulpal disease so that I could avoid a number of things over instrumenting a canal system, ensuring that the canal system is truly cleansed, that I've achieved the biological imperatives, and not just because I bought a single-file reciprocating system and a core-based [inaudible 00:13:04] that I could retrieve if I had to. I think there has to be a balance between market and science as there is in everything, be it implants, be it restorative dentistry, whatever it is. I think that's the problem. When you've got 100 systems on the market and literally new ones coming out all the time, I think there's a lot of confusion at the moment.
Howard: Absolutely. What is the gold standard for pulp capping? Would you ... You would use carries indicator? You would use a spoon excavator, and what would you place on it?
Ken: Historically probably MTA. Even that's shifting now to bio ceramics, putties, or bio dentin which is coming out of Europe. The big push in endo has been that there's obviously a need for reevaluation of the [inaudible 00:13:59] materials that we are using. You're seeing it coming out from people like LA NASA, real world endo, Martin Trope, [inaudible 00:14:10].
Bio ceramics are taking ... I wouldn't say taking over, but they're impacting significantly. The day will come, eventually, when I think bio ceramic root filling materials will represent the largest burden in terms of obturation equipment or materials that are required. It hasn't happened yet because the vast majority of people are still ... I think the world's largest obturation system is still carrier-based obturation. You'll notice that even Ruttle, Shenamblo who was one of the people behind [inaudible 00:14:47], and certainly Buchanan who for years has been the ... These have been the ruling gurus of endodontics. Their approaching carrier-based obturation now as well. You see a lot of that in Italy.
Howard: Give name brands. Are you talking about ThermaFill, SoftCore?
Ken: ThermaFill in its early days, it carried a bit of a ... There was a lot of bad ... I don't know that material was bad. I think it was, again, the implications of the material, maybe the early iterations of it weren't great. Certainly with GuttaCore and what they've done recently from a standpoint of what [inaudible 00:15:30] come up with, I think with what you're seeing with Real World Endo where they're using bio ceramics and single core [inaudible 00:15:39] cones so that it can be retreated, I think ThermaFill as it was in the early days wasn't the greatest thing going, but I think that like anything else, the iterations that have gone on over the course of decades has now lead people who at one time were shouldarian left right and center to move toward carrier-based obturation.
Howard: In my humble opinion I think the reason ThermaFill got such a bad name is because of what you were saying earlier: dentists just thought obturation was the key, and they would file things out to a 25 or 30 and shove a ThermaFill in there, and they didn't realize that you open up the canal and then cleaning and shaping with irrigants and ultra sonics and it was just ... They were basically doing radiographic x-ray. If it looked good on the x-ray, it was done.
Ken: Exactly. The interesting part about it, though, is that if you look at the early shoulder work, his envelope of motion stuff, what's happening in endodontics now for example is a the major controversy is are you doing harm to teeth by persisting with this conventional endodontic look approach, the shouldarian so-called "look"? The need to have volume in order to develop real logic flow so that you could pop lateral canals, etc etc.
The push now, certainly we see it ... I think we've seen it with people ... Mark Bolson for example, the New Jersey Endo Association, has brought in some phenomenal people. Michael Churto comes to mind. There are others. The push basically is that you're going back towards more minimalistic approach. I think again if you look at what guys like Branson and Kademi and Clark are advocating, the whole tapered concept is disappearing. I think there's going to be a need to renew obturation. It may be carrier-based, I don't know. I certainly think what you're going to see is smaller canal preparations, more tapered almost as if they were designed for silver cones. Less tapered, rather, as if they were designed for silver cones. I think you're going to see a massive push to new irrigation devices. That's [inaudible 00:18:02] photo-activated disinfection, PIPS, but again that's laser-based. We'll see. Certainly has done some work. Endo vac that [inaudible 00:18:13] came up with has some pretty strong implications. It's a bit cumbersome, but I think they're going to see a redirection.
For example, Rooter, the fellow who I believe is at Suni or Stoneybrook I guess in New York. He and Obey Peters came up with True Shape, and that's the new dense [inaudible 00:18:37]. That files going to change the need to how you obturate, because it shapes differently. Martin Trope's XP Endo Finisher is also going to change the way things are shaping. It's not Martin Trope's, it's FKG, but [inaudible 00:18:50] and all the others that are advocates for it in terms of its efficacy for true debridement, I think you're going to see some need to truly think how we're obturating root canals and just ... I think that's why, personally, I think bio ceramic is going to be important because it's hydrophillic and its capacity to flow or be controlled is impressive.
Having met with Dennis Brave and [inaudible 00:19:14] just the point to be made, you want to think about it. What we've done for all these years even with shouldarian obturation, the so-called quote, unquote "3 dimensional obturation" you can't obturate in 2 dimensions. That was such a specious concept. How can you obturate in 2 dimensions? You can obturate in 3 dimensions, but you can obturate badly in 3 dimensions.
What they've done though now is because of the bio ceramics and the ability to get those things to flow into nooks and crannies that are now being removed by better dissolution methodology, I think you're going to see a shift, and it won't be that the so-called carrier-based is the essence of it. I think sealers will be improved, but the whole goal was to minimize the sealer, right? That was the key. You wanted some massive quantities of [inaudible 00:20:06] to minimize the amount of sealer. But it's interesting because now with bio ceramic as the filling material, it may prove to be the more efficacious means of closing down a root canal system.
I think that they're making a real concerted effort. I have a lot of respect for the Real World Endo guys in terms of how they're approaching this. They're not coming at this on a marketing juggernaut. They're only bringing in people who are really committed to it, who are true KOLs, serious advocates, and doing a ton of research as well.
By the same token, just to back that up, one of the things we don't have in America which offends me to no end is the SAF file system from Steve Edsker. It's the one that looks like a cardiac stent. Worldwide it's gaining tremendous traction. Germany, India, but it was dispensed with in North America simply because the original motor didn't work. I think overall you're going to start to see that the ability to shape minimalistically but ensure that you've eliminated the labyrinthine irregularities, you're going to irrigate supremely in ways that we were never able to do. You're going to see, in my opinion, the bio ceramics or materials like bio ceramic are going to be the ultimate obtruation methodology. It will not be [inaudible 00:21:33].
Howard: Do you have name brands today for that bio ceramic?
Ken: It's the Brazzler Root ... What's it called? The sequence that comes along the sequence. My brain just stopped working.
Howard: But it's Brazzler?
Ken: It's Brazzler's material. They have the sealer, they have the putty. They even, at one point, they realized that you can't take ... You've got 7,500 endodontists in North America, which represents about maybe 10% of the people doing it. Shoulder has so many advocates that they realized that one of the things you couldn't do with bio ceramic was use a vertical compaction technique that involved the application of heat. They even came up with a sealer now that allows for that. That's not the nature of how they want to see this manifest, but they realize that in order to get people to shift the paradigms, that they were going to have to incrementally do it in steps.
It's the ... I'm blanking, but it's from Brazzler.
Howard: Every time I hear Brazzler I always have one tenth of a second like, "Aww, I miss Peter Brazzler." He was ...
Ken: He's a genius and [crosstalk 00:22:43] Jack is a super guy. Trope ... Especially, I have a lot of respect for the fellows that have come on board. They aren't FKG, they're certainly arm's length ... I mean, when you start dealing with the marketing in the United States, that sort of thing, it's not ... I have a lot of respect for the FKG company. They developed fabulous instruments, and they do a lot of research in their work. It's quite impressive.
Howard: It's my job to try to guess questions from these 7,000 individuals. Dental Town, no one has to practice alone. You threw out some terms: MTA, bio ceramic, bio dentin, and I'm sure 1,000 people are saying, "Okay, what are those 3, and what's the difference between those 3?"
Ken: [inaudible 00:23:26] was developed initially by [inaudible 00:23:30] who I believe is still at [inaudible 00:23:31] and it was essentially portland cement that was modified, and through his research and his studies, he found tremendous capacity for this thing to effect sealing and closure, this that and the other. They've introduced it for example with the root canal sealing cements which is actually ridiculous, because the stuff doesn't bond with the sealing materials. The bio ceramics, I wish I understood it as well as I should. I use the putty now exclusively for perforations and repairs, endodontic surgery. I've moved away from MTA because I do believe [inaudible 00:24:05] tends to wash away.
Howard: You buy it from Brazzler?
Ken: Yes.
Howard: Okay.
Ken: MTA now, I don't know if the patent's off, but there's MTA Angeles, there's different companies that are providing this world-wide. The endo sequence stuff, the Brazzler materials, the sealers and stuff, I think it's exclusive to Brazzler at this point, although I may be wrong. I know that there's ... The initial development of this material, if I've got it right, was interestingly enough in eastern Europe, in Bulgaria. One of the fellows on Nexus [inaudible 00:24:43] is always, for years, talked about this material and the fellow who was behind it. Again, I don't know much about the dynamics of the dental industry, but you have all these patent issues that come to forward and this that and the other. Things get shifted around and this that and the other, but I do think that's where the future's going to go.
Howard: Then what's bio dentin?
Ken: Bio dentin is I think [inaudible 00:25:05] material and again, it's supposed to be pretty decent, but the septidont has had a history of being a little questionable, if you will, with regard to research and whatnot. I know some of the fellows on [inaudible 00:25:26] has got one of the webinars up on Dental Town. A variety of those people are using bio dentin which is similar. It's similar to BC putty for example, and using it to do much the same thing MTA did. They seem to achieve the same result. Pulp caps, pulpotomies, external restorative repairs, [inaudible 00:25:44] sealing, this kind of thing.
Howard: Okay, Ken, when we're talking all this, the 3 parts of root canals: finding the canals, cleaning and shaping, obtruating, isn't it still true though that the number 1 cause of a root canal failure is they miss an entire canal, just missed anatomy? Is that still the norm, or is that no so anymore?
Ken: I think there's a lot of missed canals. I think that's a big issue, always has been. For years and years and years everybody got all excited. They found the MB2 in the [inaudible 00:26:14] root of upper molars. They didn't find it, it had been there all along. They just started looking for it a little harder. Whether it was loops or scopes or whatever, they were always there. We knew about it for 100 years.
What's interesting now is you take a really hard look at the shift in the mindset is that the lower first molar ... Look at the 2 teeth that are most historically done endodontically. Upper first molar and lower first molar in terms of decayed, missing, and filled issues. They're now looking at the lower first molar which, I guess if you go back to and study by an area that was not done that long ago, they're starting to find in some cases that there's almost 40% of the [inaudible 00:26:54] root of lower first molars has a middle canal, like MB, ML, MX. Call it what you will. The incidnets of multiple canals and bicuspids and ... When we used to look at the studies, lower bicuspids having 2nd canals in 30% of cases. The first study that came out, for example, on lower molars for example in terms of 3rd canals [inaudible 00:27:22] said somewhere between 1%-15%. The latest study says 46%.
Without question, I think the ability to identify the canal system, get access to the canal system is crucial. There's this whole new philosophy about restorative-driven dentistry and minimal access preparation which concerns the hell out of me because minimlaizing access without microscopes or without some type of magnification or some type of ability to work in that context, you're going to miss stuff. You're going to leave stuff behind. I think we need to have a better understanding of which way the pendulum is swinging, and ensure that we have eliminated source resource of infected or [inaudible 00:28:09] material within the chamber, find all these canals.
There's a trick that I've used for years that I was taught by a person I consider to be one of the geniuses in modern endodontics and that's Marguerite. I sandblast the floor of every chamber I treat. There have been people like ...
Howard: With what? A Danvil Micro Etcher?
Ken: Danvil Micro Etch.
Howard: Oh, I love that thing. God, that's mighty handy.
Ken: What a great little tool. They use everything from carries exposing agents to plaque displosing agents to ophthalmic die, [inaudible 00:28:43] who was a rooter came up with a study on that. It's interesting, Margo always talks about it. You take your Danvil Micro Etcher, you sandblast the floor of the chamber, put a drop of alcohol inside, and I don't care what you're wearing or using, the canals that are there jump out at you because you satinize the floor. These irregularities, be the effusion lines, be they canals, be they whatever, they literally jump out at you like they're 3D. They're fantastic. Tremendous too for endodontics as well.
Howard: I think the Danvil Micro Etcher, that's like WD40 married duct tape. I can't think of how many things ...
Ken: Don't forget Teflon. Teflon, the unsung hero of literally all restorative and endodontic procedures to ensure that you have isolated ... Plumbers tape to ensure that you have isolated the tooth, and ensured that your matrix is not leaking or whatever. Pretty impressive stuff.
Howard: Okay, so when ... Do you think we're approaching standard of care that a 2 dimension film of a root canal before we do it is not standard and you need to see a CBCT so you would see all the main anatomy? Or is that ...?
Ken: Yeah, I think we're in an era where you're always going to have concerns about radiation exposure, but realistically, the companies are getting better, the degree of exposure by CBCT is being minimized, machines are coming down in price. I think it's going to be a piece of equipment essential in your office for literally everything. The whole push in dentistry is to digital work flow. It may be accelerated a little bit because it's like cars. Everybody likes shiny and new. I do see the day when ...
It's like a panorex. Panorex does something, but what? Now they came up with digital pans, and most of these systems now have bolt on hard equipment that includes software that allows you to do it. I suspect that all dentistry will eventually require CBCT usage as a diagnostic gold standard.
Howard: What do you think was a greater invention in oral radiology: the CBCT or the genius on the pano who put the R on one side and the L on the other?
Ken: Who put the what?
Howard: The R on one side, the L on the other.
Ken: The R and the L.
Howard: I think that every single patient [inaudible 00:31:09] is that the right side? I thought man, that's the most genius thing that ever came out on oral radiology.
Ken: Right up there with the guy that invented whiteout and post it notes.
Howard: Okay, so we're looking for missed anatomy. We may use the CBCT if we have access to that, etc etc. Let's go back to the 2nd thing. They've got the working length. They've used an apex locator, digital x-ray or whatever. Go through your ... First of all, talk about an apex locator. Let's solve this problem. A lot of times, dentists are saying the apex locator doesn't ... Isn't really matching what I'm seeing on the x-ray. The apex locator says I'm at the apex, but on the 2 dimensional digital x-ray, it looks like I'm short. What would you say to that dentist?
Ken: X-ray meaning there's no ... Everybody's done a zillion studies showing that the x-rays aren't accurate depending upon angulation. Apex location is based upon a physiologic phenomenon. It exists. It's the differential of ... What is it? 6.25 micro amps and 40 micro ohms or whatever it is. Again, I'm getting old. I think what you've seen over the course of time is that we've gone through all these iterations. I think we're into our 4th generation in apex locators. They're using micro processors and algorithms. I don't promote product, and I never would, but the [inaudible 00:32:30] acts as the gold standard for years and years and years and then they came up with these much smaller ones which were more mobile, this that and the other.
I'm not an advocate of any company, I don't do that, but I've got to tell you the apex locator that rocks my world today is the Pro Mark by Dense Flight. If I was committing funds to buy a device today, that's the device I would be purchasing. I don't know who thought it out, but it's very clever. It's like a flip phone. It comes up, you can change it, you can angulate it, it's rechargeable, which means you're not blowing through a million double A batteries. The other nice thing about it is they're using ... It's a digital readout, I like their ... The graphic imagery is fantastic. I find that its accuracy is unimpeachable.
Yes you're short based on a radiograph, but unless you're dealing with something that's really pushed the boundaries, like a canal that's just hemorrhaging like crazy, okay you're going to have a problem. Most of us have learned how to use super [inaudible 00:33:40] or hydrogen peroxide to negate that from occurring, or even calcium hydroxide will stop aggressive hemorrhagic [inaudible 00:33:47] that sort of thing. There are obvious areas where you have to be concerned: open apexes, whatever. The standard traditional things ...
Howard: What about [inaudible 00:33:57] or irrigating with 1-50 epi to stop bleeding?
Ken: It'll do it. It'll slow it down. I guess I'm always concerned about using the root canal as a conduit for epi into the body on any level. You can still blow it out under pressure ...
Howard: What would be your first choice in the canal won't stop bleeding.
Ken: First of all, for example when you pop into a very hemorrhagic tooth, it's the chamber that just blows it at you. For that, I would use super oxal, white set the tissue, but I don't like putting super oxal down in the canals because if it leeches out, you've got a problem big time. I use hydrogen peroxide, I use calcium hydroxide. Again, controlled using the navi tips from Ultra Dent control, and leaving it in for, I don't know, 5, 10 minutes. It will stop it. It will stop it.
I guess my biggest concern with using ... It's a terrible tendency ... We're dentists, right? It's like anything else. You've got something in your hand, you get any counter pressure, you're going to push a bit harder. I wouldn't want to be using one in 50,000 into a small canal and run the risk of blowing it out like a fire hose.
Howard: I know you're not a pediatric dentist, but you are a legendary endodontist. What about when you're doing a pulpotomy or your pulpectomy, what's your agents of choice? And there is still some rumbling among younger associates who are working with a dentist our age who says, "Well, he's using [inaudible 00:35:26], that's carcinogenic, he could be inducing cancer," what would you say to that kid?
Ken: [inaudible 00:35:36] all that stuff should be relegated to the museums. I would be using [inaudible 00:35:41] sulfate.
Howard: Name brand?
Ken: The one I use is the one from Ultra Dent ... What is that one? Biscostat.
Howard: Biscostat.
Ken: Yeah.
Howard: That's for a pulpecotmy?
Ken: It's for a pulpotomy in a primary tooth. There are certainly indications for doing root canal therapy in primary teeth. The one thing I would never use is calcium hydroxide, simply because it's been shown to induce a lot of internal resorbative problems, this that and the other. Formacresol had its day 30 years ago. Let's be [crosstalk 00:36:12]
Howard: What was the difference between [crosstalk 00:36:16]
Ken: Again ...
Howard: Their own way?
Ken: These things were [inaudible 00:36:22] they just were not ... They didn't make a lot of sense, or at least as I recall.
Howard: You said 3 of them. What was the 3rd one? [crosstalk 00:36:30]
Ken: Cresident, which was great if you're trying to preserve tree stumps, and CMCP. I don't think any of those, from a standpoint of bacteriostatic, bacteriocidal effectiveness, really made a lot of sense. There's still a lot of dispute about 1 visit, 2 visit. I know that in my own ... I'm never going to shift away from 2 visit in necrotic cases. Too many chances of phoenix abscess. I've been a follower of guys like Jose Secuera in Brazil and certainly guys ... One of the geniuses behind this, the guy that ... You want to talk legendary endodontists, I don't necessarily rank myself in that area at all ...
Howard: You are absolutely a legendary ...
Ken: [crosstalk 00:37:15]
Howard: Ken, I've been in 50 countries. Fred Burnett is a legend too. [crosstalk 00:37:22] Joe Dobkin, he passed away.
Ken: Joe Dobkin, that was tragic.
Howard: [crosstalk 00:37:24] Oh my god.
Ken: Finest minds in endodontics.
Howard: I know.
Ken: Fred Burnett is probably one of the greatest teachers in endodontics. We've got people coming up today that are guys that you don't see in America, tragically. Leando Perrera. I'm working with you now as your global clinical director. I'm always trying to get these guys that have never been in America. Antonis Chaniotis, Leando Perrera, Roberto Castecu, there are some people in India, Shivani Bott. There are some staggeringly brilliant people that just don't come to North America. Jorge Vera in Mexico.
These guys are teachers, they're professors, they're researchers, they're clinicians. It's just fantastic the way things are shifting, and I'm glad to see that. [inaudible 00:38:17] I think is going to be one of the real superstars of where endo goes in the next few years, and I think it's beginning to show because you see him, interestingly enough, not in North America everywhere, but around the world. He's starting to gain more traction in North America, which is great, because he's a Toronto guy now too.
Howard: Give some rest in peace words for my buddy, Joey D. How would you write that obituary?
Ken: There wouldn't have been a roots without Joe Dobkin. I was friends with the guy who came up with the software and that's how that thing got going. I just found that when you work at ... We didn't have a whole lot of study groups, and even the groups we were working with in Toronto weren't doing much. I wasn't learning at the rate I wanted to learn, so somehow Joe Dobkin and I came together with Barnett and a number of others. Even Gary Carver was on it in the early days, Terry Pancook, who else in those days? There were ... Kademi was on for a while, he then moved over to Downtown, did a lot of good work with David Clarke.
Dobkin was a interesting guy. As I recall, he used to write software before ... He was a graduate ... You guys graduated from the same school, right?
Howard: I was in room 915 in Swanson Hall at Crayton University in Omaha, Nebraska and he was in room 919 and I swear to god, there were 88 guys on the floor and they would come from 3 floors down because you could not ask the guy a question where off the top of his head he couldn't write a book on it. He was a freak.
Ken: Totally brilliant guy. When he got out in practice ... I guess he practiced in Scottsdale, right, with John Cropcow. Those guys came up with what I still use which is still the coneless obturation system. Joe worked significantly with ... I can remember the fellow's name in Vista Dental but I don't know how many patents or how many devices he had to his name. Probably well into the 20s. He was always tinkering with something.
Just before he died actually, tragically, he was working with Mark Bolson on ... I'm trying to think if I'm saying this right: electroferetic irrigation device. I don't know if they ever got the prototype, but they certainly had done research on it. They had a Facebook page on it. I think Mark, as part of his legacy, was trying to see if they could get to bring this to market. This was work that a fellow named Bill [inaudible 00:40:50], a fellow who unfortunately also passed away, was doing on ... It's almost like activated ... I don't know if you just ... I'm trying to remember the specifics of it. I'd have to go back and read it again.
But Joe was a genius, and he was the leader of the root summits we did. He was always the moderator for years and for years and for years. Then tragically, I mean he lived a long time. He had a horrible disease. They did stem cell, and he lived a long time.
Howard: Rest in peace, Joe.
Ken: Left a huge legacy.
Howard: Rest in peace, Joey D. He was the greatest dentist to ever walk out of Crayton. Maybe one of the greatest endodontists ever. I want you to go back to something that you said profound that I'm afraid a lot of these kids might miss. I hear so many kids just flippantly say, "Yeah, I 1 step all my endo." You're just like, "Whoa whoa whoa." Rule number 1: if there's a peri[inaudible 00:41:43] you would just never do that, but when you said necrotic, explain more to these people because they might not know ... A cavity gets into the pulp, it looks necrotic but they think they're down to vital, talk more about when you can 1 step, and when you would never 1 step.
Ken: If there was ... Again, this is so, the perspective is so skewed, but in my own personal opinion, exodating the canal at the time of access, really tissue that obviously is gangrenous. You don't have to be a histologist, you're not slapping it under a microscope, but certainly tissue that's gangrenous, you can see it just by what you're pulling out. Re-treatments where there has been just various oxides and leakage and this that and the other that was permeating the dentin. Obviously the presence of a peri[inaudible 00:42:37] periredicular lesion, we get back to the question of does calcium hydroxide really work? You've got all these guys that are saying they swear by it, and then there are the guys who swear at it.
I still think there's nothing wrong with 1 stepping a case, but I still think that in this day and age with bio film, recognizing what it is that causes bio film, recidivism of treatment outcome success, and the guy who's a genius on that, again, Nestor [inaudible 00:43:10]. Published one of the best textbooks ever on that recently. This is the guy you want to talk to if you ever want to talk about ... [inaudible 00:43:17] should be the guys leading the charge for how endodontics is going to move forward.
I think that's the issue. You have to really look at the tooth in question, its strategic value, the patient's medical state. You're talking about diabetics. Look at the way we're all living longer today. We're all living longer thanks to better ... Live better through drugs. You've got to take a good hard look at the patient themselves. Are they immuno-compromised? There's so many factors that you have to weigh into account. I don't think time is the factor, or speed is the factor. You have to really have a very long, hard look at the patient's medical state, the condition of the tooth, strategic value, what you pick up in the radiograph, how well you ... Again, it's how good's your radiograph? Are you really picking up what you should?
I don't see there being a reason to plow ahead. I know it may be a question of time, an issue for patients and whatnot, but if you're going to create a greater percentage of success by delaying it and ensuring that there is a marginal difference in sterility, then do it.
Howard: Let's talk more about while you're cleaning and shaping. A lot of people use all kinds of lubricants or chlorhexadine or stuff to help the file glide. Do you use any of that stuff? What do you think of those things? EDTA?
Ken: Proglide and all those preliminary stuff are very good because if you're dealing with a lot of tissue, the value of those is it doesn't allow the tissue to be pounded and impacted. A lot of times you get into canal, they didn't use proglide or one of these things and they're pushing tissue apically, and suddenly they hit this block of tissue that's been impacted and they go, "Whoa, blocked canal." If you let sodium hypochloride soak in there for 10 or 15 minutes, it wouldn't be blocked anymore.
The value of chlorhexadine? Chlorhexadine is what I use to swab around the tooth and swab the tissues before I put a clamp on and before I do any treatment. Its value in terms of its use as an irrigant, doesn't dissolve organic debris, and it is bacteriacidal and effective. It leaves residue in combination with sodium hypochloride, so it should never be used.
EDTA, yeah I agree, but again, I use citric acid and that was Joe Dobkins' thing. I use citric acid in 20% concentrations which you can have made in compound pharmacies. I don't use EDTA any longer, but you need it as a key later to ensure that you're clearing things out.
I think the bottom line key to all of this is that everybody's run the gamut. You heat the sodium hypochloride up which is fine because you heat it up, but by the time you get it into a canal it's got about .008 CCs of volume. It's still only at body temperature. The heating it up doesn't make that much of a difference. I think the key, and I think you'll read it everywhere, the key to using sodium hypochloride is if you don't do a ton of endo a week, then take your jugs that you're using and toss them unless they're properly stored. You should probably use ... There are chlorine indicators to measure how many parts per million of chlorine are residual in what you're using. At $4 or $5 a jug, pitch it on a regular basis. I think the need to consistently and endlessly replenish throughout the procedure is the answer to optimizing your irrigation protocol, and that's they key.
Howard: What's the proper storage on bleach? Do you recommend refrigeration?
Ken: You don't want to store it in anything that's too hot. I don't leave it in the refrigerator either. It has to be stored in an ambient area that's an ambient room temperature type of situation. Not in a closet next to your suction and your [crosstalk 00:47:24]
Howard: I always cringe living in Phoenix, Arizona because so many times whenever your supplies come, you know the back of the truck is 140 degrees, and all your stuff [crosstalk 00:47:33]
Ken: By that point in time.
Howard: Oh my god yeah. Everything's been preheated in the oven before I get it in my office.
Citric acid. To those kids who ... Explain the difference in EDTA and citric acid and why ... What is EDTA and why did you change to citric acid?
Ken: It's ethaline diamine tetrocedic acid. Citric acid is ... Of course I'm pulling a blank right now, but it does the same thing. Its efficacy or at least its mechanism of action is as a keylator.
Howard: Explain what a keylator is.
Ken: A keylator simply removes the inorganic component of the dentin. In theory, it softens it, and it removes and opens up the tubuli. It's the same reason that ideally you would use it ...
Howard: You're basically saying, "Okay, look, you've got to find all the canals. The CBCT might help, and just basically spending time looking." We both agree ... I cringe when dentists try to save the crown, usually because they made it, so they drill this little bitty pinhole. I always remove the crown.
Ken: I'm going to stop you here for one second. I think there's a caveat on that: the only time that you would ever keep a crown in my opinion, unless it was part of some massive roundhouse, would be if you were the person who placed the crown in the first place, and you knew that before that crown went on, you had done a proper rehabilitative treatment of the tooth that was being prepped in terms of clean and carries, what you used to rebuild the core, etc etc. To me there's a lunacy involved in, the tooth is degenerated, you've got a lesion, you've got a crown on the tooth. The crown didn't go on there because there was nothing wrong with the tooth. You have to assume that once you get inside the vast majority of these things, you find gaps between the filling and the tooth structure, dentin that's been decayed, whatever. You can't clean out laterally or co-laterally or whatever, or circumferentially.
I have a problem with that. I always have. A tooth that is failing, crown ... I realize there's cost considerations, this that and the other, but we all know that coronal leakage is the worst possible thing for positive treatment outcomes in endodontics. Well, why would you do the endodontics only to have it leak again? I think that's the tragedy too often is that way just say, "Okay, we'll go through the crown, no problem," assuming that everything's going to be copacetic. It's just not right.
Howard: I always remove the crown. Even if I made the crown, I know it's all cleaned up and it just died, I still don't. If I just sold you a new car and then I have to come back and take a chainsaw and cut a hole through the top of it, to me it's just more kosher ... Plus the root canal is so much easier without the crown on.
Ken: That's another consideration. One of the things that fascinates me is that we've always, historically, full coverage has be the [inaudible 00:50:35] if you will of endo-restorative, but that is massively changing today. I don't know how much in the United States, but certainly in what we see daily on Nexus for example. The EMAX inlay/onlays are being done. The partial coverage. The ability to rebuild the tooth with [inaudible 00:50:54] whatever, and then do EMAX onlays or lithium disilicate onlays on top of these things. You're just going to see a day and era where there is not going to be full coverage anymore.
There's all these changes that are going on right now, I think are ensuring that dentists are going to wake up to the fact that you don't do an endo and then you restore the tooth. It's endo-restorative. It's been a continuum that should have been the paradigm for treatment from day 1. A lot of people talk about it, but I don't know that a lot of people live it. Endo-restorative is like the AAE, American Association of Endodontics, for years has tried to re-engage with the other specialties. Endo ended at the orifice, mentally that was the mindset. It's been wrong forever. Thank god for people like Clarke and Kademi and Carr and others. Rick Schwartz, Ron Franzman in the Netherlands. Guys like ...
You've got some guys that are just doing stuff like ... What's his name? [inaudible 00:52:06] in Bulgaria, [inaudible 00:52:12] South Africa ... [inaudible 00:52:13] who was I believe an endodontist to start in the Ukraine, now in Czechoslovakia. Guys who were showing you that you can do endo cleanly without blowing the tooth apart, but even if you're going to do full coverage, the beauty in preparing the tooth in advance of treatment so that you can identify peripheral root morphology and pick up all of the vagaries and nuances that make a difference through the canal identification, that's the way to do it, Howard. That's the key.
What you're describing is ideal: prep the tooth, provisionalize it, but do the endo before you place the provisional. At least work with it and prepare an environment. What these guys are doing with their minimalistic approach is that they are not taking the tooth apart, but they're opening it enough that they can get a full sense of where that root canal system is going. It's staggering the way things are changing. That's the key.
I think a lot of it is coming to the realization that things like crown lengthening which seem to be associated with a lot of situations, really doesn't give you the results that you think that it should, surprisingly. That's why I think you're seeing more of these inlay/onlay EMAX type of restoration showing up. Because those things can be carried down. There's just tons of guys, especially, again, back to David Clarke, who has done phenomenal work with his clear matrices and this sort of thing, about isolation and our ability to find margins that are subginginval without lasering or cutting away tissue.
Howard: Ken, now give us some of your ... Being around the block for 34 years, a lot of times younger dentists are having a problem, they see a failed root canal, they're looking at the lady's age. She may be 60 plus or minus, and they're sitting there saying, "She's got limited money, should I be dumping this into a re-treat and re-do the root canal that looks fine on the x-ray, it just failed and re-do all that crown? Or if I'm going to spend $2,500 re-treating a root canal, building a crown, should I just be pulling that tooth and placing an implant?" Give us some guideline 30,000 feet above the ground view of when do you just extract the failed root canal and place an implant, or when do you do a re-treat? Are re-treats passe because of implantology?
Ken: No, I don't think so. I think they key right now, which interestingly enough, re-treatments occupied a very big part of the armamentarian that was being developed for endodontics. There's a fellow right now who is working with Steve Buchanan, Yoshi Terachi, a Japanese lad who has come up. Steve just launched DentalCadray.com, it's a website, and they come up with this amazing re-treatment tip that Yoshi invented. What you see now is ... The swing initially was, "Yes, you should re-treat before you remove," so when implants came on board and everybody looked at these teeth that were failing, "Oh, screw this. Out it comes, let's go. What do you need a tooth for?"
Well, that was all fine and dandy, but implants are not panaceas either. It isn't like you take the tooth out, put the fixture in, everything's fine. We've woken up. Peri-implantitus, perimucositis is a reality. Implants fail, and when they fail they fail badly. They fail a lot worse than a tooth that cracks or this that and the other. Cost implications are monstrous.
Doing implantology today isn't like the hotel room course deal that it once was when it started out. Where it was just about, "Well, let's put the fixture in." People are waking up. It's hard tissue/soft tissue augmentation. You look at what guys like [inaudible 00:55:56] and all these other people are doing worldwide. There are guys in Russia, guys that we've gotten to post on Dental Town, Samuel Blion for example. I don't think that it's, "Gee, the root canal's failed, let's take it out and put an implant in." It's not a guarantee.
What's happened is we need to appreciate that not everybody can slip a broke file out of a root canal system or for whatever the cause of the failure is. If it's straightforward and just obviously poorly done, then I think the re-treatment is automatic. If you're looking at things like files that have been broken away, I would love to say that I can pull files out of a tooth left, right, and center, but I don't think my success rate is all that high.
I think what you're seeing is that there is a push back a bit. Everybody said, "Yeah, we can take these teeth apart no problem, re-treat them and then restore them," but there is a push now to recognize that endodontic micro surgery, especially if you're taking into account the hard and soft tissue augmentation materials that are currently available, pandemically it's there throughout the world. If you incorporate that aspect into endodontic surgery, I think you're going to see re-treatment ... There will be a pendulum swing between surgery and re-treatment that will probably lead to more surgery, but done with much greater care and sophistication.
I don't think you'll be taking out as many teeth. I think that, unless you're dealing with blatant fractures or crown/root ratios that are just atrocious, periodontal issues that are perioendo issues, this that and the other. Taking a tooth out because it's simple and easier to so-called put in an implant is a very specious statement. I think the key is, if you can re-treat it safely, you re-treat it. You have to evaluate the complexity of the re-treatment. Is it something you can do, or that you have to refer? Even the endodontist has to view it in the context of is he going to be able to remove or re-treat without doing any further damage that might end up [inaudible 00:58:05] that would lead to fracture? What's the complexity of the tooth? What's its vital position in the arc? This that and the other. Is he better of doing re-treatment? If he does it by re-treatment, did somebody ...
There was ... Who's the fellow? Bill Nudera just published an article JOE and Rodrigo Cuna I believe his name is. He's a Brazilian lad, he's at the University of Manitoba right now just posted a case the other day. You don't have to take the tooth apart to re-treat it. If it's a single canal that's failing or a single root that's failing, go back in and treat the single root. It's restricted, selective re-treatment. It could be done surgically, but again, when you re-do it surgically, you really have to evaluate what's in the canal system.
I think more and more with the endodontists and the periodontists and the restorative dentists, we're willing to communicate a little better. We probably see less indiscriminate removal, more selective placement of implants if that's what it comes down to, and I think you're going to see a pretty significant increase in endo micro surgery in the next little while. I think the pendulum will swing back.
Howard: You said you would not 1 step a necrotic tooth.
Ken: I don't. [crosstalk 00:59:25]
Howard: You wouldn't 1 step a re-treatment either, would you?
Ken: No.
Howard: Back to specifics, you have a necrotic tooth. You did a re-treatment. On your irrigation, is that just mainly during the filing and cleaning and shaping, or do you fill it up and let it sit there and replenish the soaking of the sodium hypochloride?
Ken: My irrigation is endless and constant.
Howard: But when you're done cleaning and shaping, do you still ... Do you just let it soak for 5 minutes, 7 minutes, do you have a time period of replenishing it?
Ken: To be honest with you, I use Q mix, which is one of Dent Supply's products. Particularly their second generation. I use it. I used to use MTAD.
Howard: What?
Ken: Q mix is there ...
Howard: Spell it.
Ken: Q-mix. I think it's now Q2 mix. They've got a 2nd generation out right now.
Howard: That's your intermediate medication?
Ken: No, I leave it soak, and then I dry it out, and then I place calcium hydroxide with Ultra Dent's navi tips.
Howard: Ultra ...
Ken: They're great. Dan Fischer is the widget king of dentistry. He's a genius. Who could imagine all those little itty bitty things were so important.
Howard: The first time he showed me visucstad he cut his own wrist, I mean cut his own forearm.
Ken: He used to bleed himself. [crosstalk 01:00:55]
Howard: He used to cut himself. That guy ...
Ken: He used to bleed himself. Scary.
Howard: I love that guy. He might be one of the most passionate people in dentistry.
Ken: For sure.
Howard: I always loved the way, whenever you meet him, he's always, while he's talking to you he's punching your shoulder. When ever you walk by he's [crosstalk 01:01:12]
Ken: I think he has broken more ribs among dentists than any human being alive.
Howard: Okay, then your intermediate medication would have been the Ultra Dent calcium hydroxide?
Ken: I use their Ultra Cal, yeah, I do because it's been shown ... I think it penetrates up to 400 microns.
Howard: Well, I'll tell you what, we are out of time. We're into overtime. We passed an hour, we're at an hour 2.
Ken: You mean I can't talk about the World Dental Journal and all that kind of stuff?
Howard: I just want to say, seriously, you named a lot of dentists from Martin Trope in South Africa to Joey D that passed away. You mentioned a lot of people, but in my mind, in my head, the first endodontist legend in my life that had the greatest impact on my career was you, Ken Serota. I have heard that from more people than I have heard that from Steve Buchanan, because you started roots, you were ... Now it's in excess on Facebook, but you were the leader, you were getting the greatest minds. You had the most serious day to day impact on more endodontic thinking on planet Earth than anybody I knew from probably 1988 to now. You just always been the leader of the pack.
Ken: That's pretty humbling ...
Howard: You can name specific guys from specific countries, but cumulatively you were leading the herd, dude. You did so much for me and all my friends. By the way, Joey D., I lived with him in Swanson and we both lived in Phoenix and everybody always said you're the man. You are the man, and I can't believe I got you to spend an hour, now we're an hour 3, but thank you Ken Serota for all that you've done for endo, that you've done for so many careers.
Ken: Remember Howard, never forget, no dentist should ever learn alone. Howard, thank you.
Howard: Thank you so much. Enjoy the rest of your day.
Ken: I will. You too, my friend. Take care of yourself.
Howard: Bye bye.