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AUDIO - HSP #161 - Barry Korzen
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VIDEO - HSP #161 - Barry Korzen
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When Barry Korzen adopted a new tool for his practice, he'd often wonder how in the world he ever did without it. Now he's on the other side of that, bringing money-saving tools to the industry. Find out how and why he made the transition from owning a practice to founding www.Zendo-Online.com.
A graduate of the University of Toronto Faculty of Dentistry and the Harvard University graduate Endodontic program, Dr. Korzen is the Founder of The Endo Academy (www.TheEndoAcademy.com) and Zendo (www.Zendo-online.com). He was an Associate Professor, Assistant Dean and former Head of the Discipline of Endodontics at the University of Toronto Faculty of Dentistry.
Besides authoring numerous papers Dr. Korzen has spoken to dental societies and organizations around the world and has delivered lectures at more than twenty universities. He has received fellowships from the American College of Stomatologic Surgeons, the International College of Dentists and the Pierre Fauchard Academy.
Dr. Korzen is a Past-President of both the Canadian Academy of Endodontics and the Ontario Society of Endodontists and has been a long-standing member the American Association of Endodontists and the Alpha Omega International Dental Fraternity.
b.korzen@zendo-online.com
www.zendo-online.com
Howard Farran: It is a huge honor today to be interviewing Barry Korzen one of the most infamous/famous endodontist I've ever heard of. My friend Kendo, Ken Serota just thinks you're a legend and you are a legend. I mean I could read your bio all day long and the reason I'm so excited to talk to you is that in dentistry it's kind of routine to do cleanings, exams, and filings, and crowns, and lacerations all that but of all but of all my personal friends that are dentist.
About a half of them say the hardest most stressful thing they do in dentistry is a molar root canal. A lot of them, I'll be honest with you, a lot of them feel like they have to do them because they don't want to be a good salesman. The patients come to you saying that I got a toothache. It's not like trying to sell someone bleaching, bonding or veneers.
The insurance pays 80% of it, it's a $1000, for most of my dental friends it's a difference in losing money that day or breaking your break-even point and going home in the black with some profit. I wanted to ask you and my podcast viewers the biggest majority are probably young dentists that are seniors in dental school, the first five out of me. Every time somebody says via email that I’ve listened all your podcasts are usually in their 20s.
I want to open up as, why don’t you give a Vince Lombardi speech about how can you do a molar root canal faster, easier, higher quality, lower cost and address some of these new pressures that dentist are having like in order – If the number one cause of a root canal failure is missed anatomy. Should I buy a $100000 CBCT and get a 3D X-ray of every molar before I do it? That's probably enough starting questions for you I don’t want to start the interview with more than 50 questions at one time. How are you doing this morning?
Barry Korzen: I’m doing great, thank you and it’s my pleasure to be interviewed by the star, that’s okay. We’ll give the accolade back to one another.
Howard Farran: Okay.
Barry Korzen: It’s very interesting if you talk about should somebody rot and spend a $100000 in order to potentially increase their success rate etcetera. I have to tell you that there were two defining times in my endodontic clinical career where I had sleepless nights after I incorporated something. The first is when I went ahead and bought loops for myself, I said, “Oh boy, this is really something” and I missed so much prior to that. Then when I brought in the microscope, then I really didn’t sleep, I said, “How in the world did I have success prior to that moment that I started using the microscope, what did I leave behind?”
Yet if you look at the statistics, the success rates aren’t that much different between the time we started using magnification and subsequent to that. The difference though is I think very much in favor of the practitioner who’s doing a lot of Endo, because the magnification is variable. You can change it as you require. The recording of your cases is excellent but the lining that a microscope will actually give you, allows you to sit in a much more comfortable position while you’re working and it makes the endodontics much easier.
If it’s easier, then it’ll go more smoothly and if it’s more smoothly, it tends to go more rapidly and if it’s more rapid and smooth and easier, your success will go up. It’s a combination of a number of things, should you spend a $100000? I guess it depends on how much Endo you do. An endodontist not spending it would be foolish, a general dentist who does one case a month would be foolish, so in between those two extremes you get the people who are trying to decide and get better loops if you can’t afford the microscope, but it depends on the numbers.
Howard Farran: Barry, my number one complaint on my feedback and my podcast is that I didn’t nail in specifically, my homeowner with Dentaltown, is that with the internet, with Dentaltown, no one should ever have practice solo again. I know some endodontists just listened and said, okay so then, I’ve heard that the CBCT is somehow better for orthodontics, somehow better just for one tooth molar. Can you name a specific name on a CBCT if you were an endodontist and you’re just worried about a molar and not worried about the whole head and neck for orthodontics?
Barry Korzen: You know I really can’t. Can’t because I don’t have experience in utilizing it myself because I’ve retired from practice. I actually cannot name it, but it’s interesting you asked that question because just as we, the American association of endodontists came out with a position paper along with the American association of radiologists or maxillofacial radiologists on the use of those. The president of the AAE also wrote her opinion about both the position paper and her news of it.
She was very much in favor of using it but she also said that people have to decide, again it’s similar to using the microscope. That people have to decide, if they have a nerve to use for such a thing. She happens to be in a multipurpose practice and therefore they could bring in the CBCT into their practices. On the other hand she says if you need a scan refer it to somebody who has a machine and utilize it for those patients who actually require it.
It’s not necessary to go jump in and purchase, not like a microscope where you need it you find it if you’re wire working but if you need a scan for a specific patient for a specific purpose, you’ve nothing to it at all, if you prefer it, all surgeons have them, periodontists have them. Whoever is doing a lot of implants have them already, take advantage of that, and if you get the advantage of the new technology. It’s common like everything else.
Listen, when I went into dental school, they were just taking out those slow speed hand pieces that had the loop that goes with them.
Howard Farran: The bells?
Barry Korzen: The bells, yeah, okay and they were afraid of what the high speeds, because the high speeds in all of them, you cut through that tube so quickly, it’s like having power brakes in a car in the old days. Mean you’d stop too quickly, the guy behind you will hit you, they have to make sure that everything in time will come to be the norm. Just like rotary endodontics is now the norm rather than – I remember 25 plus years ago, I introduced rotary into Canada and it wasn’t the norm.
It was so revolutionary, please excuse the pun, but it was so revolutionary that when I was lecturing on it, I had former students come up to me and say “But you told us never to use a rotary instrument inside a tooth” and I said “Right, but that’s when we only had stainless steel, we didn’t have nickel titanium.” Then I said, we’re missing one journal, and maybe foreign publications should actually consider having this journal of … we’re missing a journal of retraction.
We should be able to publish something to say, “I changed my mind.” It’s not that I don’t believe in what I said, it’s that the facts have become clear and therefore I’ve changed my mind. That’s what happened with rotary and it’s going to happen, it’s happening with microscopes especially within the specialty. It’ll happen right across the industry with almost anything you can think of then so.
Howard Farran: My first rotary was stainless steel but it didn’t go all the way around, it just went just a quarter turn back and forth.
Barry Korzen: Yeah giromatic.
Howard Farran: Yeah. I don’t think I’ve heard that word for 25 years.
Barry Korzen: You want to know something?
Howard Farran: Yeah.
Barry Korzen: There’s sealing gum, believe --
Howard Farran: I want you to give a father son talk to these young graduates because I’m still practicing in Phoenix Arizona and I see a lot of upset patients regularly that went to some of these amazing new young dentist in my area and they are so – They see the pulp as like a sacred golden cow god that they worship and they start getting too close to the pulp. They switch from a high speed to a slow speed or a spoon activator, then they put dye cow and they … they do everything to save this pulp and then they put a crown on it then it blows up, then the dentist drills a hole through it. Any way they end up in my office and they’re very upset.
Then I think, maybe I’m too old in callous that I’ve done this it’ll be 28 years, I turn 53 tomorrow. To me maybe I’m too callous but to me I don’t worship a pulp and I think that thing’s close. I take out the pulp because I figure okay, if you’re my patient, you’re 40 or 50, well, you’re probably going to live to be 80 or 90. If it’s this close at 50, then I’m going to file down the tooth and put a crown, that pulps not going to be there when you’re a 100. If I kill it, if I diagnose it to be removed now, you’re a happy camper.
If I don’t, I try to save it and it blows up on me, I’ve lost a patient and that patient might take a husband and two kids and her next door neighbor with her. Where’s the balance between worshiping a pulp and saving it with all costs versus, oh the hell with it, take the damn thing out and do a crown and I’ll further ask that question. What percent of teeth do dentist crown that within five years end up needing a root canal anyway?
Barry Korzen: You understand, because the way you lead in the question you must know this. That no matter what answer I’m going to give, there’s going to be a group that’s going to be upset.
Howard Farran: Yeah, they’re going to be upset with you not me.
Barry Korzen: All right, for sure, sure.
Howard Farran: We’ll play good guy, bad guy. I’m the good guy and you’re the bad guy.
Barry Korzen: Sure because you see the endodontist day, without a question and you think this will be the opposite, but the endodontist you will see without a question, that the best filling material for the root canal is the pulp. Therefore we have to take all steps in order to preserve the pulp, it’s an integrity. On the other hand, once it’s been compromised, and the compromise doesn’t mean like the caries has to go into the pulp, or the [broach 00:11:08] has to go into the pulp or the explorer has to go into the pulp.
If it’s been compromised because of what’s been done to it, either through the caries or through the procedure that’s taking place. That compromised pulp as you said, is going to react. It’s a tissue that has been designed in order to wall itself off from what it perceived to be a problem and now walling off is putting down secondary dentine, putting down a barrier. If that barrier happens to take place at the cervical line, where it now if the canal itself is narrow or to start with and it starts to block off the canaling out so that subsequent treatment may become necessary. It’s doing everyone a favor by actually sacrificing the vital pulp at that stage because the vital pulps that are removed have a much higher success than when you’re dealing with infection and necrosis.
Especially if that infection happens to go into the periapical region. You’re doing everyone a favor, you’re making sure that the patients will be comfortable because you should have virtually no discomfort subsequent to the treatment of a vital pulp and doing the Endo, you’re can do it in one step, one sitting. Patient will be comfortable. You can then proceed and make the ideal crown preparation because you don’t have to [regal 00:12:37] staying away from that pulp that you’ve already removed. It’s there, it’s in your garbage, that’s far away already.
You can just do whatever is the best preparation necessary, put on the best crown and as you said, it’ll be there and it won’t cause you concerns later on as the patient ages and you have a happy patient. You’ll be happy and that’s how you build your practice by looking at the pulp as something that is reactive, that is not varying, it’s just a stump that’s not going to bleed. I actually think people try to just control that bleeding, I’ll tell you, the best way to control the bleeding, take the pulp off.
You control it by removing it, then you finish your Endo, and it’ll be an easy Endo to do because you’re dealing with a canal that’s easy to instrument. Instrumented fully, quickly, dry it, fill it, done.
Howard Farran: We’re really managing two things, we’re managing a tooth, the dental health though we’re also managing a patients mind, the mental health.
Barry Korzen: For sure, a hundred percent. It’s very interesting, when you say that, it reminds me, because the first thing that I ever read when I was health school about endodontics was the textbook by the late Louis Grossman.
Howard Farran: Oh Grossman C Med.
Barry Korzen: Yeah okay, but Louis Grossman wrote the first bible on endodontics, it was very , very interesting because, when you open the book up. On the very first page, you only had one sentence, he said, “Treat the patient as a whole, not the mouth as a whole.”
Howard Farran: Oh wow, say that again, Treat the patient …
Barry Korzen: As a whole, not the mouth as a whole. I think by doing what you suggested, we are treating the patient not specifically the tooth. Now I think that’s a very, very important thing to consider.
Howard Farran: I got, are you a romantic dental romanticist you know I want to do is, restudy an audio book section on Dentaltown, because the markets going to, you like this podcast. 85% of these podcasts are listening to him while they’re driving to work, they’re multitasking. Audio books have now taken over print books, I’m going to start an audio book section on Dentaltown that’s going to be up in a couple months but I want to get guys like you and me to go back and read some of these classes while we just sit down and read into a microphone for six hours, so they can read like these Louis Grossman textbooks, you know it’s gone.
It’s really gone, the 5000 kids that just got out of school they’re never going to see this book but if guys like us bring back these old classics and put them in audio version, we’ll bring Louis Grossman back to life.
Barry Korzen: That’s right absolutely.
Howard Farran: I bought the first three books by G. V. Black and I mean they’re novels and I’m going to literally sit down and read every single one, I would read a Pierre Fauchard book but it’s in French and I’m going to have to find someone – Do you speak French? You’re from Canada.
Barry Korzen: No I’m from Canada but I’m not from that part of Canada.
Howard Farran: So French Montreal but you’re from Toronto Canada?
Barry Korzen: Right.
Howard Farran: Then you went to Harvard.
Barry Korzen: Went to Harvard at Toronto correct.
Howard Farran: Where are you now, are you in Toronto?
Barry Korzen: No, right now I’m speaking to you from Israel.
Howard Farran: Tel Aviv, Jerusalem?
Barry Korzen: No, Jerusalem.
Howard Farran: Wow, how many miles is that from – What is that, 10000 miles from Phoenix?
Barry Korzen: Oh, it’s got to be more, it’s 10 hours difference in time.
Howard Farran: Wow, that is so amazing I think you’re my first guest from Israel.
Barry Korzen: Here we go.
Howard Farran: I want to ask you another thing about the infection. When I get out of school, it was overly simplistic, streptococcus mutants cause decay. Now, we’re hearing microbiologist say that almost every quarter they discover a new bacteria in the cavity, and what’s more interesting is by the time the cavity gets four millimeters deep.
They don’t even find streptococcus mutants anymore. When I was in school, P. gingivalis caused gum disease, now there’s more than that. Is there a main bug that's causing endodontics or is it just all over the board? I mean when you say there’s an infected pulp because the questions going to be these young dentist are always thinking I need to put you on antibiotics for today and we’re going to do the root canal tomorrow. Is there a main bug, is there a main antibiotic? What do you do in triage?
Barry Korzen: I think one of the biggest problems we have in treating patients who come in with an emergency situation is that they are.. they never get scheduled in. Like in others words you say, how many emergencies am I going to have today, because I like that sort of [inaudible 00:17:41] back that in. It never gets scheduled in and unfortunately we’ve all fallen in to the big problem of trying to deal with the emergencies in an expedient way and that often means that we do something incorrectly, why over medicating?
It’s been a big thing now about these super bugs developing in hospitals [inaudible 00:18:04] because of over medication. In endodontics I think the practitioner sometimes forgets because they’re pushed against the wall, patients always expect us to do everything right away. You go to a lawyer and ask them ask them a question, let’s say we get back to you with our thoughts on that.
You got to a physician they will run a test and we’ll get back to you with the diagnosis. Go to a dentist, they want it done today. Not this afternoon, and not later this morning but now, I want everything done now and what sometimes happens is that we get sort of backed in to this corner where we think we have to do everything by the way. Sometimes what happens is that the dentist might prescribe an antibiotic because the patient has pain and you really don’t think you have enough time to deal with him in the way you would like to. Put them on antibiotic for 24 hours and bring them back, when you can bring them back in a more convenient time schedule.
The only time antibiotics really should be prescribed is when they are at times of an infection, which means swelling, redness, pus that gets developed if you do an incision drainage. That's when you have to do antibiotic regiment. Other than that what you have to do is, you have to remove the source of the problem. It’s faster for you. Now, there is nothing wrong with a patient coming in a lot of pain with your going ahead and giving them some look after you've done a diagnosis of course, the proper diagnosis.
Even though it’s a local anesthetic, and saying “We’re going to help you out today and we know you’ve been in a lot of pain, this will get you comfortable now and I’d like you to sit in the waiting room for the next half hour, 45 minutes, so I finish my scheduled patient, I’ll bring you in and make sure you’re comfortable.” Then the best thing you can do for that patient is to go ahead and do the -- Initiate the endodontic treatment. Not do a pulpotomy, not do a full pulpectomy.
If you can’t do more medicate it, close it up at that time but at least get the pulp out completely because that’s where the source of the discomfort is coming from. If there is infection, if when you open up the tooth, and the pus is draining out, you’ve got to get them on an antibiotic. That’s after you've looked at it and made your diagnosis at the same time, once you’ve done that to the patient, you have to make sure that you’re doing something for yourself.
That is, you have to make sure that you’re not adding any bacterial contaminants. Too many young practitioners even though a 100 percent of the cases they did in school were done with the rubber dam. When they come out, they think that's a step that's part of academia. It’s not part of routine, and that’s not correct. The tooth has to be isolated, there’s no question about it. The bacteria that are common to the inside of the mouth for the saliva are not common for the root canal.
If you go in there and start putting instruments inside the canal and pumping these bacteria, with the salivary contamination, you’re going to have a problem and that problem is not going to happen tomorrow. It’s going to happen tonight, when you’re home with your family and it blows up on you and you have to make that return trip to the office, but if you take those few extra minutes put on a rubber dam, isolate the tooth, clean out the pulp, medicate it, tell the patient that they’ll have some discomfort because they came in with a lot.
If they expect some, they’ll be able to deal with it. If they expect to go home from the dentist and have no discomfort, because they paid for treatment and you haven’t warned them about the normal post operative feelings that they’re going to have. They’re going to call you, and if you want to retain the patient, you have to respond to that call. So, do all the things that are necessary to start them on the road to healing. Don’t skip steps, and don’t push them off. That’s the best message I can give.
Howard Farran: I thought they meant when they said practice on a rubber dam to put a rubber dam on the ceiling above you, that you’re always practicing under the rubber dam.
Barry Korzen: I’ll tell you something, no listen, [inaudible 00:22:21] this is a true story. I got called into the dental clinic once, I had to – At school, when I was the head of the Endo at the University of Toronto. I got called into the clinic with a really a fourth year student who had these structure sort of hovering to the side and they [inaudible 00:22:51] wanted for me to demonstrate something.
What was it? They had done an incision in drainage, and they were going to put a rubber dam drain in. There they are with this big by six by six piece of rubber, cut into the shape of a T, trying force the six by six into this tiny little slot that had been created. I said, “What are you trying to do?” The student says to me, “Well I told the instructor that you gave a lecture on this and you showed us how to cut that, and I’m trying to put it in.” He’s said, “If Korzen showed you how to do that, I want to see him do it.”
All I was doing was standing in front of a 125 students and so they could all could see, I took a six by six and cut it into a shape of a T and this person and probably half the class, thought that I meant to take a six by six and shove the whole thing into this little slot. You know what? That’s practicing in the rubber dam, not under the rubber dam.
Howard Farran: Back to what the antibiotic, if you had that draining that red, you don’t have a culture, you wouldn’t know a bug it is, so what would be your Stevie Wonder shot gun antibiotic or do you think statistically you know a bug it is.
Barry Korzen: I think you have to go, this statistically as far as what works most of the time. I think what works most of the time is the amoxicillin for the great majority of patients who are non allergic to penicillin, but you will find that you’ll use fewer and fewer antibiotics if you just take the palpate. You really will, because if you’ve got drainage, if it’s pours out and all of a sudden it stops you’re basically through with the problem.
If you've gone an incision in drainage, there’s little likelihood that you’re really going to require the antibiotic because you given a [inaudible 00:24:48] for escape for the infection. I’d stay as much as possible, I would stay away from the antibiotic routes.
Howard Farran: You mentioned those three papers is there any way on Dentaltown we have 202000 members from 206 countries, who have posted four million times and we have at 51 categories and one is Endo. Is there any way you could post those three papers on the endodontic forum?
Barry Korzen: The paper on the --
Howard Farran: The CBCTs that you were talking about earlier, you said there was a position paper from the --
Barry Korzen: You’re right.
Howard Farran: Then there was another paper written by the president, the woman who, this summer?
Barry Korzen: Yeah. I will write her and ask her for her permission to re post it. I’m sure they wanted to re post it because they like it [crosstalk 00:25:36], it’s no problem.
Howard Farran: You could post that on Dentaltown?
Barry Korzen: Yeah, sure thing.
Howard Farran: That would be so amazing I know a lot of our viewers just heard that and they want to read that. I want to ask you, when a patient looks us in the eyes and says, “Dr. Korzen what percent chance … what’s the likelihood …” we hear this all time, my cousin Eddy had a root canal and guess what? They end up pulling it anyway. Then when you ask – When dentist’s are sitting at lunch together and you say, what’s the percent rate, the success rate of a root canal? Dentist quote a wide range of numbers.
I don’t know anybody who’s more expert on this than you, what do you tell your patients? We’re talking about a molar root canal, not number eight, not an incisor but for a molar root canal, someone says, what’s the percent chance that this things going to work, what would you say to the patient?
Barry Korzen: Let me just go back one step and that step is that the expert on this, is actually Shimon Friedman who is the head of Endo at the University of Toronto after I left and he was the head for over 20 years and he’s just retired from that. He actually published a number of papers called the Toronto study where they studied thousands and thousands of cases that accessed the success rate and from everything to an Endo, a vital cases to re treatment cases etcetera.
He is the expert I’m not the expert. I just talk about what other people have found and basically what they found was that the success rate is exceptionally high with Endo. You really can’t take a number and apply it to a specific case, because there are factors that come into the case such as the healing capability of the patient that you’re treating, just as one sort of thing, but I can assure you that the success rate is exceptionally high close to 90%. In that 10% that do not fall within the success, the initial success, if those cases are retreated then you’re talking about another 60% of those re treatment that are actually successful.
We’re mopping that up initial tooth that couldn’t be anywhere to around 95%/96% of where we started. We’re starting with cases a lot of the time that has been compromised to the pulp. Whether it’s just very inflamed or whether it’s infected, it’s been compromised. An old surgeon would never put an implant into a compromised bone in the tooth. They’ll always start with something that has a great chance of working because it’s not infected.
You’re not going to stick an implant into an infected site. When we’re comparing the alternatives between doing something with the tooth which is Endo versus implant, I think, I don’t know very many dentists, actually I don’t know any dentist, who’d actually in their own mouth. Would like to have the implant before they try the Endo, because you can always go to the implant at the end of fail but the third thing is extraction and no replacement.
Of course there were people who will accept that as well, neither yourself or Dental townies or myself, would be able to convince those people no matter what we say to them, no matter what statistics we give them but endodontic treatment has been, has always been, and will continue to be the forefront of saving teeth. This is the way we save teeth. We can replace teeth more sophisticatedly, than we used to be able to because of implants versus dentures but the safety Endo is improving all the time.
Our technology is improving all the time, change is almost on a day to day basis and it’s a great thing for the patients to have choices and me, if I needed something, I would have the Endo first, I’m sure you would and then we look at the alternatives if it’s not successful but that’s very infrequent.
Howard Farran: Barry I hope these young kids out – The most common Endo question I see for dentist on Dentaltown that have only been out five years and there was one just posted again late last night, so you know he’s stressing about it this first thing in the morning. They have a hard time looking at a broken down molar saying, “Should I do a root canal, or should I pull this and do an implant.”
The question lays now, you were saying, I don’t know if I can get a two millimeter feral all the way around the tooth, or would you just talk a little bit about helping the young kid deciding, what goes to your mind as saying, you know what, “Let’s try to save this” or you know what, “this has been violated, let’s go next step, extraction, implant.”
Barry Korzen: I think the most important thing is per the individual to recognize what their limitations are and if they put into place those limitations, and know where the barrier is, then the next question that they have to ask themselves is, now that I know my limitation, do I impose my inability to go beyond that onto this patient or is there someone else who can take care of this for the patient.
If we go ahead and we say to the individual then to say, “You have two choices, you can do the treatment” because it falls within your parameters of what you’re able to successfully handle great. Then no problem. If on the other hand it falls outside of those then we have to decide is referral to someone else a viable alternative. In many places of the country, it’s not.
Everything is dependent on the individual practitioner, because there is no viable alternative in that. Not a prosthodontist to send them to their main [inaudible 00:31:55] an orthodontist to send them to their [inaudible 00:31:57] periodontist to create that. Everything falls on that solo practitioner, and therefore, those parameters are the yes or no, very easy to me.
I think the last thing you have to consider for any practitioner is the monetary aspect of it, because even though it’s very important for practitioners to be able to say, If I refer this patient now, I’m not going to pay my expenses for the week on this one patient. I think that doesn’t become a dental question, that becomes a philosophical question. The one thing that I am very proud about our profession that’s kept me interested in the profession for so long that makes me love the profession is this camaraderie that we have with one another.
That we rely on one another, you’ve created it with Dentaltown, where everybody now can feed in to one another. It happens in the small community as well, okay that you can say, look, “I’ve got this patient and I’d really loved to treat them maybe you can just see them for a consultation and help me along with this and get me to the next stage.”
“When I know that I can’t treat it, the next one is yours but just help me go through this” and I don’t know any dentist who would not help another dentist out. Whether asked for their opinion or their expert advice.
Howard Farran: I know and the most beautiful thing you said on this interview so far was that you know, you ask any endodontist and he’ll tell you the best thing to save a tooth is the pulp tissue. How did you work that exactly, the best selling …
Barry Korzen: The best selling for the canal pulp.
Howard Farran: So many of us that has to be my number one is hobby is water flotation. I’ve spent so many gazillion hours answering every city council men and all [inaudible 00:33:51]. Here’s a profession that tries to reduce its business with water flotation and it’s been successful in 70% of the American towns. Then I mean how beautiful is that?
Barry Korzen: I got to tell you something, can you imagine the association of undertakers of America actually raising funds for cancer?
Howard Farran: Yeah.
Barry Korzen: Oh.
Howard Farran: Yeah.
Barry Korzen: It’s not going to happen.
Howard Farran: I want to ask you another question. I think some of these – I think a part of the human mental condition is sometimes we oversimplify things, and I think some of the dentist might have thought back in the day, Endo was two appointments. Your first appointment you’d find all canals, cleaned it out, medicate, get them back two weeks off trade. Then we move to one step but I think some people are one stepping way too much. Would you talk about when one step is appropriate and when it’s definitely not appropriate?
Barry Korzen: Sure. I think that number one that, if the canal … if the pulp is vital and you’re doing collective Endo, there’s no problem wrong whatsoever in doing a one step. If it’s a situation where the coronary portion of the canal has started to break down, but the apical third half of the canal still has vital tissue in it, you can do one appointment endodontics, because the connection to the periapical region is still in a normal state.
Howard Farran: How does this kid know that the apical third – How does he know he’s dealing with vital tissue, how does she know that’s she’s pulling out vital tissue and not infected tissue.
Barry Korzen: If you go in with an instrument that allows the tissue to actually be removed in total like a small barbed broach, or a rotary instrument turning very slowly. Perhaps even a rotary instrument that you use with your thumb and forefinger to rotate it. If you’re able to get this tissue out in a solid piece, you’re dealing with vital tissue.
If on the other hand, by going into that apical third of the canal, you initiate a lot of hemorrhaging, it’s already inflamed. When it’s inflamed, the periapical tissue is inflamed and when that’s inflamed, all you’re going to do by instrumenting completely, is you’re going to force some debris down through the apex. It happens all the time. You’d never get a 100% of it out through the corona and anything you push in the apex that’s already inflamed will create more inflammation.
That’s why cases that have large apical radiolucencies actually end up being more comfortable post treatment than those that were vital cases, because you have nothing, no vital tissue in direct contact with the apical constriction, so you got a lot of leeway. If you get a part of cement out there, just going into the space, it’s not pushing up against the lateral tissue. If you’re dealing with something that was either infected or inflamed, do it in two steps, there’s no pressure.
I think one of the most important things is allowing yourself enough time to do it in one appointment if that’s your initial intention. The worst that can happen was that when you go into the tooth you find that it’s a case that shouldn’t be done in one appointment, and if that’s the case, have another cup of coffee because you’ve now built yourself some spare time. If you don’t leave yourself enough time and you decide, partway through the treatment, maybe I can finish this, that last step is going to be less than ideally done.
Unfortunately, even though it’s the most important part of endodontics, is what you take out of the canal rather than what you put in to the canal. If you haven’t taken the proper time to instrument, then what happens is they will never get a proper seal to the canal. There was a paper that was written, the 1870s published back in a journal of the Canadian dental association, where somebody described feeling the canal with sparrow droppings.
He had a very high success rate, by his standards. Again, it’s taking things out of the canal that shouldn’t be there once you’ve encroached upon that canal space, that’s going to make or break the success. If you just fill the coronal half of the canal, a lot of the time, that might be sufficient but we don’t know in that patients lifetime, how much gingival shrinkage is going to be, how much bone exposure is going to be, how many accessory canals are going to be exposed as everything shrinks away with time.
Therefore you don’t take any chances you fill the entire canal to the best of your ability. You have to leave yourself enough time to do all that. If you scheduled enough time, great, if you haven’t, stop, make it into appointments.
Howard Farran: More specifically, Dr. Korzen, are you saying that you don’t do a one appointment you do a two step because of postoperative discomfort or because of five year success rate.
Barry Korzen: No, I say you don’t do a single appointment because of what you find in the canal, I think much too often, that a lot of us have gotten used to Cookie-cutter types of treatments. If it follows within this range and you know we have a chart, if we push that button and say, “There we are we can do this one on one appointment.” It’s the patient that’s going to create the criteria for you.
If you have someone who has all of the criteria, of being able to be done in one appointment, and yet they walk into your office and they’re exceptionally nervous, and they are concerned about every little thing. Like the light bulb that’s flickering in your overhead, are you going to able to see enough? That sort of thing, that’s not the patient that you want to take any chances of actually inadvertently over instrumenting or getting some seal through the apex and that creating a problem which will lead them into having some discomfort.
What you want to do is make sure that you’ve taken all of the steps to treat that patient in the best possible way that they are comfortable after they leave your office and will stay that way. That’s your best advertising essentially, “I had this root canal done, I had it done in two appointments but I got to tell you, I don’t know what people are talking about?”
I remember seeing another full page Ad for HP computers about 20 years ago when computers were like the new thing on the block. HP computers with somebody sitting on the chair going like, “Selecting your next computer shouldn’t be as difficult as deciding on having a root canal.” We’ve come a long way since there but every patient has to be looked upon as their own entity.
You can’t apply the rules just the same way you shouldn’t – When you are instrumenting a canal for example, you make 90% of that time doing step one, step two, step three, step four, but for that patient, what you find inside that root canal may mean that you go step one, step three, you don’t need step two for that patient. Don’t go to step two and spend the time because it has to be done because that’s the rule.
On the other hand, you don’t skip a step just because next patient is in the waiting room. You have to make sure that everything is done based on what you find for the patient, for the best interest.
Howard Farran: Barry, we hear some people saying that I want to ask you twofold, that the number one cause of root canal failure is missed anatomy which is why some actuary people say the number one failed root canal America is the maxillary first molar because they miss NB2. The second most failed root canal is the mandibular second molar because the distal canal, is two canals sometimes one. Do you think failure rates of root canals follow missed dental anatomy like that, or do you think that’s an over simplistic statement? What if someone said to you, what if one of your student just said to you, “Barry, list the top three or five reasons why root canal fails?” How would you answer that?
Barry Korzen: I think that the missed anatomy is a very significant situation especially when you’re dealing with a necrotic pulp, because then, what you have is necrotic tissue that’s been left behind. On the other hand if you’re dealing with a vital pulp, these other canal aberrations may or may not be of significance. I think that some of these missed canals and the one that I found most difficult while on treatment were lower anterior because they’re very difficult to pick up radiographically, very difficult to get into and to clean.
The saving grace of this was that very often they started at the same point and they ended at the same point. They came around and looped and came back to the main canal. We actually seal both ends of those missed canals and that’s why we had success but if there is an [inaudible 00:43:48] or those canals to a point where you’re not able to seal it, then we have problems.
That’s why irrigation is such a big factor now in endodontics. By irrigating the canals profusely, and the materials are reused for irrigation, we’d use them for use, and use and use but now we have more great methodology in being able to utilize them. They are able to get into parts of canals that we cannot instrument. We may even be able to see them but these are accessory canals that make [inaudible 00:44:21] angle and in order to access them, we’d have to destroy so much tooth structure, now we may be weakening the tooth that we’re trying to save.
It’s a tossup situation. I think root canals are successful most of the time and the failures are due to, as you said, missed anatomy. Sometimes misdiagnosis, sometime iatrogenic problems, sometimes a problem that’s created by the dentist rather than helped by the dentist. We’re dealing in a very tight area and at where sometimes success is measured in millimeters. Like there was a big discussion on Dentaltown yesterday, last evening, about what do you do about the – Can a number 20 file clean out all of the vital tissue at the apex.
I don’t know, depends how big the canal is, that’s basically the answer but people are concerned about the small things and rightly so because that’s what makes us good professionals. That’s what drives us to rue by looking at that last millimeter, can I do better in that last millimeter and are we going to get failures, sure but a physician didn’t get failures in that would say meters. It’s the way it is.
Howard Farran: I’m going to ask you an embarrassing question but I can’t think any point better to ask for but you know how they say some topics. You know how they say some subjects are just in the closet. I never see this discussed on Dentaltown, but when you’re going out to dinner with dentist, I mean every once in a while after a couple of drinks. Some dentist will say, “You know what? I just think something’s wrong with these tooth or I think there is bugs or I’m just not sure.”
I still go back to Dr. Angelo Sargenti’s formula because I think, why not put some stuff down there that’s going to kill all the bugs and germs. Then I still use gutta percha and everything but I’ll switch from like a Grossman cement to a Sargenti deal because I want an active ingredient to kill those bugs because I’m not sure about this one. They never say it in public, they never say it, but if you watch the dental lawsuits obviously there is dentist in America using Sargenti root canal. My question is, did you ever meet Angelo Sargenti from Italy and what would you say to dentist that are in privately, every once in a while using that.
Barry Korzen: I have to tell you a related story to you. I never met him personally but I actually was in a lecture that he gave in Toronto. It was interesting that he gave different lectures on the same topic depending on the audience he was speaking to. When he was asked why, and of course I know a Sargenti material he called N2 because N2 was the second nerve.
Howard Farran: I never knew that, what does that mean? The second nerve.
Barry Korzen: He took out one nerve and you put something else in, that’s the second nerve.
Howard Farran: I never knew that, I never knew that.
Barry Korzen: That’s why he called it N2. When he was asked if he – Why he developed it, in the way he did. He said his original reasoning was for those poor people in developing nations and at the time Europe in general was more of a developing nation as compared to the US. I think they’d surpassed in certain areas, I’ve done a research etcetera. All of North America but his rationale at the time was to help people out who couldn’t afford to keep their teeth, to make a paste that in case the instrumentation didn’t completely remove all the debris, this paste would kill whatever was left.
You see a lot of the people would keep their teeth and they’d be better off, that was way before implants etcetera. He says, it’s sort of been taken out of context now. When he spoke in Toronto, he spoke about using it as a sealer along with gutta percha in order to help take care of any remnants of bacterial debris. When he went to Northern Ontario where dentists few and far between he used to tell them fill the whole canal with it, because he had the assumption that they didn’t have the technical ability to take care of the same things as the big city guys were able to do.
He didn’t want them to run into problems. Somebody in the audience said, “Dr. Sargenti, have you ever had a root canal?” He said yes. He said, “Was it done with your N2?” and he said, “No.” He says, “How was it done?” He says I actually went to [inaudible 00:49:38] to have it done. He said, “Why?” He says, “Because I could afford it.” I think that summarized the whole thing.
I have seen cases where the Sargenti paste has been pushed through the apex, always inadvertently, but has caused so much necrosis. Has caused nerve damage when it’s gone into the mental foramen. The problem is that with every other sealer that we use, people are happy to see a part of the sealer at the apex or part of the sealer at the apex of lateral canal.
If it’s an N2, or a Sargenti paste, you don’t want to be happy, because that patient is going to be in pain, it’s problematic, it has to be removed right away surgically. It’s just not worth it you don’t need that sort of material to be put into the canal. It’s like taking a canon and feeling it up and then just shooting it out hoping it won’t hit someone, but were dealing with an empty space that typically has an opening at the end of it and if we apply our filling [inaudible 00:50:53] under pressure, some of that is going to get out there and it’s going to cause a problem.
Howard Farran: I just recently saw a lawsuit where it went out the apex, it completely pickled the inferior alveolar nerve and the patient got the full maximum of the malpractice of one million dollars.
Barry Korzen: It’s just not worth it.
Howard Farran: One million dollars and I was thinking to myself, I wonder if I would just go purposely get the procedure for one million dollars.
Barry Korzen: Had to, just have a root canal.
Howard Farran: I want you to talk about your amazing –Tell people what zendo-online is or how did that come about. Tell everyone about zendo-online and where did that name come from, was that from the book Zen in the art of motorcycle maintenance?
Barry Korzen: No.
Howard Farran: Did you ever read that book?
Barry Korzen: No I didn’t.
Howard Farran: That was a big hippie. I went to a great university at Omaha and I wasn’t there a day and a priest walked up to me and said, “You got to read this book, it’s Zen and the art of motorcycle maintaining, it will change your whole philosophy of life.” It was a great Zen book and I’m when I first saw zendo-online, the first thing I thought of was Zen.
Barry Korzen: That's actually – That’s where we got the name from because we’re trying to bring the Zen approach to endodontics, simplification. Endo was not simple, we know that, we both know that and all of your townies know it, but you can simplify something a little bit and I actually retired from the university and a little over seven years ago.
I thought okay, I’m going to be retired, I’m going to improve my golf game, it didn’t improve. I love dentistry and I love endodontics so much that I want to keep my finger in it. One of my last positions at the university was as the assistant dean and one of the things I did as assistant dean was to interact with the dental industry, so I had some connections. I said to myself, “Most of the endodontics that’s being done today is being done by the general practitioner.”
They’re always getting the short end of the stick when it comes to pricing, because it’s the large companies, the large practices that actually get the best prices, that’s why you’ll rarely if ever see ever see it on from the major companies, the price online. What you’ll see is check with us for the pricing, because every office, every practice has a different pricing structure. What I decided to do was to look for a company.
Howard Farran: Your time out rotary files mostly.
Barry Korzen: I’m talking to our rotary files primarily but also other things, but I want to keep it simple. In other words, not all range of different products. What I found was the best product in a specific field, for example MTA. One specific MTA that’s actually packaged in capsules because the average general vendors, it’s not going to go through a bottle of MTAs. What they’re going to do is they’re going to spill have the bottle before they get to the other half, so the economy of scale doesn’t work for them.
Plus it’s been shown that if you open a bottle of MTA, being hydrophilic, the last particles in there don’t work the same, because they’ve already absorbed moisture from the air. Even if you keep it sealed, right after each open, once it’s opened it’s not the same as when it was manufactured. I was looking for some specific products that would simplify the user experience or the dentist primarily the general practitioner and also simplify the buying experience.
When you look at Amazon and how they’ve gone from selling few books to controlling the world. What’s happening is that, I said, let’s use the power of the internet to bring to the average general practitioner or endodontics that wanted to become involved. Part of the purchasing power of being able to buy online. I approached a company Micro Mega, in France and Micro Mega is probably one of the oldest if not the oldest manufacturer of endodontic files they started in 1907.
Howard Farran: Are they still independent or did they get bought by someone?
Barry Korzen: Independent okay.
Howard Farran: Where are they at Italy?
Barry Korzen: France.
Howard Farran: France okay, so Angelo Sargenti was in Italy right?
Barry Korzen: He was in Italy.
Howard Farran: This is France, Micro Mega.
Barry Korzen: Micro Mega, the giromatic we talked about that was Micro Mega. Micro Mega is a world player, they are up there with as far as endodontics with the [inaudible 00:55:48] with the side runs and everything. They are a world player. I went to them and I said, “Look, what I’d like to do is I’d like to private label your instruments. Not all of them, because dentist don’t need a 1000 different file designs in their drawers.” They’ll find something they like, and that’s what they’ll use but they don’t need to buy everything under the sun or as soon as it comes out.
I want to try all of your instruments, and I want to pick the best one, two different systems. One a single file system, one a three file system and I want to private label it. I’ll private label it and I want to simplify the package and I want to also go ahead and take away the one thing that drives up the cost a bit, which is the pre sterilization, because every dentist has a sterilizer. You don’t have to buy something that’s been pre sterilized that’s going to add to the cost of it and just sell it online.
Online only, which means no salespeople to support, no head office to support, no auxiliary office to support, no branch office to support. Just sell it online and the prices will be right there, everybody will see what the price is. There’s no buy in this conference everybody gets to buy in discount. This is what we created, they agreed but we couldn’t use the Micro Mega name.
We could only create our own names. The name was Zendo, to simply things, didn’t hurt that the last three letters of my name are the same Z-E-N, as Zendo but that was a side issue.
Howard Farran: It’s zendo-online.com right?
Barry Korzen: The company is Zendo, the online site is zendo-online.com. Our prices --
Howard Farran: What do you say the site was, the site is zendo-online.com?
Barry Korzen: Right but the company name, the official company name is Zendo.
Howard Farran: How was that different than the endoacademy.com?
Barry Korzen: Listen, you can take the teacher out of the dental school but you can’t take about, cutting the teaching out of the teacher. I wanted at the same time to create a site where people could still learn a lot about endodontics without being forced to read heads. I set up this endoacademy.com, it’s got that endoacademy.com. It has one little lock on each page that said that – With Zendo, because got to pay for it somehow, so the sales and Zendo help paying for this educational site but you’re not forced to buy to go on the site.
There’s no registration, there's nothing required to go on the site. It separates the educational component from the retail aspect of it because I didn’t want people to say, “I’m a [inaudible 00:58:53] user but I really like to look at just stuff, but I don’t want to be influenced.” Oh fine don’t be influenced, but just learn about endodontics.
Howard Farran: On the endoacademy.com, do you have online CE courses?
Barry Korzen: No, no that’s your job.
Howard Farran: When will we get honored and graced with a online CE course of view?
Barry Korzen: I don’t know, it’s coming up. I just started a blog on dental [inaudible 00:59:19] and I actually posted – Earlier this morning I posted something that we had on the Endo academy that was dealing with separated instruments and whether people have to be concerned if they separated an instrument and the patient has to go for an MRI. Is the metal that’s inside the tooth going to be a problem?
I posted the response from – I found an expert in that field who specializes in MRIs and he gave a very distinct answer for this. Posted it on Dentaltown because I know that’s where everybody wants to learn goes. We posted this morning, getting quite a number of readers.
Howard Farran: We are out of time but I have to hold you for overtime because you opened up a whole can of worms when you said that a single file system or a three file system. You have to go back and explain that, that I know. My job is to guess questions and our last episode at 7000 years, I know people were driving a car thinking what’s the difference in a single file system and a three file system? That’s what you said right?
Barry Korzen: It’s what I said. When various manufacturers talk of a single file systems, us included. It’s a file that will do all of the shaping of the canal. That doesn't mean it’s the only file that you have to put inside the canal. What it means is that once you have access and once you launch your orifice open, and once you have your canal gone from the coronal down to the apex, so that you’ve established a glide path and your working length, then all you need is one file to shape the entire canal.
Every manufacturer has a single file system, ours is called the zone and for those people who want to cut down the number of instruments they’re actually using. The zone is great because it has three different zones in the file configuration, so that it can do the work of three different files but there are those who are more comfortable in doing it step by step. For those we do actually have those three zones configured into individual files, so having three files, but it still means you have to go open the apex.
You have to get your glide path, you have to get your working length, you have to then shape the canal so you can shape it with one instrument, you can shape it with multiple instruments.
Howard Farran: The single file system is called the zone?
Barry Korzen: Right.
Howard Farran: What’s the three file system called?
Barry Korzen: The three file is called the Zenith.
Howard Farran: The Zenith, you just love the letter Z don’t you?
Barry Korzen: I love it because it’s the end.
Howard Farran: I know you can’t get by volume price, but on the whole for a general dentist, what is the difference in pricing buying going to zendo-online.com and buying my files versus what they are paying through [inaudible 01:02:20].
Barry Korzen: For example our clause are all 29.95 a package, a package of five files. If you were to buy exactly the same file on one of the other companies, the prices would range. For example the zone is 29.95 a pack of five. Of you went onto another site I don’t want to name the people only because it’ll be embarrassing for them, but it’s over $90 a package.
Howard Farran: Oh my God, you’re one third the price?
Barry Korzen: If you go to the zenith, again we’re 29.95 a package, the same site sells the zenith under the Micro Mega name, as they’re at $40 a package, price of eventual, varies depending on the circumstance but we’re always much less for the same product.
Howard Farran: What percent less are you on the range, what percent would you say usually on the range.
Barry Korzen: I would say from 20% to 40%.
Howard Farran: 20% to 40 then sorry to hold you overtime, I’m so grateful that you’re here.
Barry Korzen: I’m great for the time.
Howard Farran: You’re making my mind spin again, I always single user file and throw it away, I can’t think of a big, bigger nightmare than having a file break in and I almost never ever, ever have one break. What do you say to the people who autoclave their files and reuse them.
Barry Korzen: I say, sleep better at night and throw them away because how it does.
Howard Farran: Would it be gross if you and Anning got a procedure done on your prostrate or heart or catheter and you found out they used it on the guy in the room next door before you and autoclaved it, wouldn’t that just be creepy?
Barry Korzen: It’s worse than that, one of the problems is, that if they autoclaved it was still okay, maybe, maybe and if didn’t know about anything better, but if we put this files under stress, and it’s not the same as doing an upper casket and then going your head and using a mesiobuccal canal on an upper molar, where it’s tight to start with. You’re stressing these files or it’s just not worth especially at the price point now, it’s just not worth it.
Everyone should know, again I don’t want to point fingers, but every company, every single company that manufactures these files in the small print say, “Don’t reuse, single use only.” They tell you that, and if you think they’re going to back you up if you a court case because you separated an instrument and it’s interesting, how we’ve developed a nomenclature, files never break, because that means somebody has to break them.
They separate because they just fall apart, we always take the blame shifted to someone else but the manufacturers always say, “Single use only.” It doesn’t matter what the sales people tell you about, it’s all right, you can do it two or three times, trust me. For always follow the manufacturer’s rules of use, when you’re following the steps and when you’re following the instructions, because you’ll never get into trouble.
Howard Farran: Okay that we are at a hour five, I have to stop, all I want to close with is that that guy that followed you at University of Toronto. My God, I’d love to do a podcast with him after you though, one two punch, I would love that. If you can deliver any other legends like yourself, to podcast. Please send him my way because, when I talk to the man on the street, the woman dentist in the practice. Most of our stress in clinical dentistry comes from all of Endo. It’s not from a single crown or stuff.
Barry Korzen: I wish to have hair.
Howard Farran: Then my last thing I want to say is my mother, her big dream was to visit Jerusalem, and I send her on some retired ladies trip. A whole bunch of ladies went over there and I think that was the highlight of her entire life, so thanks for Jerusalem and thanks for all the tourism and when I talk to you I realized I need to call -- I need to hang up and call my mom and send her back again.
Barry Korzen: Send her to me I’ll take care of her.
Howard Farran: Send her to you?
Barry Korzen: I’ll take care of her.
Howard Farran: All right she’d love that but anyway thank you so much for your time.
Barry Korzen: Thanks Howard, you’re welcome.
Howard Farran: All right bye, bye.