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VIDEO - DUwHF #703 - Justin Kolnick
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AUDIO - DUwHF #703 - Justin Kolnick
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In 1977, Dr. Kolnick received his dental degree, cum laude, from the University of the Witwatersrand, South Africa where he was awarded the Gold Medal of the South African Dental Association. He was the first graduate of the Dental School to be awarded the prestigious University Scholarship for Overseas Postgraduate Study. In 1982, he graduated from the postdoctoral endodontic program at Columbia University in the City of New York.
For the past 36 years, Dr. Kolnick has been in private practice limited to endodontics in Westchester County, New York. His practice, Advanced Endodontics of Westchester, has four office locations and includes two partners and four associates and is dedicated to fostering excellence in endodontics through education and the incorporation of the latest technology. In 2008, Advanced Endodontics of Westchester became the first laser-assisted endodontic practice in Westchester and in 2009 incorporated Cone Beam CT into all offices. In 2011, Dr. Kolnick created The Endodontic Microsurgery Group, dedicated to performing endodontic microsurgery in a unique, state-of-the-art facility designed specifically for endodontic microsurgery and sedation.
Dr. Kolnick has been committed to endodontic education, first as an Associate Clinical Professor in Endodontics at Columbia University and then as an Attending at Westchester Medical Center and an Associate Clinical Professor in Endodontics at New York Medical College. Although he no longer holds these positions, he is currently a visiting lecturer in several graduate endodontic programs and continues to lecture extensively on a local, national and international level and has published several articles on endodontics.
www.WestchesterEndo.com
Howard Farran : It's just a huge honor for me today to be podcast interviewing Dr. Justin Kolnick who just released a while back a continued education course that's getting rave reviews, called Lasers in the Management of the Apical Third of Root Canal Systems. In 1977, Dr. Kolnick received his dental degree cum laude from the University of Witwatersrand, South Africa where he was awarded the gold medal of the South African Dental Association. He was the first graduate of the dental school to be awarded the prestigious university scholarship for overseas post graduate study. In 1982 he graduated from the post doctoral endodontic program at Columbia University in the city of New York. For the past 36 years Dr. Kolnick had been in private practice limited to endodontics in Westchester County, New York, his practice, Advanced Endodontics of Westchester, has four office locations and includes two partners and four associates and is dedicated to fostering excellence in endodontics through education and the incorporation of the latest technology.
In 2008 Advanced Endodontics of Westchester became the first laser assisted endodontic practice in Westchester and in 2009 incorporated cone beam technology into all their offices. In 2011 Dr. Kolnick created The Endodontic Microsurgery Group, dedicated to performing endodontic microsurgery in an unique state of the art facility designed specifically for endodontic microsurgery and sedation. Dr. Kolnick has been committed to endodontic education first as an associate clinical professor in endodontics at Columbia University and then as an attending at Westchester Medical Center and associate clinical professor of endodontics at New York Medical College. Although he no longer holds these positions he is currently a visiting lecturer in several graduate endodontics programs and continues to lecture extensively on a local national and international level and has published several articles on endodontics. For everyone listening who didn't watch your course on Dental Town how did lasers work their way into endodontic therapy?
Dr. Kolnick : Well lasers has been around for a while but in 2008 they developed the first radial or side firing laser tips and then that made the application into endodontics really more significant. So we've been involved with lasers for almost ten years now, since 2008 or nine years now and it's become a very important part of our practice.
Howard Farran : Before the laser would just go straight out and it could go out the apex but now the laser light comes down and makes a right hand turn and goes to the side?
Dr. Kolnick : Correct. Correct. So a very small percentage of the laser light is emitted through the tip and about 90% passes laterally to the walls of canal.
Howard Farran : So how often, if you did a hundred root canals how often many of them would you use a laser on?
Dr. Kolnick : Everyone.
Howard Farran : Everyone?
Dr. Kolnick : That's part of our standard protocol.
Howard Farran : So you know, when you talk to dentists, I've been a dentist 30 years this month and you say what percent of your root canals fail, they always say well knock on wood I've never even had one fail and then you see four thousand endodontists, what? Of the four thousand endodontists in the United States what percent of your practice is retreats?
Dr. Kolnick : Probably 50 to 60%.
Howard Farran : Okay. So you must only be working on immigrants who had root canals in other countries and then moved to the United States?
Dr. Kolnick : Pretty much. Pretty much.
Howard Farran : Practice limited to immigrants who had a failed root canal done somewhere else. So though I love insurance data the most because it's so brutally huge samples and they're, the last study I saw from insurance was that if an endodontist does a first molar in five years five percent are extracted and a general dentist does the first molar in five years ten percent are extracted. Why do you think five percent of molars are extracted five years later after an endodontist does it or ten percent five years later if a general dentist does it?
Dr. Kolnick : Well that's a very loaded question. I think a general, a general dentist that's well trained should be getting the same results as an endodontist that's well trained. The work is technically very difficult. The anatomy of the root canal system is very complicated, especially in molars and everything was going along pretty smoothly until the introduction of cone beam CT and then when we started looking at endodontic treatment in three dimensions we started to see significant differences than looking at it in two dimensional radiography and there was, there are quite a few studies out now that show around anything from 30 to 40% of root canal therapy that looks good in two dimensions that actually shows signs of alveolar periodontitis in three dimensions. So the results, depending on who's looking at them and what technology is being used to review these cases the success rates can vary significantly. So the studies that were done by insurance companies are all two dimensional studies.
Howard Farran : Yeah, that's why I love the study of just going with a simple extraction. Instead of someone deciding whether it failed or not this was just a well what percent where actually extracted? So when a, so would you say that the number reason of a root canal failing is you didn't get it all cleaned out and the largest culprit would be a missed canal and then the second biggest reason would be that even though the canals you found you didn't get it cleaned out well enough?
Dr. Kolnick : Well I think we need to discuss this a little bit. The main reasons why endodontically treated teeth fail are more structural than endodontic. So vertical root fracture is probably the most common cause of a root canal treated tooth failing. If we looked strictly at endodontic reasons for failure there are whole hosts. It could be anything that contributes to not cleaning out the root canal system adequately. It could be root canals that were missed. It could be root canals that were ledged or the anatomy changed with the file system that's being used. So anything that predisposed to leaving more bacteria in the root canal system could be responsible for an endodontic failure, but by far the big push today the big concern is on preserving more tooth structure and there are certain individuals that more recently guys like John Khademi and David Clark and Gary Carr, these individuals have really started a movement for minimally invasive endodontics to preserve more tooth structure and that's where the emphasis is right now.
The problem with that, with smaller access cavities, with smaller tapers on root canal systems it gets even more difficult to clean apical third of root canals. So that's where laser technology for us has become very important because we are able to clean the apical third of root canal systems without having to open the root canals themselves to any great sizes.
Howard Farran : So on these structural failures do you think the point o six taper is just a little too much, not minimally invasive for the average molar?
Dr. Kolnick : It depends where the tapper is. If the taper is in the peri cervical area, especially the coronal two-thirds of the root then yes it is too large. The, there are some file systems that are o six taper but only in the apical three to four millimeters and after that it's reduced to either an o four taper or an o two taper. So the idea is to try and clean the end of the root canal system while preserving dentin in the apical, in the coronal two-thirds. So the o six taper that extends the length of the file is too large, yes.
Howard Farran : So, this is Dentistry Uncensored, so feel free to throw anyone under a bus. So what file system would you say is too aggressive? Just your standard o six taper file from the o six ... ?
Dr. Kolnick : Well we're seeing that the companies, one of the largest file companies would be DentSply, DentSply Sirona and they, they've made a concerted effort to come out with new file systems to replace those ProTaper systems that were considerably you know, larger, the files the tapers. So I think all the companies are working towards coming out with more flexible files and lesser taper files.
Howard Farran : What, they always complain about name brands. I mean dentists are all surgeons working in operatory with their hands all day long. They like names brands systems and I know what they're thinking and they're listening, that they want to know what system you use.
Dr. Kolnick : Uh-huh (affirmative). Well let's just back this up a little bit. I think, I don't know the statistics but I think that Dentsply probably has the major share of the market but I think the number two in line now is basically a no name brand which is called EdgeEndo. This is a file system that was designed, the company was started by an endodontist and they seem to have captured ...
Howard Farran : In Albuquerque, New Mexico, right?
Dr. Kolnick : They've captured a huge percentage of the market and the files are significantly cheaper and so their popularity is really a testament to the company. If the files weren't working then you know endodontists wouldn't be buying the files.
Howard Farran : So what do you think the average DentSply file costs versus the EdgeEndo?
Dr. Kolnick : I, probably 50% more.
Howard Farran : For DentSply?
Dr. Kolnick : So, the EdgeEndo files is probably around five dollars a file. Say 20 dollars for four files or that could be 28 dollars for six files and the other companies could be in the range of 40 dollars for six files.
Howard Farran : So, you know i remember, he was in a very long lawsuit with DentSply over the patents of these files, wasn't he?
Dr. Kolnick : I'm not familiar with the politics behind all of this but I wouldn't be surprised because you know there's so much going on in file design, in file material, whether it's the type of wire, the nickel titanium wire that's being used, any patents on that, any patents on design. The patents on whether it's a 360 degree rotary or whether it's reciprocating. So I'm really not privy to all that. So I try not to pay too much attention to that.
Howard Farran : So you just really just opened up Pandora's box. What do you think about the difference in a full rotary versus back and forth?
Dr. Kolnick : Well we use ...
Howard Farran : Reciprocation?
Dr. Kolnick : I think both systems work. Some of the studies show that more dental mud or filings are pushed out of the system with a reciprocating type file but I think, I think both systems work. You know you'll have dentists who swear by each of them and give good results. I don't think that the, I just, my philosophy on file systems is that the purpose of a file is simply to create a pathway to the end of the root canal system that allows me to get my irrigation there. The studies show that a significant percentage of the root canal system is never touched by a file. So it could be 30 to 40% of a root canal system is never touched by a file. So we all seem to agree that irrigation is the factor, but there are a whole lot of issues with irrigation because unless you get the irrigating file to within one to two millimeters of your working length with a positive pressure side vented needle, the irrigant isn't getting to the end of the root canal.
If there is accumulation of vapor, apical vapor lock at the end of the root canal, an air bubble, the irrigant isn't getting to the end of the root canal. So sometimes we see on the internet a dentist will have a dental assistant to irrigate the canal for 30 minutes. Doesn't really matter how long you're irrigating for. If the irrigant isn't getting to the end of the root canal it's not going to do its work. So there certainly are irrigating system like apical negative pressure. Typically the end of vac system EndoVac which actually sucks the solution down to the, into the root canal system there, has proven to be very effective but it requires opening to slightly larger file sizes in the apical third and certainly laser therapy. Laser activated irrigation has become a really big, a really a new finding in endodontics because we're able to activate whether it's plain water or whether it's sodium hypochlorite, we're able to activate it so that it permeates throughout the entire system.
Howard Farran : So what is this laser system that you're using?
Dr. Kolnick : I use the Erbium, Chromium: YSGG Laser. This is typically the laser that's used by the Waterlase, Biolase Company.
Howard Farran : Is that who makes it, Water, Biolase?
Dr. Kolnick : Biolase makes the Waterlase system. Another company is the PIPS. Everyone's heard of the PIPS system which utilizes also an erbium but an erbium YAG laser and their protocol requires that you only place the laser tip within the chamber of the root canal system where as the Biolase system requires that you, gives you the option to take the laser tip down within the root canal system, but the Biolase system ...
Howard Farran : You're saying it's the PIPS system? PIPS?
Dr. Kolnick : Well the Biolase system is not the PIPS system. The Biolase system is a different type of laser. So they're both erbium lasers. One is the erbium YSGG and the other one is the erbium YAG and the properties are very similar, the wave lengths are very similar but the technique is very different. One uses water and the one uses full strength sodium hypochlorite. So the problem with using full strength sodium hypochlorites and activating it with a laser is that the solution goes everywhere and unless you really got a tight seal around your rubber damn and you've corked it with a sealant, a sealing agent it's very easy to get the solution into the patient's mouth.
The other situation with the lasers is that it will push the solution out the end of the root canal. So if you're pushing water out the end of the root canal or you're pushing sodium hypochlorite out the end of the canal it makes a big difference. So the system that I've been using for the last almost ten years is the Biolase system and just to let everyone know I am a clinical instructor for Biolase. I do train the endodontists who buy their system but I'm not employed by the company but it's for ...
Howard Farran : Do you train general dentists on it or just endodontists?
Dr. Kolnick : Well the, I pretty much just do the advanced training for endodontists.
Howard Farran : Does Gary Carr, does he ever teach general dentists or is he still only teaching endodontists?
Dr. Kolnick : Well Gary Carr, his teaching reaches everyone because he has you know he's made many instructional videos that are of access to everyone. I don't know if he's doing any formal teaching. We just came back from The American Association of Endodontists meeting last week in New Orleans where I did two presentations and a workshop. I know Gary did at least two or three presentations and you know, Gary is in a league of his own. He's certainly the father one of the fathers of modern day endodontics. He introduced first of all the ultrasonic tips for us. He introduced the microscopes but more importantly he taught us how to, the ergonomics of endodontics and most important he taught us how to think for ourselves. There's a lot of questioning going on now in endodontics. We're questioning the literature. We're questioning old techniques, old ideas and I think it's a very healthy thing.
Howard Farran : So was Ben Johnson there, the founder of Tulsa Dental Products?
Dr. Kolnick : I didn't see Ben. I'm sure he may've been. I didn't see him there. I don't know if he was, I didn't see him lecturing but certainly he's one of the top guys. He's certainly has made his mark in endodontics.
Howard Farran : Can I tell you a funny story of how I perceive the difference between Ben Johnson and Gary Carr?
Dr. Kolnick : Uh-huh (affirmative).
Howard Farran : Back in the day I would've learned from Gary Carr but he'd only let endodontists in there, so I just thought well you know I'm Catholic, saying I'm a endodontist that's only a venial sin. I mean it's not a mortal sin. So I went down there and just, went down there with Mike Tortola and we were sitting in the class and just loving it but he found out about 20 minutes before the end of the class that I was a general dentist and I got a scolding of my lifetime but Ben Johnson on the other hand I called him up and I'm in Phoenix, I called him in Tulsa and I had all these questions and he said, you know what dude he said you should just fly down here on Southwest Airlines. It'll only cost you 200 bucks and spend the day with me and he let me go down there and spend the day with him and then go to his house. Another one that was like that was John McSpadden in Chattanooga.
Dr. Kolnick : Yes.
Howard Farran : I called him up and he says you know, he says you have way way way too many questions. Why don't you just jump on a plane and I said well what's the close hotel to your office and he said my house. He said my house. He picked me up at the airport.
Dr. Kolnick : Yeah. Absolutely. There are many. There are many people who have contributed in that way. I mean some have set up teaching institutions you know like Steve Buchanan for example. A lot of the people that are teaching also have got a financial interest in the products that they're talking about. So I think that both general dentists and specialists just need to be aware of you know full disclosure from everyone because if they're pushing a certain file and it's a file that they have a financial interest in then it's certainly clouds the situation a little bit. I mean Gary Carr has been above all of that. He really really, you know he really hasn't got involved with the you know the endorsement of products that he gets financial reward from, although he does have his own company. They do sell tips. You know, I think everyone has an agenda. I have an agenda. You may have an agenda.
Everyone has an agenda but I think that transparency is the number one thing and you know you're putting me on the spot here. I know all these gentlemen and I have high regard for all of them and you know Gary's certainly is one of my mentors. He has, his office has been open, his home has been open to students and dentists alike. He has this TDO organization and the software that he's produced and there are literally thousands of people that are learning from him all the time. So I guess he had to draw the line somewhere in terms of bringing people into his facility or his office.
Howard Farran : Is he still racing horses?
Dr. Kolnick : I don't know.
Howard Farran : Well you know, when we started Dental Town in '98 a lot of dentists did not want any dental manufacturers on there and I said dude if you took away 500 dental companies we're sitting outside on at rug with a bunch of stuff from Home Depot and if all the users of this stuff are saying they wished it was red and it was blue don't the manufacturers need to know this? I mean, and then the dentist would say well they're selling something for a profit. I'm like oh, so what are you a volunteer in a public health dentist? Pretty sure you're making six figures income selling root canals and crowns. So I think the only key to that stuff is as long as it's all transparent it shouldn't be ...
Dr. Kolnick : I lost you. I got you back. I got you back. I lost you the audio but I'm back. Okay.
Howard Farran : As long as they're, I mean everybody has an agenda. I mean a dentist has an agenda to sell dentistry and so why, what's wrong with a dental manufacturing company selling their supplies? I think the most functional relationship is actually Europe. Americans, when you go to the Cologne meeting every two years they, CEOs of the company and their scientists are in the booth and they do all the communication directly and there's no dental lectures and then you come to the United States and those people are like taboo because they're selling stuff, they're off in their booths and then you go to some middle man who's talking about all these different systems and I think the Europeans just have a much more trusting relationship between the dentists and the dental manufacturers as experienced at the Cologne meeting and Americans just by and large are extremely cynical people.
Dr. Kolnick : I don't know. I don't know. That's your experience. I think that it's all, everything's garble now. It's hard to even differentiate between you know American dentists or European dentists. At the AAE meeting recently there was a huge contingent from overseas, all over the world and I would like to see already a separation between commercialization and the specialties but I think that's a thing of the past. I don't think we can afford to put on these big conventions without the financial help from these companies.
Howard Farran : The convention attendance across the board is going down. It's been declining for decades as people move to like your online CE course on Dentaltown or YouTube or this podcast.
Dr. Kolnick : This may have been the biggest attendance ever for a endodontic meeting. I know that I'm lecturing at the greater New York at the end of the year and they're expecting I think from 55 to 60 thousand attendees. I think that some meetings are still very very strong and then of course you have the online. The education online is huge today. Especially the CE credits and it's much easier to listen to some very knowledgeable people online than have to travel halfway across the world to listen to them. So yeah, I think Dentaltown is an absolute example of that. Sure.
Howard Farran : So there's been a lot of changes in sealers. So, I mean I started out with Grossman cement. Do they do even sell that anymore?
Dr. Kolnick : Yeah.
Howard Farran : Can you buy a bottle of Grossman cement?
Dr. Kolnick : You can buy the, some of the sealers today are based on those sealers. You can still get them. The big push today seems to be towards the calcium silicates, the bioceramic sealers which are showing real promising, promising results. You know they are bio active materials and they continue to be bio active until they set within the root canal system and they pretty much don't shrink on setting which is a big problem in previous sealers. That's why we needed to keep them as thin as possible and keep the Gutta-Percha as wide as possible within the root canal system. So now there is a trend towards rely more on the sealer and less on the Gutta-Percha. So the single cone Gutta-Percha with the bioceramic sealer is gaining a lot of popularity right now.
Howard Farran : What sealer are you using?
Dr. Kolnick : I'm using a bioceramic sealer made by Brasseler.
Howard Farran : That's the one. That's the bioceramic sealer that's getting the most buzz isn't it?
Dr. Kolnick : Yeah, but there's a lot of competition coming out now. There are actually sealers that have MTA mineral trioxide aggregate in them now that are proving to be very popular. The problem is with the cost. The sealers are very expensive and I think that as competition grows the price will come down but there could be maybe five or six on the market right now that probably are just equivalent in terms of their capabilities within root canal systems.
Howard Farran : I never understood why that MTA cement cost more per gram than heroin when it was just swimming pool cement. I mean that's all it was, right?
Dr. Kolnick : Portland cement. Yeah.
Howard Farran : Portland cement. I mean how come I can buy a gallon of it for my swimming pool but when I buy a gram of it in dentistry I mean it's like it's some, a diamond n the rough. Wasn't that kind of funny?
Dr. Kolnick : Yeah. It was funny and it was sad. I mean certainly very expensive. There are alternatives now. So there is competition. There are cheaper products available but still you only need a small amount of it and the packaging is improved. It's not so much in one sash anymore. You can, you know, you can get smaller amounts so that you don't have to waste. Waste has just been reduced but I think bioceramics right now in term of sealers, the bio active sealers seem to be the big push right now.
Howard Farran : So, how many of these Biolase, Waterlase do you own then, because you have what?
Dr. Kolnick : A bunch.
Howard Farran : Four? Four? You have, how many endodontists are in your four locations total?
Dr. Kolnick : Well I need to just clarify that a little bit. We are currently going through a merger with, another endodontic office is merging with us. So until the merger, when the merger's complete there will be seven endodontists in four locations.
Howard Farran : So you have one Biolase, Waterlase in each location then?
Dr. Kolnick : We have a total of seven.
Howard Farran : Seven Biolase?
Dr. Kolnick : Yeah. Seven of the all tissue lasers. Yeah.
Howard Farran : How much, so, for someone listening to this and says well I want to get into laser cleaning of the apical third of the root canal system, I think they should take your CE course on Dentaltown, how much is this Biolase, Waterlase you know?
Dr. Kolnick : Well they've just come out with the smallest and least expensive all tissue laser on the market. I believe it's going for just under 40. Something like that. Maybe 40 thousand. The bigger machines and most of the companies are around about anything from 60 to 70 thousand. So the prices, the price is almost half now of what it was before. Certainly coming down and more compact. It's just been released actually. I just received mine a couple of weeks ago.
Howard Farran : What's the exact name of it?
Dr. Kolnick : It's called the Express. The Biolase Express.
Howard Farran : So it would be the Biolase, Waterlase Express?
Dr. Kolnick : Yeah. Biolase is the company. I guess Waterlase is the technology and the Express is the unit.
Howard Farran : It's small? How portable? How small and portable is it?
Dr. Kolnick : It's about 25 pounds. You can, there's a handle. You can lift it up and move it around. The limitation of this particular laser is that it's not designed to cut teeth. So if you want to do cavity preparations this is not the laser for you because there's insufficient power but for all the endo applications, for the perio, periodontitis, implantitis, soft tissue, it's all compatible with this new machine. It's a four watt machine and the iplus which is their high end machine is a ten watt machine. So it will cut enamel more effectively than the smaller machine.
Howard Farran : So what's the bigger ten watt one called?
Dr. Kolnick : The iplus.
Howard Farran : The iplus. I wonder what the i stands for.
Dr. Kolnick : If you say, I don't know. I, intelligence. I don't know, iplus.
Howard Farran : IPhone. Well the iPhone that I use is for internet, isn't it?
Dr. Kolnick : iPhone, innovation, I don't know. I don't exactly ...
Howard Farran : So yeah. So you're saying the Waterlase Express would be great for an endodontists for cleaning the apical third and for a periodontists that's still a LANAP procedure, right?
Dr. Kolnick : Well that's a different, LANAP is a different company.
Howard Farran : What company is that?
Dr. Kolnick : You know I'm not sure. That's not my field but it's the erbium YAG. It's a, also an erbium all tissue laser but it is the YAG as opposed to YSGG. I'm not sure of the company. Maybe ...
Howard Farran : Millennium Dental. LANAP is Millennium. Millennium.
Dr. Kolnick : Right. Right, but the, I think the protocol for Biolase for the periodontal protocol is called the repair. Repair protocol.
Howard Farran : So their LANAP protocol is called the repair protocol?
Dr. Kolnick : No, no, no, the Biolase protocol is the repair, is the repair protocol and the Millennium protocol is the LANAP procedure. I'm not familiar with the LANAP procedure. I'm a little bit more familiar with the repair because it's the same machine that i use but I really don't, for the most part I don't treat periodontal disease. So someone else would probably be a little bit more of an expert to speak on that than me.
Howard Farran : So there's another famous endodontist in your backyard. You're in Manhattan, right, one of your locations?
Dr. Kolnick : I'm just, no, just north of Manhattan in Westchester County.
Howard Farran : Barry, oh my God, whose the guy with the ... ?
Dr. Kolnick : Musikant.
Howard Farran : Barry Musikant.
Dr. Kolnick : Right.
Howard Farran : He's always talking about files breaking in, he likes his file because he thinks it breaks much less. Do you think file breakage is a big problem? Do you think Barry Musikant is onto something with that?
Dr. Kolnick : Well let me find some wood to touch. We don't break files anymore. So I think file breakage really is not the problem that it was before. He uses the, he created the SafeSider file. I'm not too familiar with it. I believe it's also a reciprocating file and he's had a lot of success with it but I think, I think that a lot of times the manufacturers play on the, they emphasis the breakage of files and this puts everyone into a panic but really we, unless you abuse the file that you're using most files today and it's a new file, you're not using it 50 times if it's a, most of them are supposed to be single use, you should not be in a situation where you break files.
Howard Farran : You know we, my 30 year, I graduated 30 years ago May 11 and last week you know they had a big part for at the UMKC alumni meeting but a lot of the dentists were talking about it and particularly one of the endodontists in our class was talking about that, when we were in school 30 years ago, four classes of 120 had six endodontists in the endo department and some of these private schools have one and so a lot of people, a lot of endodontists are telling me that some of these kids are coming out of school where there was only, where the facility it's so small that they don't even know basic endo. Do you see that anywhere or do you not see that?
Dr. Kolnick : Well you know the schools that I'm involved with and I've lectured probably in about a dozen programs around the country, I think that they, that it's not really a problem. I think the, I don't think that general dentists that are finishing their program have sufficient training. So I don't know whether some schools are pushing a lot of the more complicated work off to the post doctoral program so that the undergrads aren't getting much exposure. Some of the requirements are ridiculously small. It may be five teeth, one molar, a bicuspid, a few centrals and then they're done. So once again that type of education isn't my thing.
I'm more of a visiting lecturer but I've been involved with Columbia University with Freddie Barnett's program, at Einstein, USC I've been there. I've been at Uconn. The programs that are around here I think have got good staff. You know, I think there's always work that has to be done to get the programs better but you know I'm not an educator. I have to tip my hat to those endodontists that are full time educators. I think that we don't have enough of them. I don't think that the money is there and I think that most of these teaching spots are taken by foreigners who either aren't licensed to work here or who are really dedicated to teaching. So you know I really have to tip my hat to these individuals.
Howard Farran : I want you to, I want to change subjects completely and go to something totally different. The natural selection of a dentist, I mean in order to get into med school, dental school, or law school you had to get A's and so dentists were the boring people sitting in the library every night as opposed to the business people who were in frats and drinking and had girlfriends and all that stuff. So yeah this very shy introvert scientist who does surgery with her hands all day and you have to be a great salesman to sell cosmetics and veneers and all this stuff but a toothache you don't have to sell. I mean they come in and they say gosh I'm in pain, Dr. Kolnick can you help me but she comes out of school and she says I have 350 thousand dollar student loans. The insurance pays 80% of the molar root canal but I hate molar endo. I don't want to do it, but she knows she needs to change that attitude because she's got to pay off a 350 thousand dollar student loan.
Dr. Kolnick : Absolutely.
Howard Farran : You can't, you can't, and she might be in a rural area where if you say well you've got to drive an hour into Flagstaff she says forget it, just pull it, what would you say to a 25 year old kid who came out of school and says I hate endo? I hate it?
Dr. Kolnick : Well if you hate it don't do it I mean but if you need to do it you get trained. I mean there certainly are plenty programs, continued education programs whether they're on the internet, you have to keep studying. I mean, when I trained there was no, there were no microscopes. There were no rotary files. There was no nickel titanium. There was, you know, everything along the way we had to teach ourselves and then we became the teachers. So if it's something like lasers where I decided to make the investment and the commitment nine, ten year ago, I'm the one, one of the few that are doing the teaching right now. So it's continued education. You've just got to be committed to improving yourself. There are institutes all over the country. Many of the mentors that we discussed earlier, these are the people that are doing the educating. You have to, you have to keep learning.
Howard Farran : Another problem this 25 year old has, she's working in a group practice or there's different specialist and the oral surgeon, she sees a failed root canal and the oral surgeons are, somebody already tried it once. Let's pull that thing out and go to titanium and then the endodontist is saying no, no, no, you should re-treat and she's like, what are you thinking when you see a failed root canal? What are you focusing on the most that makes you go towards retreatment versus titanium?
Dr. Kolnick : Long term prognosis. So what we're looking at is you know we want to win the battle and we want to win the war. We want what we do to be treated well, to be restored properly, and to be in the patient's 15, 20 years from now. So if a tooth, we can pretty much treat anything but if it's not restorable, if the, you know there is inadequate ferrule you really have to take all the restorative, the restorative situation into account. I think some times endodontists or dentists may undertake to treat something that really has a really poor prognosis in terms of you know five to ten years. So I think the big thing I would look at would be long term prognosis. The other thing is to do no harm. You've got to make sure that you're going to be helping the patient. There's quite a big discussion today especially with the advent of cone beam CT about these radiographic findings that we are seeing at the end of root canal systems.
You know, many of them today are not being treated even by specialists. The patient may come in with a small periapical radiolucency that's been there for 30 years and the tooth is restored, no work is planned on the tooth and you know it's a really calcified situation or there may be a large post in there and you have an eager dentists, endodontist may go into redo it because he sees that very small finding at the end of the root canal and he may end up destroying the tooth in the process. So and the patient certainly is less well off afterwards than if the tooth were just left alone. So there is quite a trend now in endodontics to be more conservative with our thinking and to be more long term with our thinking in terms of long term success and really the outcomes really are patient orientated outcomes.
What we you know, we often do a lot of things for ourselves. We want to see a lateral canal on an x-ray or we want to pat ourselves on the back for doing a really good root canal but ultimately it's the patient. It's the patient that needs to be happy with the tooth. If we do a beautiful root canal and the patient still has pain in the tooth it doesn't help. It doesn't help the patient. So it really has to be patient centered, our treatment planning, our considerations and we move forward from there.
Howard Farran : You know, it's interesting talking to ENTs in the valley where they say that someone will claim they have had allergies for ten years and they go in there and they find failing root canals and they're saying that, or even failing sinus lifts and they say this problem they don't know, it seems to be getting larger. More ...
Dr. Kolnick : Well there's certainly, it's surprisingly how high the percentage, the percentage of patients suffering with chronic sinusitis, chronic maxillary sinusitis that have a dental component is quite high.
Howard Farran : How high do you think it is?
Dr. Kolnick : I mean it's, there's some studies that can go as high as 40%.
Howard Farran : Yeah. Yeah, I'm trying to get them to build a course on it and do a podcast with me and some of it he says is crazy. Like you'll go up there and it'd be like white candidiasis infection, you know all around the sinus and so I want to ask you an emotional question. You, there's no right or wrong. Here's an emotional question. It seems like dentists go to the church of odontology and there's a missing first molar. So since they worship teeth they just blow a hole in the sinus and pack it with cow bone and titanium, all that stuff but then when I go talk to the ENTs the rhinologists the how do you say it, otolaryngologists they're like hey doc stay out of my place. Stay out of that damn sinus. You had two teeth there. They've been doing bridges since the Egyptians three thousand years ago. Leave my sinus alone. We're, and I know you're jaded because you're an endodontist. You know, you come from the church of odontology but do you think that dentists are too bias against bridges and too quick to go in and do a sinus graft?
Dr. Kolnick : Well I get the feeling that they are too quick to pull the plug on the tooth. So I think ultimately saving the tooth would be the best solution to this problem that you've presented. You know from my experience with doing surgery in and around the sinus the sinus is quite a resilient area. I think the sinus heals rapidly and does well provided you, you know, you keep infection out. So I got to imagine that with all the sinus lifts and implants that are being done right now that, that I think the prognosis is good. You know if it's well done I think it's there's no real problem with doing a sinus lift and placing a graft in the area but once again it needs to be done properly.
Howard Farran : Change of subject. Back to endo failures. What percent of failed molar endos are do you think from a leaking crown?
Dr. Kolnick : You know there are studies and I just don't have the statistics on my fingertips. I think that ...
Howard Farran : How many years have you been an endodontist?
Dr. Kolnick : 35 years.
Howard Farran : So in 35 years what would you intuition be? What would you gut tell you?
Dr. Kolnick : Well there's certainly a big tend in endodontics today to provide some of the restoration of the endodontically treated tooth. We have the tooth under the rubber damn. We're working under high magnification. We can see if the system is carious free, it's clean and a lot of people believe that it is the endodontists that should be building the core or placing the post while the tooth is under you know aseptic conditions. There's no doubt about it that restorative failure is one of the leading causes of reinfection of root canal systems. So it's significant. I don't know what ...
Howard Farran : Exactly. I feel sorry for endodontists in labs because you know if a dentist sends a crown back and says it doesn't fit, remake it and the lab man's like okay dude you only see your impressions. I see ten big dentists doing crowns all day and you have the worst preps and the worst impressions but they live in fear that if they say something they're going to lose the five thousand dollar a month account. So if you're out there listening and you need to call your lab man. The only way you're going to be a better dentist is to call your lab man and say, dude look I'm hungry. I'm humble.
I'm not an arrogant doctor or lawyer. I'm not like that and if I can be a better dentists please help me and they need to do the same with the endodontists because of these endodontists they'll say, the general dentist will refer the root canal to you but he says but I want to do the post and buildup because that mental midget is only thinking about billing out the post buildup and the saliva which has a billion bacteria, fungi and virus per CC I mean that's insane, but the point I was making is I, whenever a root canal failed and you know a root canal, and I see a failed root canal bone crown I never did the retreat through the crown because I'm like I don't even know what's under this thing and I always take off the crown because I wanted to see, you know I have to get all the decay out first. I had to get the ferrule out. I needed, sometimes they needed perio what crown lengthening therapy.
Yourself or a periodontists, whatever and I just see, I just think well what percent of the vast majority of retreats do you think they go through the existing crown and do you really think that's a good idea. I mean the only reason anybody would want to keep the crown is because they don't want to pay the lab bill of making a new crown but if hell if it had CAD/CAM and CEREC, now we're down to the price of a block.
Dr. Kolnick : Right.
Howard Farran : What do you think about doing retreats through the crown?
Dr. Kolnick : I think going through older crowns is definitely a problem. You know we see a lot of causes where the crown is actually quite new on the tooth. You know, these new bonded crowns, the seal is excellent, there's no sign of decay and there's nothing wrong with going through the crown to do the root canal therapy but very often we'll go through the crown and we'll see caries and we'll see that it's compromised. The crown has to come off. You know, I think a very high percentage of older crowns are leaking. A very high percentage.
Howard Farran : So how old would that crown have to be before you said I'm taking it off and plus when I take off the crown I just feel like I can do so much better endo because you can see everything as opposed to trying to do it looking through some bb hole.
Dr. Kolnick : Well we also like to have the crown off because we want to preserve tooth structure. So when you go through a crown, the you don't know what the original anatomy of the tooth was and you don't know where the core of the tooth structure is. So you'll often end up making an access cavity that's much larger than it should be, you end up destroying tooth structure but you know in situations like bridges you can take your whole bridge off if it's an abutment but a surprising number of cases we treat are teeth that have had crowns placed within six months.
Howard Farran : Okay, so that leads to my next question which is a bio, that was a perfect segue for my next question. You're doing, you're removing the decay, you remove the MOD amalgam, you're removing decay and you got a little bitty pulp exposure. Which do you think is more predictable to seal, the pulp exposure or to do the whole endodontic therapy and seal the apex at the very bottom? Which one's more predictable to seal? Would you ... ?
Dr. Kolnick : I think if the root is immature, if it's a child and the root is immature I think vital pulp therapy is in order to try and preserve the root canal, the pulp tissue so that the root can develop normally. So certainly the pulp caps, pulpotomies generally are done more in permanent teeth that are still developing. In adult teeth where the root canals, the roots have fully formed the, a traumatic pulp exposure or created by a burr, not a carious pulp exposure may respond quite well to a pulp cap. You know, I don't have the statistics on that but I think that, I think if it's not a carious pulp exposure and the root system is fully developed and it's a small exposure certainly you could do a pulp cap that'll work very well. There is even a trend in certain circles now not to remove all the decay in a tooth that has a deep decay and there have been some surprising results showing that teeth have actually done well when some of that stained or hard dentin is left behind and not removed.
Howard Farran : Yeah.
Dr. Kolnick : Some people are ...
Howard Farran : Good luck explaining that to a jury why you left decay.
Dr. Kolnick : No, no, no, I simply come from the school where pulp is exposed, certainly carious pulp exposure we would do the full root canal therapy.
Howard Farran : Yeah, I, if you were going to do a pulp cap how, what would you do? Would you use MTA? Would you, what would you do it with?
Dr. Kolnick : First of all we would use the protocol we use in our office is with a laser. So there's a laser protocol to do a pulp cap or to do a partial pulpotomy or the so called sveck pulpotomy or a full pulpotomy. The most atraumatic way to do it is with a laser, with the Waterlase that we use it's very effective but basically the bioceramics, the bioceramics are the materials for that. You know? No more calcium hydroxide. That's, was MTA, the white MTA, the grew MTA but we see more staining of the teeth with that.
Howard Farran : What about just going down to you ... ? What about just going down to your swimming pool store in Phoenix, Arizona buying just a bucket of Portland cement?
Dr. Kolnick : Well that's not medical grade. That's not medical grade but there are quite a few materials by Dent and by the you know there's a, the BC putty. There are a lot of products on the market today that are actually stimulate the either cement them if it's at the end of the root canal or a dentin like material to bridge these, you know these pulp exposures or pulpotomies and it's been very successful.
Howard Farran : So you said you've been doing seeing a lot of teeth that need endo that were just recently crowned?
Dr. Kolnick : Yes.
Howard Farran : Well what did you think, what mistakes or what causes do you think are the most common, do you think it's iatrogenic reasons? Why do you think you're seeing a lot of new crowns that need a root canal?
Dr. Kolnick : I think one of the most common reasons for this situation are correct teeth because a dentist often there will be a crack in the tooth and maybe the cusp breaks away and the dentist looks at it and thinks well that's set, you know, the crack is no longer there. The broken piece of tooth is gone but yet we can see often that the crack does extend deeper into the tooth. A lot of the, I think the cracked tooth syndrome is probably an epidemic condition that we see today. The occlusal stressors, the clinching grinding, everything that contributes to it, you know I'm not a restorative dentist but I think probably in the New York metropolitan area or any big metropolitan area probably anyone over the age of 35 should be wearing an occlusal guard or a you know a mouth guard at night because of all the clinching and grinding that's going on. So ...
Howard Farran : Or maybe they should just leave Manhattan and go live out in the country. Maybe they'd stop grinding their teeth if they moved to upstate New York.
Dr. Kolnick : It could be. I don't know. Maybe it's the political situation that's causing people to clinch and grind a little more.
Howard Farran : These are crazy times aren't they?
Dr. Kolnick : These are crazy times. So I think the biggest complaint we have when a crown is placed on a tooth that it looks like it's quite normal to accept the crown, no you know deep excavation, no pulp exposure and yet the patient complains of you know acute temperature sensitivity or biting on hard objects and you test it with a tooth sleuth and you see there's pain on release of biting. These are characteristic of cracked tooth syndrome. So I would say that probably the majority of cases that we end up treating after new crowns are placed or from a pulpitis, usually from an internal crack in the tooth.
Howard Farran : You know, try, try, let's see I only got you for five more minutes. Let's stay on that then because this is a big thing, because they ask a lot on Dentaltown they'll take a picture. They remove the MOD amalgam and there's a black line on the floor underneath it and they're like you know, help. You know, what, how do you analyze cracks? You take out the MOD ...
Dr. Kolnick : It's a big problem ...
Howard Farran : You take out the decay or it's a, talk about, just rant for another four and a half minutes on crack.
Dr. Kolnick : Sure. It's a really big problem for us because typically if a crack causes the tooth to become nonvital or the pulp to become infected it's usually not a good sign for the tooth. So if we evaluate a crack and we open up into the chamber and we see that the cracks runs through the floor of the chamber or if the crack runs down the root canal, below the level of the CEJ these are all very poor prognosis situations but we can't, we can't extract every tooth that comes in with a crack because we see so many of them. So the teeth typically that we treat are teeth that are vital. When we transilluminate these teeth the blockage of the transmitted light usually isn't total. It's partial. The oblique fractures that undermine a cusp as opposed to running the center of the pulp chamber have a better prognosis but any time there is a pocket associated with a crack or there is a focal or periapical legion associated with a cracked tooth then the tooth really needs to come out.
Howard Farran : One last deal. Were you born in South Africa?
Dr. Kolnick : I was born in South Africa, yes.
Howard Farran : What is it with so many of the worlds greatest endodontists coming out of South Africa?
Dr. Kolnick : It just must be the accent I think.
Howard Farran : It's the accent? I mean it's got hell of a legacy. I mean it'd be like, I mean don't you agree?
Dr. Kolnick : We had a really good training. In South Africa you don't go to college first. You go six years into dental school. So here it's four years college, four years dental school. So we give them actually two years extra training in dental school but we don't have the liberal arts education that many of the American dentists have.
Howard Farran : So you're able to do endodontics without taking all those courses in sociology, anthropology and political science?
Dr. Kolnick : We are. We are and the other thing is we don't have the specialists there so we had to do it ourselves. We had to be trained and we had to do it ourselves.
Howard Farran : Who do you stay in touch with that's an endodontists from South Africa today? Any?
Dr. Kolnick : Who? Dr. Marty Trope. Martin Trope.
Howard Farran : Amazing man.
Dr. Kolnick : I'm not sure really off the top of my mind. There are a whole bunch that I don't think that you'll know but I think you know, Marty Trope. Do you recall any names?
Howard Farran : Well you and Martin, I mean Martin has an online CE course on Dentaltown too and I mean and I've lectured in Johannesburg and Soweto and I mean I, that's an amazing country. 50 million people. I mean it's probably the wealthiest country in South Africa, in all of Africa wouldn't you say?
Dr. Kolnick : It was. It was. The money seems to have disappeared. So you know I think Africa is a continent unto itself. The way governments run in Africa a little different from the ways governments run in the Western world and you know South Africa is a country that's been reborn and it's going to take probably you know a good two, three, four generations for that company to evolve the way it should and I think it's on its way. It's, as I said I've lived in America longer than I've lived in South Africa but I go back every year. My family's there. I go back to lecture every year and I think it'll find its way. It'll find its way and it's certainly one of the most beautiful countries in the world.
Howard Farran : Oh yeah. Every time I got there I take at least two or three of my four boys with me.
Dr. Kolnick : Oh, yeah.
Howard Farran : We just love it. Last question. I get you for 45 seconds.
Dr. Kolnick : Yes.
Howard Farran : I love insurance data. Can you explain to me why over the last 30 years the number of apicoectomy and retro fills has just been trending down? It's almost like it's an animal that's going to go extinct. Why ... ?
Dr. Kolnick : There are two reasons. One because the way that the surgery was being done was, had a very poor prognosis. Second of all the teeth are being removed and implanted but a tooth that is indicated for apical surgery should have the same success rate as the retreatment.
Howard Farran : So when are you doing apicoectomy or retro fills? What this, what tooth condition are you looking at when you're doing your apicoectomy or retro fills? Is it just a file you can't get out? Is it a, what's going on in the tooth?
Dr. Kolnick : It's persistent infection and we have to decide whether the best approach is through the root canal or whether it's surgical. If going through the root canal system is going to weaken the tooth excessively or if the system is blocked and there's no way down to the end of the root canal system then we will resort to the apical surgery. Apical surgery in many cases is the most conservative approach because it preserves more tooth structure than going in through a crown, taking a post out, spacing a bicuspid in the weak tooth and once again you may win the battle but lose the war because we're looking for long term success for these teeth and long term we're talking about ten, 15, 20 years.
Howard Farran : I love that saying. I've never heard it before, you may win the battle but lose the war. That's a, I just love that. Is that a South African saying?
Dr. Kolnick : It must be.
Howard Farran : It must be? Yeah. I've not heard that one before but hey I just want to tell you I can't believe a guy like you gave me an hour. I mean you gave us an online CE course that everyone loves and I know you're a busy endodontists with four locations. I just want to tell you thank you so much for spending an hour today with me and all my homies.
Dr. Kolnick : Thank you. Thank you. It's been a pleasure.
Howard Farran : All right. Well you have a great day.