Dentistry Uncensored with Howard Farran
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1203 All things endo with endodontist Judy McIntyre DMD, MS : Dentistry Uncensored with Howard Farran

1203 All things endo with endodontist Judy McIntyre DMD, MS : Dentistry Uncensored with Howard Farran

6/5/2019 2:56:31 PM   |   Comments: 0   |   Views: 130

Growing up in sunny Los Angeles, CA, Judy McIntyre wanted to become a dentist ever since she was a little girl. 

VIDEO - DUwHF #1203 - Judy McIntyre



AUDIO - DUwHF #1203 - Judy McIntyre


She attended the Harvard School of Dental Medicine, where she graduated Magna Cum Laude. At Harvard, she performed research on dental unit waterline biofilms. After graduation, Dr. McIntyre obtained a coveted endodontics residency position at the University of North Carolina at Chapel Hill. Alongside renowned researchers in the field of endodontics, traumatology and pediatric dentistry, her thesis and research regarding traumatic dental injuries (her true passion and great interest) has been published in numerous professional journals.

Howard: It is just a huge honor for me today to be podcast interviewing Judy McIntyre DMD MS she's an endodontist at Hopkins endodontics in Hopkins Massachusetts growing up in sunny Los Angeles California Judy wanted to become a dentist ever since she was a little girl she attended the Harvard School of Dental Medicine where she graduated magna lotta I'm so dumb I don't even know what that means at Harvard she performed research on dental you know water biofilms after graduation dr. McIntyre obtained a coveted endodontic residency at the University of North Carolina Chapel Hill alongside renowned researchers in the filter endodontics traumatology and pediatric dentistry her thesis and research regarding traumatic dental injuries her true passion and great interest has been published in numerous professional journals she's worked in private practice in the south before returning to Massachusetts after completing the Massachusetts Dental Society Leadership Institute she remains active in the society she resides locally with her family and rescue dog she enjoys spending time with her family and friends when she's not in the office and it's just a huge honor for you to be on the show today because when you go to your website Hopkins and add on calm and you look at all the papers that you polish I mean you've been in on you've been published in PubMed more than most of my friends have even logged onto PubMed but they're all dental traumatology permanent to 3-play implantation after avulsion root fractures and children Elementary School staff knowledge about dental industry effectiveness of dental trauma education for elementary school staff you are you you're almost like an endodontist and a for pediatric dentist

Dr. McIntyre: I do see quite a bit of children and I'm blessed that most endodontists don't want to treat kids so you know that has sort of become my informal subspecialty obviously as a mom I've been able to handle a lot of children with finesse you know I really take a lot of pride in the that I don't need I don't even have a nitrous sedation certificate I am able to I know how to give nitrous but honestly I figure I can rationalize with most kids that are seven years old enough I've done one six year old all anesthesia most of them don't even tear up for me I just have sort of a way that I get them to convince  them that we need to fix their tooth and I need their help and we're gonna do it together

Howard:  that is that is so amazing and it's just an attitude I had my mind open on this when I am podcast interviewed a dentist who does hypnotism and he was from Ireland no he's from glad was he from Scotland and he said something that blew my mind he said well Americans don't treat patients with anxiety oh my god we do we put him to sleep he was that's not treating and that's just knocking him out and when they wake up they're still afraid of dentists because I'd rather spend the time upfront get into their head build trust get a relationship going and treat the anxiety and that's what you're saying you're saying I don't want to not these things I think

Dr. McIntyre: yeah  I mean sometimes I'll actually ask the parents to leave so that I can work and it's successful it I'm I just really r think the kids for their confidence and trust when we're done because they allow me to do what I need to do and it's  amazing but yeah parents sometimes aren't that helpful

Howard:  this is a dentistry uncensored so I don't want to talk about anything everyone agrees on I want to get right to the the controversy I'm when I was little all the OB all the gynecologists know obgyn and they were all men now they're all women and in my 32 years being a dentist I'm seeing pediatric dentists shifting from all-male to all you know I mean some of these graduating classes and specialty programs have six students and five of them are women do you see pediatric dentistry turning into a female specialty

Dr. McIntyre: I know quite a bit of female pediatric dentists I'm an endodontist I would say now in pediatric dentists I probably do know more females than males and in endodontics I would say it's still about half and half I know that's totally unofficial 

Howard: I mean I got four kids and they've made turned into five grandkids and I would rather go take my grandkids to a female pediatric dentist and have grandpa do it so um so those are good for root canals you know I always think about that you know 

Dr. McIntyre: I do get a lot of compliments about how gentle my anesthesia techniques are and I don't know maybe it's cuz I have small hands maybe it's cuz I'm a female who knows

Howard:  so what do you think that the listeners listen to you today don't really think about traumatic dental injuries and then don't like an endo I mean I think of endo as a bacterial invasion a cavity got into the nerves and that's pretty much all the root canals I see what percent is traumatic dental injures injuries leading to endo is that is that one percent of the root canals five percent what do you think is how prevalent is that 

Dr. McIntyre: so I loved your question just now because you gave me kind of an aha moment in terms of traumatic dental injuries and endodontics really because what I try to tell my referring dentists and what I try to tell my general dentists is both of them need to have that perioperative conversation to understand and lay the foundation down for what's coming we don't know what's coming whether a tooth is gonna need a root canal or in a traumatic dental injury if it's going to be able to be saved but you've got to have that initial conversation first to anticipate so that when something unforeseen happens like the root canal being needed in just plain operative dentistry restorative dentistry prosthodontics dentistry and with dental trauma people aren't so hysterical about it excited  not in a good way about it or when they abscess all of those things if you have the conversation beforehand then it's not such a big unforeseen surprising event when it's needed overall dental traumatic and except effect 20% of the population that encompasses all of the injuries so we're talking about in you know enamel dentin fractures pulp exposures with the fractures but in terms of the injuries that require endodontics later most of those would be the luxation injuries and of course 100% of the avulsion injuries will necessitate endo absolutely do not pass go do not collect $200 you need a root canal if your tooth has been knocked out and you'd be surprised at how many people still don't realize that and the dentists will tell them let's watch it there's only one scenario where you watch yes it's true it's true the only time you're gonna watch an avulsion injuried tooth is with an open apex usually two millimeters more open radiographically otherwise do not pass go root canal root canal within seven to fourteen days always a hundred percent of the time 

Howard: Wow and not to get off-topic but a lot of these injuries to enter your teeth that end up needing a root canal and it's also almost everyone puts a post in it too but it's like when you study posts I mean he almost could come away thinking the only indication of a post is if you want to further fracture the root foody what's your view on these dramatic injuries and post 

Dr. McIntyre:  you know this is actually right now kind of a lighting up topic on Instagram in terms of endo and restorative issues so right we both learned that you need a post to bridge the restorative to the root if you have enough tooth structure you don't need a post so again with I completely agree with you if these posts the larger posts the cast posts the screw posts will tend to fracture teeth both anterior and posterior in anterior teeth as well I believe there's a movement positive movement towards using fiber posts and you know we don't always have to put that post in if there's three or more walls of remaining if there's the ferrule you know I just challenge everyone to really assess whether a post is needed

Howard: I  think that most interesting thing about a ferrule is that word comes from barrel making I mean I mean those that was on it on a 50 gallon barrel that was that little metal collar around that and they figured out eons ago that if you put a little metal ferrule around the barrel a barrel ferrule that the barrel was you know ten times stronger and then they started moving it to one at the equator of the barrel then one about halfway up and one halfway bottom and so a barrel maker knew everything about ferals you know hundreds of years ago that dentists are still having a hard time understanding they it's your bonding agent isn't going to keep that ground on if that restoration doesn't have a two millimeter ferrule all the way around it you're kind of in trouble Instagram she's dr. Judy endo the Riu I you're on Instagram you have a face for Instagram I have a face for iTunes so you can you can do all that out public stuff on Instagram before we pass dental traumatic done on juries is there any anything you think my homies need to remember most I mean is it still the same thing if you can get the tooth and  hold it in your mouth until you get to the dentist is the best bet 

Dr. McIntyre: I would say that's probably second best with all due respect because in the mouth in the cheek it can still undergo injury to those delicate PDL cells so what I would love is to find a cup find milk or you know nurses school nurses might have those save the tooth kits that are just like this big and they're $20 some coaches might have them I've posted on Instagram I Drive around with the save a tooth kit because I'm that type of person then always anticipate that injury but the saber tooth kits are really inexpensive I donate a few every year to my local school nurses milk even if it's shelf-stable milk like caramel but that milk is good cold preferably skin preferably in a ziploc bag find the tooth put it in there get to your dentist siblings are the best bet for replantation they're amazingly confident hysterical moms just won't rise to the challenge but give that to youth to a sibling and they'll be happy to put it back in in terms of everything else just you know after the emergency room if the emergency room and physicians have been involved if the emergency room has given their blessing you know get to the dentist even little types of injuries you should always have that baseline exam to make sure that we know what we're starting with so that should a tooth necrosis later on radiographically change or aesthetically change then we know at that time what it looked like at the day of injury and then from there we can compare a lot of people don't understand that we need that comparison and that is beneficial information so that we can watch the progression of any changes 

Howard well it's really hard for you because you're up there in Boston with all those Irish people they probably bring the tooth in soaking and Jameson whiskey and think they they did everything right and they don't have as long 

Dr. McIntyre: as long as it's not water not water the water because it is the cells are hyperosmolar so they will burst when placed in water so that will cause more destruction so again something like saline obviously what's best is like a storage medium like the saber tooth kits because that they're neutralized for the cells and for whatever reason so is milk but not water not dry so again if your cheek is your third best option put it in the cheek and get to the dentist

Howard: Wow and you know you just said something that if is gonna seem so silly a hundred years round like you said at the emergency room you know the emergency room doctor wants you to go see a dentist it's just so insane that eight and a half percent of emergency room visits or odontogenic and origin and they could remove a brain tumor I pass they can you know do a liver transplant but they got your teeth and then oh and then these DSOs you know these dsos why isn't the largest DSO in America the chain that just has a dental office in every emergency room of every hospital in America and they're the only thing they do in Phoenix Arizona is they give you a vicodin and pen BK and then 

Dr. McIntyre: because that doesn't help anything at all and the doctor is unfortunately because the rest of the body is able to heal they physicians generally don't understand that because the teeth can't heal right if a tooth could heal would I have a practice would I have a specialty no the tooth is the only part of the body that cannot heal after significant injury so I'm not sure if both patients and doctors need a lot of verification in that area but yeah the vicodin is just not going to help and neither is that the antibiotic will help temporarily most of the time yeah 

Howard: and I've read um so many papers post on dental town that I'm you know good a good chunk of people addicted to opiates they got their first dose at their wisdom teeth extraction

Dr. McIntyre: third molar extractions absolutely

Howard:  yeah when did you trade heroin oh when I got my wisdom teeth removed well was trying heroin a good idea I mean if you said any mother hey do you think your daughter at 18 just try heroin just one time everyone would say absolutely not that's a really bad idea and then that's what we do all day long well 

Dr. McIntyre: and  you know the 30 pills I had my wisdom teeth extracted I you know it was a uneventful insignificant extraction I ate the same day of course I understand there's more complicated ones but really advil and Tylenol the literature shows is shown to be more effective and you know we definitely if we're gonna prescribe you've touched on a lot of points here we just got to do it a little bit more responsibly all right four four tablets maybe five but you need to get that tooth either extracted or started with canal therapy pronto and you only need four tablets for it to get you into weight and through the weekend you don't need anything more 

Howard: I tried one time writing for  tablets and she just added another four in front of it and the pharmacist said are you really he's prescribed him 44 true story but anyway um we just had almost six thousand kids graduating from dental kindergarten school last week and they're coming out here and again this is dentistry and sensor I want to talk about the real confusion in the marketplace is there's that they go to the convention there's like a hundred different endodontic file systems and right and they're like they're like come on Judy you're an endodontist for decades I mean you're published in PubMed and have that Magna cume a lot of things they they don't want to figure out all the all these endow files and then they're cynical part which I love and I hear is that they're like well Howard it seems like every root-canal training seminar you go to is sponsored by the dental endodontic file manufacturer so it's almost like they're smart enough to realize maybe before I start learning about what you want to say about this file I need to know which file system I could use because the continued education and the people selling the files is so United one to one I mean do you agree that a lot of the endodontic file seminars are corporate sponsored and could be biased to their own file

Dr. McIntyre: absolutely and you know we can't do a lot without sponsorship so I'm not gonna totally dig that but really I think the crux of your question is how do all of these graduating students learn what might work for them and really I honestly just this just clicked this year at the a meeting in Toronto when I was chatting with a few colleagues and everyone the companies make endodontics look like c-can do try one do one and you're it practically an endodontist and you should do you know first and second molar root canal I can tell you it's rough out there any molar some premolars that I get like there it's tricky you've got to be able to feel within the canal system what you're doing it's not about one file system it's about knowing what you're doing and feeling the pathway to lead you to the apex if you can't feel it then you shouldn't force it and it should go to an endodontist because even the most expensive file system even the best file system is not gonna give you a pretty root canal if you don't have a mastery of what you're doing and what you're feeling and what exists within the  tooth Anatomy 

Howard: Is CB CT becoming the standard of care I mean can you just really like back in the day have the PA and that's you know you look for all the canals or do you think ICS CB CT getting a three-dimensional image you're trying to make sure you know the anatomy is that standard of care

Dr. McIntyre: so standard of care is a tricky definition and you know I know that all of our associations especially our specialist associations you know when I sit on these committees like using the word standard of care can get a little tricky like I believe a rubber dam is standard of care but I'm not sure that cone beams are standard of care I would love them to be because they are so informational and diagnostic and helpful but  I just know that a lot of practitioners don't have comb beans yet so I think though the meat of your question is how have I found it helpful I mean in pretty much all of my retreatment and surgery cases I explain it to patients as a roadmap right your root canal failed for some reason and I need to figure out what that reason was is there a crack there is there a missed canal that two-dimensional x-ray is not showing me is there a missed root there that is just you know kind of hidden or is there a lateral canal there's so many things to keep in mind again with endodontics that the comb beams are super helpful the surgery options you know if I'm doing a premolar or a suck it molar or first molar I want to know where that inferior alveolar canal is and the mental foramen is so totally helpful I'm not gonna guess on a PA is what I think might be you know a radiolucency that is just a shadow or or an artifact that the comb beam has been super helpful especially all the extra funny funky cases that we ended on a sketch which is quite a few

Howard:  which CBC t-con beam do you like 4 molar endo being an endodontist versus someone else I can orthodontist who wants the full face and skull for ortho what do you like so you know

Dr. McIntyre: without being to advertise me I have a cave ochre comb beam I think that for most endodontists the focus though is on the resolution so it's that that smaller field of view I take most of mine are 6 by 4 and I do it as at an 85 micron resolution so um you know that gives me the most information of what I need it's not 100% diagnostic it doesn't detect all fractures or cracks within tee but it's super helpful and can suggest all of the possible reasons why a root canal might be failing or help determine me and the patient thinking about how to treatment plan a tooth that is failing or need surgery you know it will give me a better conversation to have with the  patient in terms of success when we're discussing 2 different treatment options I believe most orthodontists you know obviously have the full head I want to say that they use plan mecca maybe I'm really not sure to be honest 

Howard: so on the on the cave oh you use the cave Oh on their website they got the cave Oh Opie 3d with SAP I imagine that's for the Adonis I got the cable paint 3d they got the cave Opie 3d pro and then the ikat flex V series the first time so which of those four did you get the op3

Dr. McIntyre: I have the op3 so the earlier version which is that it was actually called a Gen Dex 

Howard: oh yeah because that's a by Danaher out of Washington DC and they just st. all these and so you have you have the old the original cable Opie 3d and then the same with

Dr. McIntyre: the last version before cable rebranded so so a very recent it's only two years old but yes it's already old yeah and 

Howard: yeah that is amazing and then they have the ikat flux and that is that it's very popular among a lot of practitioners a lot of dentists a lot of general dentists restorative dentists yeah sue and 

Dr. McIntyre: cable also makes the Nomad which is super helpful so does so then Danaher or Kiba owns I can't yeah do you know how long have they owned I can't you know that or I don't know but I know that when I call my rep which is pretty often they'd he has the option for the Nomad and ikat so  I want to say all this happened quite recently but I mean I'm not sure I don't I'm not on the cuff of the market in terms of CBC T

Howard: so  what would you say the top three reasons are that you like a CB CD is that mostly just fine making sure you're not missing a canal I mean isn't that the number one cause a root canal failure you just miss an entire canal 

Dr. McIntyre: yes so it's Anatomy because the general dentist usually has obviously gone in there before me the root canal has failed for whatever reason and I need to figure it out and usually there's a missed obviously in what I seem usually it's a missed mb2

Howard: in which did I purchased up her first molars maxillary molars yeah so what percent practice what you say is retreat of mb2 zon maxillary first molars that's pretty specific

Dr. McIntyre: I would probably say maybe 10 to 20 percent but I'm not fully prepared to answer that question but probably 10 to 20 percent 

Howard:  so kids there you have it I mean you don't want to hurry up and get a  on the wrong diagnosis of dreamliner I mean I if you want your doctor to do anything well it's the diagnosis and treatment line I'd rather them get to a on the treatment plan and a C on the treatment then get a on the treatment and it's the wrong I it's the wrong treatment and so it just missed Anatomy 

Dr. McIntyre: I mean that's well when you think about it you know those tooth studies are there for a reason 98% of maxillary first molars have that mb2 so if you're only finding three canals then you know chances are that you probably missed one you know when you think about the statistics again so say this is one more time so ninety-eight percent it's as high as 90 percent of maxillary first and second molars have an MB - 192 - yeah I mean it's  the high 90s so they're there and most of the time when by the time they get to me as an endodontist I will say that a lot of them are calcified they're not easy to get into I will trough with ultrasonics use my microscope you know I'm working hard on these they're not easy and they're hidden sometimes and they're not where you expect them I mean most of the time there are they are where I expect them but you know if you're not anticipating it you it's easy to miss 

Howard: yeah and you know that's right I always tell you orthodontists are afraid of like smiles drive club coming I said well you know they'll take over the whole industry because when you go to work you don't really do anything and you're just sitting on the computer and it's just a real easy lazy day right they go no I worked my butt off and at five o'clock I'm exhausted and I said that's why it's not as easy as it looks so I'm right there's a reason there's 4000 on us out there and  the thing that Gerald Dentists need to learn is uh you know pick the low-hanging fruit but you know I am you know I couldn't I can do a lot of things but I certainly don't want to be a jack-of-all-trades I mean it just doesn't make sense um there's also a new oh go back I want to hold your feet to the fire she's driving to work right now she says come on you just tell me what file system do you use I don't wanna I don't want to go I mean like if you go to Cologne Germany this last year there were 400 different implant systems she doesn't want to get 400 how many how many in atomic file systems do you think there are

Dr. McIntyre: alright so if I were to suggest four again to focus on the low-hanging fruit obvious cases the anteriors the bicuspids that general dentists want to try to do the straightforward ones the not the three canal premolar ones please don't do those but I would you know always I still even as amended honest I used my K files first I work everything up to a 15 and  on calcified canals that's not easy as for an endodontist even so I started 6 8 10 and then 15 K files and then what I loved when I was in residency and you know in the general dentist setting on for easier cases I loved profiles they also have this serious 29 DENTSPLY makes those they are just straightforward very safe files that just really are very resistant to fracture I can't say enough good things about them I used them for a decade there they're a great file system I would say I don't use them anymore because they just I just don't have those easy cases anymore so I need something more aggressive and then you know make sure you clean  you for anteriors you should be ending for the most part on a at least a 40 50 60 I mean 20 sized finishing on an anterior tooth is just not an anatomically correct you're trying to put you know a Bigfoot shoe on a child like it that you've got to match the filesystem to the canal the finishing file to the canal systems with so otherwise you're not cleaning like you said very basic clean clean clean that's what I do I'm a glorified cleaner 

Howard: so when she's talking about DENTSPLY that's now and got married with Serrano so now it's densify Sirona but tulsa dental was because my buddy Ben Johnson he started the thermofilm endodontic files he was an endodontist in Tulsa Oklahoma and  but I can say this because he's my buddy and he would he wouldn't care the counter-argument about these rotary files is too much to destruction there's now a lot of people are saying we're weakening the tooth 

Dr. McIntyre: okay so I'm glad you asked and clarified I hope I just didn't cut you off um so I have always been an oaf or taper girl you know I that's what I kind of refer to myself as often so you have the bigger file systems I'm just gonna name one off the top of my head which and I'm not bashing here but pro tapers conventionally have had the variable tapers and  they're preps look like this the profiles when you buy the oh four series because I'm an oaf or girl you're conserving the root structure at the top the cervical dentin that is so important for the restorative dentist and I've actually been saying this for a decade and a half that is super important to structure and I love that root canals can look so pretty with the variable tapers but there's no reason to take that much of the cervical the radicular dentin away we really should respect that tooth and respect the restorative options and I believe as long as you're cleaning well consider the smaller tapers consider the O four taper I finish on oh four s and I would like to say that I'm extremely successful I don't treat my work very often and you've got to consider the fact that when you remove excess tooth structure radicular  that's what leads to fracture strip purse weakening of the tooth structure and then obviously when there is a post that's added to everything that's just been taken away and the tooth gets very weak we've got a respect what we were born with what the patient was born with

Howard:  I am I have noticed so with dental tower the quarter million members since you know 99 and 67 thousand of download the app I can see what they're searching and one of the first correlations that we've noticed way back into the 90s is that the more money something costs the more time they're gonna spend search I mean who cares about trying a new bonding agent if it's you know 50 bucks but when you're gonna go buy a CBC T or a CAD cam or something you know something six fingers they're like I want to make sure this is right there's a new expensive sawn endo it's almost like hooking this tooth up to dollars right so so get so I want you to talk about it seventy thousand dollars worth of information because again if it was seventy dollars she wouldn't care she would just buy one and try it but for 70 grand she really wants to know if this is a good idea what are you what are your thoughts on this 

Dr. McIntyre:  I cannot speak much to it because I don't have one but I have seen the cases because I am always on Instagram and I follow a lot of my friends and in other instagramers who have this on endo and I must say I am super impressed with the way it cleans the way it respects the tooth structure the dentin the way it gets into lateral canals that even as an endodontist i might not be able to get into it looks like an amazing cleaning machine I don't have one my friends that have one eventually do love them there is quite a steep learning curve I mean generally ascended honest in particular because we're so unique is what I call this we are creatures of habit we you know any change kind of unruffled all our bark feathers so there is quite a learning curve to it but I also know that it will supposedly reduce the post-op sensitivity that a lot of patients have and it really allows a lot of the retreatment to be done in one visit I do Myra treatments in two visits so it obviously is a very positive thing I'm just not at the point where I can afford one quite yet so 

Howard: and what she just said to me is um you know I've been doing this 32 years there's a distinct difference between high-priced bleeding-edge and we're still not sure versus leading-edge them the early adopters start buying it and so many times in my early five years on a school I tried something brand new and end up having to they all failed and so now when you're an old dog like me when we see this new exciting stuff we are so excited that all these young whippersnappers are gonna go try it all and we'll just sit back and smoke a cigar and just watch and then two or three years later the price comes down and we determine if it's a good buy or a bad buy but it has to be bleeding edge versus leading edge because you haven't bought one in your endodontist in big city boston

Dr. McIntyre: well the price of it actually has gone up from what I understand about ten thousand dollars over since it was originally released on you know now being a decade and a half out I have also seen things come out and fail and yes the literature there is some literature on the success of son endo but it's not independent research so I completely respect what you're saying it will see time will tell right yeah baby 

Howard: but it's exciting to you but not enough you go whip out your checkbook and pay seventy thousand dollars yet you're not is that a fair assessment I'm well I also have a smaller practice so yeah so yeah I'm just not there yet where I can introduce that into my practice and so it's so bizarre when you're listening to dentist talk about root canals I mean that the first question comes up is what are you operated with and I'm always there and thinking who cares I mean my endodontic instructor you say it's nice if you find all the canals and get them all cleaned up you could write that one with bird doo-doo as long as your audit later first why do dentists always talk like they'll come up to me and they'll say well what do you think of thermofilm actu ben jonson it's like what is Therma they'll have to do with the root canal did you find all the canals and get it all cleaned out what is this obsession with observation 

Dr. McIntyre: you know I don't know but it's still endodontists obsession we you know warm vertical hybrid cold lateral a little bit of all of the above you know now there's all these bio ceramic materials and I mean everything it's just always exciting we're always I guess trying to challenge ourselves as a profession to do better I don't tend to obsess too much about what I fill with I have changed my sealer in a decade and a half but again I want to wait for things to prove themselves to me to be successful .

Howard:  did you switch from grossman cement to some new bio ceramic thing?

Dr. McIntyre: I did I did so I had started and used Grossman's Roth if you will for many many years and then I used H+ which I really loved because I could mix it however I wanted to stay with Roth but a little different and then yeah I just started using the bio ceramics dealers which you know are very user friendly antibacterial I want to say osteogenic but the words not coming to me you know it's just again a great material from what I can read in the literature so I have moved on to that and I I'm excited with how everything looks I guess is how we grade ourselves in terms of endodontics 

Howard: speaking of looks a lot of you know like you say dentists I mean you go out drinking and watching a ballgame and you know endo comes up is you know what were you Audrey with um and some of them are so upsets the observation like some of them we call them apical barbarians they  want to get all the way the bottom with a puff of sealer at the end and then you got these pulp lovers you want to stop a half millimeter short make it look old are you an apical barbarian or you a pulp lover

Dr. McIntyre: so I was trained at North Carolina so we were taught there dr. Martin trope dr. oz gear Sigurdsson we're both there while I was there so we were taught to not violate that apical foramen at all and that you know a half a millimeter shorter was better so as to not so we were truly taught not to puff we were talking about nothing love are we talking cigarettes or root canals so we were taught that you know the puff is a violation of that apex which is not supposed to be everything beyond the root canal the apex of the tooth is not our territory we're supposed to clean from within so decreased bacterial load from within and do everything in that contained system and to not what did you call it a pickle burger not you know not violate that that closure that restriction he ism I tend not to puff on sometimes in lucency I will try now but I'm a decade and a half and your we're not supposed to tell anyone about that I'm also in Boston, Boston is a puffy kind of place so here the residency programs you know encourage puffs shoulder was here you know it's all about the puffs here so sometimes I know that my referring dentists you know like to see the puffs but I generally was taught not to 

Howard: Martin is a heck of a guy he's uh he was on the show episode 305 he's made some endodontics ce course on that back to these kids who just got out of dental kindergarten school because seriously when you look at the data and send me an email Howard at dental town calm and tell me how old you are and what country you're from or the comments in YouTube but a lot of them they have a hard time talking about root canals to patients I mean the most complicated skill you're ever gonna have my wife is  talking to other sapiens on the surface and I remembered the endodontists a few years ago but I thought it was laughable they wanted to stop using root canal and using a endonek therapy and then the inclusion people wanted to stop using TMJ and use TM d and say hey why don't you just all speak Greek I mean I mean I mean if the humans all call it TMJ and I'm treating humans I'm not a veterinary dentist if you come in and say your TMJ hurts I gotta talk to em J they talk about root canals and it's not a puzzle no one wants a root canal so so talk to these little kids about how do you talk about scary stuff like root canals and you know

Dr. McIntyre: I feel like this is so important for the restorative dentists who then refer because when you talk of that proper conversation with the patient the patient can get really upset and of course no one wants to hear that they need won't quote the root a root canal because apparently those words are so terrifying but little plug here modern-day root canal therapy or treatment is not scary and it should not be painful but restorative dentists that are replacing the imodium algum that see the pulp horns shrinking away from their restoration you should have that conversation hey if we're gonna change this restoration hey patient um you know Miss Brown if we're gonna get that phone done maybe you should have a consultation about needing a root canal before we place the crown before we change that restoration hey let's take a periapical film of this tooth before we change the restoration because it might be dead already all of those things if you just lay the proper foundation to the patient have that one does two-sentence conversation it's not a surprise when they need it when you tell them and it can avoid a lot of hard feelings that might result when eventually you you as a dentist have to say I think you need a root canal right because that's so much more surprising than the the precursors the little laying the foundation in terms of a conversation before hands and

Howard:  I and I want to also tell you one thing about how humans work is um if I tell you I'm gonna do a filling and then halfway through Italian I need a root canal I am a very bad guy if I tell you're gonna need a root canal and crown and then after I get all the decay removed it turns out I'm just gonna do an MOT composite now I'm Batman Superman so you owe and that you treatment plan you know I warranty everything five years and and so I've had associates for 32 years and a lot of them treatment plan and it does last a year they say well I tried my best well dude the person's gonna live 85 years are they supposed to come in here and drop a grand every year for 85 years because you have no idea what you're doing so you have to treatment plan aggressive enough to last five years hell in 85 years I mean I mean they still that's who's gonna need a lot of additional trim but it's gotta last five years and you got to diagnose aggressively enough so in my practice when someone says oh you know Judy you're just gonna need a filling today and then you do the FA and it's for 250 bucks or an MOT filling and then 30 minutes later your baby dental kindergarten school mentality says oh I changed my mind to a $2,500 root canal bill and crown then I say well guess what you're gonna do it all for the fee of a filling cuz that's why you told Judy she needed and she was only prepared for a filling and if you thought it might have needed a root canal a crown and you're a doctor you should have said that before so satisfaction equals perception of what is happening - what I expected so common algebra says you want to increase satisfaction you got to sit there and and deliver you know you what they are expecting and I'm always the zero because I'm one of those guys that hold that PA at arm's length and if I think it's gonna be a root canal - arm's length I treatment plan for a root canal and then I hope I'm wrong but you can't believe verse those steps 

Dr. McIntyre: that's right and again I really post a lot about those those Pope stones and the calcification and the pulp horns shrinking away when you see that on the bite wings you should take the PA when you see that the whole canal is calcifying I can't get down canals that are blocked so it's always better if you have canals that are calcifying and you're planning to do that crown there's a time and a place for a prophylactic endo because guess what I'm not going to be able to help if they're completely calcified and then they abscess and let's remember usually a majority of crowned teeth will ultimately at some point during that tooth lifetime need a root canal what present I mean the literature in school told me 80% so that's four out of every five crowns needing a root canals at some point in their lifetime now if you think about all the patients out there with crowns obviously you think that can't be true right that just seems so low I I submit teak to most people let's take the PAS I'm pretty sure there's a lot of dead teeth out there that that can surely fill up my schedule the calcification process is a process of a live tooth in response to injury if you see calcified canals that means that tooth is not healthy that tooth probably needed that root now as soon as you put in that restoration as soon as you place that crown now we both know though a lot of times a patient can remain asymptomatic but they might still need a root canal good for them but that doesn't mean that they don't need a root canal it means that there they've just been luck lucky to be asymptomatic right 

Howard: I am going to throw you off a cliff right now all right you have your parachute on and a helmet so again I don't ever want to waste anyone's time talking about everything everybody knows but there is a serious and what you just said about you know the  infection coming in the tooth and the pulp is trying to save itself by laying down dentinal to structure and receding from that pulp so there's pediatric dentists saying you don't need a pulp on a council crown it's doing a temple just use silver dying diamond fluoride and see them every six months and paint this stuff on and you don't need to the only reason you're taking them to the operatory and putting them sleep and doing six pulpotomy and chrome still crowns is because you're gonna make a gazillion dollars but you have this anesthesia risk you have this anesthesia risk I'm doing with the young pediatric dentist the thing they hate the most is when a two-year-old doesn't wake up in the o.r because she was put to sleep and they're and they're looking at that case you're saying first of all I would have not even done the whole thing I would have just delayed  all the silver diamond sure and it's a very emotional argument 

Dr. McIntyre: so you know I am familiar with SDF and I've actually placed it on my children's grooves and pits and  incipient decay I don't know and again I'm not a pediatric dentist I don't know that really for the gross caries I know from what I understand the gross bombed-out pediatric cases that you might be referring to I think it will halt and terminate the active curious process but that doesn't necessarily mean that a root canal can be avoided if that if that makes sense and I don't feel like really fell off a cliff there Western 

Howard: well you're if you are entered into this debate you're gonna wish you to wish you never were entered that debate because 

Dr. McIntyre: it's a very very we we need films like because we're talking theoretical like you know we need to make sure that we're referring to the same cases not primary teeth where I'm not talking about primary teeth I'm talking about the first and second molars of children with moderate small decayed not big decay here because the big decay ultimately without an opening pecs will need a root canal not just STF 

Howard: um so do you think just give me your thoughts on summer diamonds Laurie I mean do you think this is

Dr. McIntyre: I think it's great so far so far great I would love to see probably more literature from what you're saying about the bombed-out teeth with SDF whether they will ultimately avoid root canal therapy later in life 

Howard: and the other thing about this whole issue though the whole issue the reason it's so prominent again when I'm hearing these people talking now and remember they're drinking so they're under the influence and but it's they just cannot stand this problem with pediatric anesthesiology and air I mean you're talking about board-certified pediatric dentists with board-certified anesthesiologist and every few months on social media some kid didn't make it out of that room and then and then what you said earlier in the beginning is that again if you treat the anxiety and you start talking to these kids I mean you're you're you're almost always going to base if the what do you say six and over or seven are over 

Dr. McIntyre: generally my rule is seven and over I had a great six-year-old but for whatever reason she  worked but um I've even worked on a five year old without nitrous um but again you have that they have to just you have to feel it you have to feel the connection there has to be that consultation but but yeah generally seven year olds and over I don't need nitrous

Howard:  so again framing this pediatric decay a lot of people use a lot of silver diamine fluoride to get a four year old to age seven absolutely and you're not treating the anxiety by putting I mean like Michael Jackson he  had issues and he was treating it with propofol and it didn't treat the issue and then he had a drug interaction problem and now he's gone and maybe he should have talked to a doctor about is there any way to sleep without Pro final and me is there any way we can treat this three-year-old without IV sedation and intubating them and maybe we can delay decay with silver diamine fluoride until you're old enough to treat their mind and so I want to tell you one of my pet peeves with my homies when they use endodontists they're so it just really actually helped they say oh you do the root canal but I'm gonna do the buildup in the crown well you're fighting billions of bacteria you just found all the canals you clean them all out you just operated it and now you're gonna have some I mean isn't that the most perfect biological time to do the best buildup you can and we're not gonna wait two weeks so that you can build Delta Dental I mean I just wish endodontists would just say it's not even an option we're doing the buildup because we're not insane 

Dr. McIntyre: I mean I think I just need to get that little blip and just put it on my webpage you know I mean I would love to I don't know that I would keep any of my referring dentist though but the referring dentist that I have are wonderful I will generally when I am concerned about potential contamination a lot of endodontist that truly are concerned also will lay a whole floor composite over their gutta-percha that is a newer trend that you know is  a great in terms of the movement in the right direction I worked in a general dentist office for almost a decade I would do the core or I would send the patient under the rubber dam down to her chair and she would do the core but still under the rubber Dam and again it's just like you said almost everyone should think of this light bulb it's it's decreases chair time decreases staff time decreases patient time it's too obvious why aren't we doing it 

Howard: you know they come out of school you know their mom made them and your mom's your mom I just had dinner and my mom last night and she didn't understand my joke I tricked her I had her stand on the stairs onto the picture of me my mom the stairs and I posted this is my biological mother but today technically she's my stepmother because she was standing on a step of a stairway and I my mom said that was the stupidest joke but when they come out of dental kindergarten school they go back to work with their mom who's a dentist and she just one steps every root canal she does and you don't want to argue with your mom and that's one of the things they're stressed about doing dentistry different than your mom you're working for your mom in the family business that you've had for three decades see one steps everything and sometimes they're like so when do you one step when do you two stop and if you did a hundred molars what feet to the fire how many would be one step and how many would be two stepped 

Dr. McIntyre: you know this is gonna be the probably the most embarrassing answer to your question that you might have ever had but um I - step probably 90 to 95 percent of my cases just because what I am getting is either necrotic obsessed or calcified and I just can't clean to my level of standards in one visit so I'm putting a lot of medication in I'm asking patients for their time and coming back and I don't two-step much I want to say probably in this past year I might have one stepped three cases

Howard:  wow that is so profound so obviously she's an endodontist so she's getting more difficult cases than your average routine but bread-and-butter toothaches but cleaning a champion and that's another trend so when we switch from endodontics to the business of endodontics the number one complaint I'm hearing from all these DSOs is that 10 20 years of this dsos they're endodontists are actually doing less root canals per day and spending more time by like some of these DSO say 20 30 years ago our average and Adonis completed for root canals a day and they booked an hour for each one and now 20 years later they're doing 3 a day and they're booking an hour and a half for each it's true it's true it's true as you switch from an American Chevy Chrysler Ford to a German Mercedes Benz it's not a game of volume and they take longer 

Dr. McIntyre: they take longer the reimbursement code for the challenges or whatever are generally not covered I mean we are working harder and definitely not smarter it's just not the good old days of Dentistry anymore I work hard every day 

Howard: ok again I'm trying to focus this down because the people on podcast they're all 30 and under if you're 30 you know a 30 and a half send me an email at dental town Howard at downtown comp but another big question they always have at this stage of their career right when they get out of school is the apex locator says I'm there and the x-ray it looks short yep yeah you know this is one of my first papers actually was on apex locator 

Dr. McIntyre: so I understand apex locators a lot but should be honest  I use an apex locator almost every single time and I can understand why there's faulty readings to be honest I feel when I'm at the apex because I've been doing this for a long time right when the tooth is alive like has live tissue in it or wet too wet or if there's an amalgam or there's a crown metal it's not gonna read correctly so that's a lot of cases just take the film the apex locator is there as an adjunct it's not the panacea so again I think you spoke to it like we just want a guarantee and the  easy way out but what we do is not necessarily easy so well I hope these papers I love your papers in fact if you go to dental town you go to endo you should start a thread because you can upload the PDF paper on to dental town just like if you have a YouTube video you can yeah you can do that because I'm and I notice I'm you're you do a lot of these papers with my buddy a Marten Trope but it seems like you and William ban our buddies to you guys do a lot of stuff together is that is that one of your endo buddies um tell me the name again William Van you 

Dr. McIntyre: oh well man sorry bill van bill van and I are tight oh you call him bill van okay yeah so I mean so tell us about house really yeah yeah we have a love for pets together we love drama together we've published a lot of things together  he's a great guy he's a great guy very knowledgeable 

Howard: um so um I can't believe we went over an hour and I love talking to you and I could talk to you for 40 days and 40 nights but I won't tell you another thing another issue about the dental kindergarden schools is they say they say Judy I graduated with $287,000 student loans I don't have the money to join the Massachusetts Dental Society and the easiest thousand dollars I'm going to save is I'm not gonna begin involved with the organized dentistry and you're really involved with organized dentistry I mean there's mass use now site so what would you say to that 25 year old girl says I know how to save a thousand bucks I'm not gonna join the Dental Society 

Dr. McIntyre: you know it's not for everyone but there's a lot of perks to organized dentistry there's a lot of behind this that not every dentist even the participating dentists in the dental society realized you get the discounts on insurance you get the peer review you get the journal you get some travel discounts you get a lot of the office resources from that the ADA might have or that the local Dental Society might offer there's a lot of camaraderie it is a hefty chunk to pay but I feel that particularly with what we're faced in modern day dentistry managed care and the reductions and reimbursements organized dentistry for me has got to be our saving grace because you know I hate to be a Debbie Downer to the kindergarteners but it's just not the good old days of Dentistry anymore and I hope and pray that organized dentistry will be the ones that continue to fight for us in terms of our profession and our future because without it we're going to be the minority and the DSOs will be the majority

Howard:  yeah and I'll tell you I'm it's it's I know when you're a young kid you think everything's what it should it could in la-la land but the bottom line is politics  is power and money and if you don't have a seat at that table it's not gonna go well in your favor and my only complain about all the DOS IDs I've been a member since I dental school is that they don't market what they're doing enough I tell them all they need to have weekly newsletters about all I mean if you knew what was going on at the Arizona assembly just dental related it's nonstop and right and who do you thinks gonna fight for you the DSOs the Delta Dental did your patients I mean when they talk about does they want health care free what does that even mean are they gonna arrest you and graduating from dental school and chain you up in a government office and have you lived there or do free stuff and they go oh we don't worry that well then how is it free oh well we want to raise your taxes and if you don't pay them and then look at the taxes government how much how much tax oil I don't know but pay me now and if you have the wrong I'm out you're gonna go to jail it's like what and then the people want to know why they have so much yeah so so I mean you have to be at and also the other thing I've noticed that the most effective state dental societies is they have one guy in there who's just a politician legislator and then another guy the inside man is running the nuts and bolts of the organization but my god is just all politics and you need to win there and then what I think the most funny is these people that are against the Essos all those bigwigs I mean if you own a hundred or five hundred or thousand officers you've been on my show they tell you which states they're avoiding because of their dental societies now I'm like hey other forty dental societies did you just hear what he said so  I mean I mean go to your Dental Society and make me a Venn diagram of DSOs that stay out of which states and why and then be more like that I mean because I am you know these DSO guys they're my buddies I mean a lot of them are just amazing good dentists but I have a serious problem I had four kids and I'm glad I never killed them because now they've maybe five grandkids which is you know that's  the only purpose of a child is making a good job and when I pass on I want them to go to a dental office that's owned by a dentist not an MBA from Arizona State University who's publicly traded on Wall Street I want a dentist and every company that makes a car the CEO is actually a mechanical engineer  and the fact that Boeing makes these no one's even talking about the real case for this this Boeing problem Boeing management is downtown Chicago and their planes are made in Seattle and Wichita Kansas that's the whole problem you don't have MBA’s in Chicago making airplanes from factories thousands of miles away they just don't get it the guy that's a CEO of Boeing if he was an aeronautical engineer and a pilot this wouldn't even be an issue so the Boeing deal dental insurance companies they're not dentists right so but I'll get on a soapbox and I don't want that to happen no I love this so much because it's the things they don't want to talk about it's icon you know it's like um I had dinner with my mom yesterday and my five sisters my brother and when I sat down the table I got everybody said hi say hey let's only talk about religion and politics all through dinner and everybody started laughing and of course we didn't talk about those two things because they're not pleasant but again you're gonna pass on one day and I want my grandchildren going to a dental office that's owned by a dentist I want him to write in an airplane where the boss is actually a pilot with an aeronautical engineering degree and I want them to drive a safe car because the CEO wasn't actually an engineer just imagine how simple all this stuff found man we went way over time but is there any question that I should have asked that wasn't smart enough to 

Dr. McIntyre: I just think maybe just encouraging more of the kindergarteners as you call them the  young dentists to take the PAS before their cementing the crowns to really challenge the amount of tooth structure that is left and to lay the foundation for that conversation that this tooth might need a root canal when the restorations are within two millimeters of the radiographic pulps on you you've got to inform the patients because otherwise the the patients won't handle it well when they get surprised later on or abscess unexpectedly so it's all about informing and forming and forming just like you said be their superhero rather than what they perceive to be their the enemy that what that did not tell them about what might be coming and 

Howard: last question you know have to answer how do you start out in heaven in Los Angeles California with a beach and palm trees and make a decision don't remind and my busted I mean you went to Harvard what do they tell you at Harvard why do they tell you go live in the frozen Cambridge area 

Dr. McIntyre: well as you know the California Dental environment is not the best so I can't complain too much I do miss the weather there I miss my family but it was a very beautiful love story and that's why I call Boston home now 

Howard: and go to her website it's Hopkins Hopkins and Oh happened oh it's the shorter version is hop endo okay hop endo oh so that's a website if I go to hop endo www.hopndo.com works too okay let me I did not know that I'm glad I said some hop endo okay um but go to her website just to read her procedures or papers I really wish you would started throwing on tunnel town Judy and say Howard told me to upload these videos cuz I thoroughly enjoyed reading all that with Sam middle stet about it so we're working on it we're working on it yeah just amazing work but I'm so but seriously yeah thank you for publishing the CEO on auto transplantation that was awesome thank you you know dedicating gently just tell whatever that was um that was what was the day of that that was um last summer by dr. Judy McIntyre I tweeted that out this morning and push that out again before you came on the show but seriously uh thank you for everything you've done for dentistry thank you for coming on the show you got to just go to dental town and take her online C course category under surgery oral surgery transplanting molars and it's the course everyone's given it a five star review it's an amazing course thank you for I'll come back any time and chat with you well hey if you ever something if you ever have something you want to talk about you know my email hard a dental town come on I'd love to have you back awesome see on Instagram okay and what's your Instagram key dr g dr judy endo dr. Judy and I just remember Judge Judy dr. Judy endo but uh all right I'll see you on Instagram have a great day 

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