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Howard:
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I am humbled today. It is just beyond a huge honor to be podcast interviewing the legend in endodontics, Martin Trope. You got out of school in '76. I got out of school in '87. You were a legend all through my dental school. I mean, you were just ... You're the cat's meow. I want to read your bio just in case there is one dentist living under a rock who doesn't know you.
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Dr. Martin Trope was born in Johannesburg, South Africa, where he received his BDS degree in dentistry in 1976. From '76 to '80, he practiced general dentistry and endodontics. In 1980, he moved to Philadelphia to specialize in endodontics at the University of Pennsylvania. After graduating as an endodontist, he continued at the University of Pennsylvania as a faculty member until 1989, when he became Chair of Endodontology at Temple University School of Dentistry.
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In '93, he accepted the JB Freeland Professorship in the Department Endodontics at the University of North Carolina in Chapel Hill School of Dentistry. Named in honor of one of the founding fathers of endodontics, the Freeland Professorship recognizes significant contributions to [inaudible 00:01:16]. That is just a huge wow, wow, wow.
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Dr. Trope is currently Clinical Professor, Department of Endodontics School of Dental Medicine, University of Pennsylvania, and in private practice in Philadelphia. Dr. Trope is actively involved in the development, design and promotion of new technological advances of endodontics. Presently he acts as Clinical Director for Brasseler USA. Dr. Trope has created Next Level Endodontics continuing dental education program, combining his extensive background of the theoretical world of academics with his considerable experience in private practice.
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Again, I can't tell you how humbled I am that you decided to spend an hour with your buddy Howard. We were saying we lectured together in Brisbane, Australia. Would you say it was a decade ago, 15 years ago?
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Martin:
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15 years ago. Yeah.
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Howard:
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Oh man, where does the time go? Did I have hair back then?
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Martin:
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No no, just before. You looked the same.
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Howard:
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I looked the ...
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Martin:
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I had hair back then.
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Howard:
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How are you doing?
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Martin:
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Doing great. We're very, very excited actually, to be putting a cloud online curriculum on Dentaltown. This is my new project, and what's going to keep me busy the next 5, 10 years. That's to basically have an endodontic, and hopefully in the future, dental curriculum online similar to what you would get in a dental school but of course with all the advantages of the online ability to go world wide and to come back to the lectures, et cetera.
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Howard:
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I think the internet is so cool. When the thing came out in '98, I dove right on it with Dentaltown. I personally would come home at night, and I'd be stressed out about something and everybody that I talked to, Dad and Mom, spouse, everything, they would just say they would say a prayer. They would burn a candle. My dad would say "Well, tomorrow morning I'll offer my communion to mass." It was like, I just wanted to talk to a dentist!
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Then in 2004, what got me the most excited is ... I hope no one finds this offensive, but you could get a root canal done in Phoenix, Arizona. Then, you could drive a hundred miles south of Phoenix to New Galas, Arizona and get a root canal. It was just a standard American root canal; but you drove across an invisible line into Mexico. You'd see these root canals coming up, and you're just like, "My God, what the hell ... What is going on?" We always forget that there is 2 million dentists around the world, and only about 500,000 have enough education training to have a good shot at it. A million five are ... The training is not quite up to speed at temple.
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With the internet and YouTube, and Dentaltown, and your online curriculum, I think the internet is going to close the difference between how a million 500,000 dentists practice, and 500,000 in rich countries like Denmark, and Sweden, and Australia, and Canada, and the United States. It's so excited to go to Africa and have these dentists come up to me ... You're from Johannesburg, born in Johannesburg ... to have dentists come up to you in Tanzania and say, "Oh my god, my family put me to the best dental school in Ethiopia, and I thought I knew everything, and then I found Dentaltown, and it's like, thank you so much. I mean I feel like my education didn't even start until I found these courses on Dentaltown." It's just so romantic and cool that the internet is going to make the variance between the best and the not so good, it's going to really close the gap and we're going to see it in our lifetime, in the next 10 years.
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There was a dentist I watched in Tanzania, who was just amazing. I mean, right there in Tanzania, hardly any facilities. He had basically a lawn chair for a patient chair and he absolutely knew what he was doing. He accredited it all to YouTube, podcasts on iTunes like we're doing now, and Dentaltown. Thank you so much for all that you have done for dentistry; but to have the vision to start realizing it needs to be digitized and put in the cloud so that all 2 million dentists, if they have the motivation and the determination to go for it, they can get the information and get it done on behalf of their patients.
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Martin:
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Yeah, well I certainly believe it's the future. I want to be at the cutting edge. We're also going to pair those with hands-on courses at different sites like anywhere in Africa, or Asia, South America, and of course, in the US. You'll be able to take the basic courses, if you want, on the cloud, and then if you need a hands-on instruction, we're hoping in the very near future to pair those to different territories. Hopefully we'll have a dental school outside of ... a dental institution, if you will, and that's the hope.
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Howard:
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Martin, how many years have you been doing root canals, and how many you think you've done?
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Martin:
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Well, I have been in academia for many, many years. I wouldn't say I'm the same as an average endodontist clinician. I graduated in 1982 as an endodontist, '76 as a dentist. It's almost, how many years? 30-something years as an endodontist and I suppose I've done 30,000, maybe?
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Howard:
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You've done probably 30,000 root canals. When anybody emails me about these podcasts, I swear, at least 98% of them are under 30 years old. Here, you've done it for decades, you've done 30,000. You're talking to thousands of dentists right now that are probably 30 and under, they've only been doing these a couple years. What are the basic requirements for a successful endodontic treatment?
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Martin:
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Well, very, very simply, I couldn't put it more simply. If there's no microbes, you have success in endodontics. We have a number of situations. We have situations where you have a vital tooth, irreversible inflammation where the patient's dying of pain, et cetera. That tooth is not infected, but it needs a root canal, right? Our job as a practitioner is to do the procedure without putting bacteria into the root canal. In other words, maintaining the aseptic environment.
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You take out the pulp, because your prediction is, it's going to become necrotic and infected. The patient's okay, and you haven't ... This is something that most dentists do not get to, but you as the dentist have not put microbes into the root canal system, you will have a successful case. I actually don't care how ugly the root canal looks like on the radiograph.
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The biggest challenge we have in endodontics is when the tooth is already infected. You have a lesion, with or without swelling or pain. Now, it's a major challenge to get rid of the microbes. We're aiming to sterilize the root canal system, we're getting closer and closer, but we're not nearly there yet. We basically talk about disinfection rather than sterilization.
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Now, having said that, this is all must be done so that there's something of the tooth left behind, because we have to acknowledge the easiest way to get rid of the microbes is to extract the tooth. This all has to be done leaving a very, very solid foundation which is basically the [dentin, or 00:09:19] tooth structure. This is our challenge. I could get rid of the microbes if I move 90% of the root, but we've got to remove the microbes and leave enough root so that tooth has a solid foundation for the rest of the patient's life. So, no microbes and leave enough structure so that the tooth doesn't fracture, or break, and you're home free.
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Howard:
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What percent of the time do you think ... and we'll just say the United States ... is the isolation so poorly during the root canal, that when the dentist in there getting the access, drilling into the bone, maybe they're drilling the access without the rubber dam on or whatever, or they have a rubber dam put on leaky or whatever. What percent of the time do you think we're actually introducing microbes into the tooth and setting us up for a lower success rate?
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Martin:
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90% of the time. If I'm talking about the general practitioner out there. Now, that doesn't mean that's definite failure, of course. As you said, it sets you up for a lower success rate. If I, by some miracle, do it, perfectly aseptic root canal, and I show you the x-ray. You say, "Oh my god, that's horrible!"
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I can still say to you, "This will be successful," because there's no microbes, right? We all see that in our practice, these cases that are 7 millimeters short, hardly anything in the root canal, but there's no disease. By some miracle, no bacteria got into that root canal on that particular case. However, even if you've got a good looking root canal, if you do it aseptically, you should get a 95, 98% success rate, but the success rate is probably 70, 80% due to the fact that number 1, people don't use a rubber dam.
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I blame the dental schools for that. They don't use an aseptic technique. I can't tell you how many people pass you the file holding the part of the file that goes into the root, thinking that they've got gloves on their hands that it's aseptic. It's not. If you're doing a simple experiment, touch the file, and put it in an incubation chamber and grow the bacteria. You'd be sick if you saw what grows off that file. This is really something that is not taught very well, and something that is ... I think there is a statistic that over 70, 75% of root canals in the United States are done without a rubber dam.
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Howard:
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7, what percent?
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Martin:
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75% in general practice are done without a rubber dam.
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Howard:
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Most dentists that tell you they've practiced on a rubber dam is because they tacked a rubber dam up on the ceiling above their operatory.
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Martin:
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Yeah, maybe. It's so easy and it should be a situation where we're old enough to maybe ... I graduated in '76, and when I used to go home after working, I used to evaluate how busy I was by saliva marks up my hands, without gloves. Today, if I think of putting my hands anywhere near a patient without gloves, I want to throw up. It should be the same about doing a procedure without a rubber dam, thinking of all those bacteria going in there. Once you do it, it takes 3 seconds, and it makes the procedure so much easier that I just ... It's one of those things, I just cannot understand why there's such resistance to doing it, and using it.
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Howard:
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A lot of these young kids, I mean I can give names, they come out of school and everything the endodontist taught them goes out the window because they're working for some old man who's 65, says "You know what? I just spread this paraformaldehyde paste down there, and that kills all the germs." What would you say to that kid? I mean, they hear this, and they believe it.
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Martin:
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Yeah.
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Howard:
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They say, "Well this is the real world."
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Martin:
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Yeah, no.
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Howard:
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"These guys are academia, and you just spread this paraformaldehyde, it will kill all the bugs."
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Martin:
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Yeah, well I always tell when I start off my lectures, if I've got time. I always say, "You know, the problem is that the dental school, we say 'put on a rubber dam' otherwise you won't get a signature." Basically the kid starts to think of a root canal as 6 signatures, and once you've got 6 of these procedures with the 6 signatures, "I'm out of this damn place," you know?
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Then, they're going to practice, and the old guy or gal puts his or her arm around them, and says "You know, forget all that BS you learned in dental school. I'll tell you how to do a denture in 1 visit, a root canal in 30 seconds," and all these things. Because they don't have that feeling that if bacteria get in the canal, this is the worst thing that could ever happen, they accept that. Of course, they're under tremendous stress to accept it because they're the employee, and they're being employed. It's a real, real problem that they should resist when they're told not to use a rubber dam.
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Howard:
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I think endodontic questions are interesting because young dentists always come up to you and ask, "What do you treat treat your canal with?" You always stop and say, "Who cares? I mean, a root canal is about first, you remove all the decay."
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Martin:
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Yeah.
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Howard:
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Then, the only thing the files are doing is probably not even going to remove, what, what would you say? 50% of all the infection would be filed out mechanically. I'd say about half?
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Martin:
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Doing a lot better now, but the traditional files were even less than 50%.
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Howard:
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All the filing is doing is so that you can get the irrigants down, like bleach, to disinfect the tooth.
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Martin:
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Yeah, yeah. Again, up until very recently. There are tremendous advances in endodontic technologies that are allowing us to claim and to do better, but generally the file is making space, disrupting the biofilm, and then allowing the irrigant to get in there to do the disinfection.
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Howard:
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Well, talk about that. What's the best way? What tips could you share to these listeners about how to disinfect a tooth to increase their chance of endodontic success?
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Martin:
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Endodontics is moving into a new era. The young people who are listening may know the name Schilder, and Schilder was a very famous for talking about 3 dimensional, ... which of course is a misnomer, because there's no such thing as 2 dimensions ... Filling the root canal in all it's dimensions, and what Schilder understood very, very early was that the root canal is not round. The root canal is a miniature of the root, and that puts us at tremendous disadvantage because our files are round.
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If you want to clean, physically, with a file, a root canal, you have to aim to the largest dimension, not the narrowest dimension. If you do that, you're really weakening the root tremendously because you're making a round shape in a non-round and very, very narrow, in certain points, root. Schilder had this obturation technique of warm gutta-percha, which in itself was ... It was brilliant in filling the 3rd dimension, or the dimension you can't clean. It has tremendous problems with shrinkage, et cetera, but we'll leave those aside.
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Not until very recently, have we been able to file and actually disrupt the wide part of the canal. We are now in endodontics, going into a 3D era, if you will, where every company is going to be fighting for the dentists' business by saying that their 3D file, which is basically a file that gets into the widest part of the canal, is better than the competition, et cetera. We're going into a completely different era.
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Now, that allows us to be more conservative with our filing because we only have to have enough space for the irrigant to get down there. Then, this 3 dimensional technology will allow you to disrupt the biofilm in the widest dimension, allowing you to keep the thinnest part of the root as strong, and as thick, as possible while at the same time, cleaning the widest part of the root. This is very, very exciting. We're at the very beginning.
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There was a file in the last year or 2 out of Israel, actually, the SAF file, which was the breakthrough file that showed us that this was possible. Company I work with, we have got the XP Finisher. Actually, I have a podcast on Dentaltown on the XP Finisher. There are other files that are coming out, and I'm sure in the very near future, every company will have a 3D file.
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Howard:
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Well, talk about it. You put up an amazing course on Dentaltown, 'Achieving the Goals of Endodontics and the Use of the XP ENDO 3D File Finisher,' 2015. To the listeners who did not see that course on Dentaltown, tell us about that course and why they should watch it, and what they're going to learn.
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Martin:
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Well, this is the new era. Basically what I showed in that podcast, and what is true is that we are able to be very conservative with our round filing. Our round filing, as I said before, only takes care of the minimal diameter, because the root is not round. You can't get to the maximal diameter because you'll run out of root in the minimal diameter. It allows you to be conservative in the minimal diameter, because the file can stretch out without changing the shape of the root.
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Basically, it's a very thin file which is not strong enough to change the shape of the root, but it's very flexible because based on the temperature of the body, it expands and contracts. When you put it into the canal, it can go in straight, but as soon as it gets to body temperature, it wants to get a hook shape. When you're spinning it, it will expand and contract based on the anatomy of the canal. In that way, it's able to get into the widest part, scrape away the surface, and biofilm, and everything that's causing disease, but not actually take away sound dentin, which you need for restoring the tooth, et cetera.
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Howard:
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That is just bizarre.
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Martin:
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Yeah.
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Howard:
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I mean, that is just so bizarre. It's not your standard nickel titanium file, then. Well, what is it?
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Martin:
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Well, that is nickel titanium, but it's not a file, per say. It's a scraper. It's analogous to a periodontal scaler. In perio, after years, and years, and years of trying, they know that with biofilm, which is plaque, which is present in a root canal internally as well, you can't really rely on disinfectants because the biofilm, by definition, is resistant to everything because the biofilm creates its own protective layer.
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The periodontists, still today, say you have to scale and root plane the root because you've got to disrupt the biofilm mechanically before the irrigants can go in and kill the bacteria. This is basically a scaler, which moves into the irregularities and just scrapes away the biofilm as a periodontal scaler would do. Then, the irrigant comes in by this instrument, agitating and making turbulence in the irrigation, pushing it all over the place, to then kill the bacteria that are exposed by this internal scaler, if you would.
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Howard:
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[Rella Christian 00:22:31] told me about a year ago that they're finding out now that the biofilm on plaque, there's actually fungus in there. There's actually candida albicans in there, and the fungus is helping making that protective biofilm. Is there actually fungi candida albicans inside the biofilm in endo?
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Martin:
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Yes, absolutely. Absolutely. We don't really know what it's role is. It has the same role in the internal biofilm, but we don't really know it's role in pathology, if you will; but it can't be good. These microbes are all potentially pathogenic, and can cause [apical periodontitis 00:23:13].
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Howard:
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The file you're talking about in your course, that XP ENDO 3D File Finisher, that's sold by Brasseler?
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Martin:
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Yeah, well it's not available in the US at the present time. It's available all over the world. There are just some issues in the US that have to be taken care of. It will be available in the next 2, 3 months.
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Howard:
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Is that patent stuff?
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Martin:
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Potential patent issue, which they're working on, yeah.
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Howard:
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Are you upset that you left South Africa and moved to a country that has 1 million attorneys?
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Martin:
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Well, I'm not upset I moved to the country, but I'm upset that the country has 1 million attorneys.
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Howard:
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Oh my god, it's just crazy. Okay, you're talking about this 3D file finisher. ... Is bleach the cat's meow on killing [this? 00:24:10] Is your XP ENDO 3 file finisher doing that in conjunction with bleach in the canal? Is that a big component of why you're using that file?
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Martin:
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Yeah. We haven't replaced bleach as our go-to irrigant. We should have. We should have found a better irrigant, but bleach always rises to the top, primarily because it dissolves tissue as well as kills bacteria; but probably because it's cheap.
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Howard:
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It's a dollar a gallon, right?
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Martin:
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Right, right. You know, to replace it with something else, you really have to prove tremendous superiority to justify an increased price and no one has been able to do that yet.
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Howard:
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Will you talk more about irrigants, because sometimes you'll be sitting at a table with dentists, and some of the dentists said ... I mean, I heard this conversation just a month ago where a dentist says, "Well, I'm trying to kill all the bugs, so first I do bleach, and then I do EDTA, and then I do the [chlorhexidine gluconate 00:25:16], and then I do hydrogen peroxide." The other dentists are like ...
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One dentist said, "Well, doesn't the [chlorhexidine gluconate 00:25:24] actually leave an oil residue?"
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Martin:
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No.
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Howard:
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What do you think of someone using 4 different irrigants as opposed to bleach? What do you use?
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Martin:
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Okay, I'll tell you what I do. Again, to me, a vital tooth and a tooth which is infected with [apical 00:25:44] periodontitis are 2 different animals. You talk about them, you treat them, you think about them completely differently. In a vital tooth, there are no microbes. This is a preventative disinfection protocol, number 1. Number 2 is, you want to get rid of the vital tissue which is going to be a substrate for future infection with coronal leakage, or things like that. I would use actually a higher strength bleach in a vital tooth, than in a necrotic infected tooth, which surprises a lot of people.
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If you really think about it, the strength of the bleach increases the ability of the bleach to dissolve the vital tissue. Any strength bleach kills bacteria very effectively, as long as the bacteria are [planktonic 00:26:37], in other words, loose in the canal. I use a half strength just because it's convenient. I dilute my bleach 1 and 1, and I do my entire procedure under bleach, sodium hypochlorite. Then, when I'm finished, I will use this XP instrument. If you don't have the XP instrument, if you are located in the US, you could use an ultrasonic endodontic tip, which agitates and moves the irrigant. Now, what you're left with is hopefully a minimal amount of organic tissue, but you still have a lot of smear layer from using the file, which is pushed up against the dentinal tubules.
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The next irrigant I use is sodium hypochlorite. I place my sodium hypochlorite to length, which means that I use a 30 gauge needle for irrigation. Very, very, very important. You cannot rely in the irrigant to go ahead of where you are, because it's a very narrow tube and air bubbles, what we call a vapor lock, develops at the tip of the root. If you want an irrigant to go to the full length of the root, you have to put your irrigating needle to the full length of the root. You use a side vent needle so you don't push it through the apex, and you've got to go to at least a 30 size because the narrowest irrigating needle is a size 30.
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Howard:
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Do they make the bleach in the anesthetic [carpules 00:28:29] so you can just use your 30 gauge syringe?
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Martin:
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No, no, no, no. You can buy 30 gauge irrigating needles that you add to any syringe.
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Howard:
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Wouldn't it be a lot easier just to buy packages of anesthetic in the same needle that already has the bleach in it? You can just plop that in there with the syringe?
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Martin:
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Then you're getting into cost issues again.
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Howard:
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I never understood the cost issue on a root canal because basically, you're getting a thousand bucks for it, and you're really going to nickel dime on gutta-percha and sealer. It's like when dentists said they're going to reuse their files.
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I'm like, how would you like to go to the doctor and have them sticking things inside your body, like a heart stent, and say "Yeah, we reuse it. We autoclaved it. It was in your grandpa for 5 years, and he died. We took it." I mean, come on! You're getting a thousand bucks and all you need is some rubber dams, some gutta-percha, sealer, and some files. I mean, how?
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Martin:
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You're not going to get any explanation from me. I've never understood it, and I never will understand it; but you will be amazed what people will do to save a couple of bucks. Then you go to Thailand, or somewhere in Asia, and they get a quarter of what you get, and they will not compromise on anything. I just don't understand the cost [inaudible 00:29:47], but it's the reality. It's the reality.
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Howard:
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I've always wondered ... I always wish I could have a box of anesthetic [carpules 00:29:55] just filled with bleach.
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Martin:
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Yeah, yeah.
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Howard:
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So you could just use your 30 gauge. Okay, my job is to ask questions that people don't understand. I know there's one kid out there saying, "What's the difference between a biofilm and a smear layer?"
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Martin:
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Just let me finish, just the irrigating.
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Howard:
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Okay.
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Martin:
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[crosstalk 00:30:12] finish that. Then, that is followed with EDTA, which is to get rid of the smear layer. The difference between the 2 is biofilm is a plaque of bacteria or microbes, because bacteria are candida, et cetera, yeast, and these are under the definition of microbes.
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Howard:
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And viruses.
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Martin:
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Which are in their own environment, eco-system, protected from the outside. Bleach doesn't work very well. Nothing works against them unless they're scraped out.
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Smear layer is a inorganic debris which is basically root structure, which is pushed into the dentinal tubules due to the filing. You cannot really work on a tooth without creating smear layer. You create smear layer by filing the root canal. You create smear layer by scaling and root planing. You create smear layer by burrowing the root. This is just debris that doesn't go up into your suction, that doesn't go up into the air, it is packed against the dentin. You need 2 different things to remove them. Sodium hypochlorite, bleach, kills bacteria and dissolves vital tissue. EDTA is a chelating agent which gets rid of calcium, or binds calcium, which is the major component of inorganic debris. Now, that's a vital tooth.
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With a non-vital tooth, I add chlorhexidine as my final rinse. Now, it's not the chlorhexidine you give your patients to rinse their mouths with [peridex 00:32:00] or one of those which are .12% chlorhexidine in alcohol. This is 2% chlorhexidine in water. That's your final rinse in an infected tooth. We are finished with the vital teeth, I'm now dealing with the infected teeth.
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Now, why do I add chlorhexidine? I add chlorhexidine because chlorhexidine is a very good medicament to move through the dentinal tubules. Sodium hypochlorite doesn't move through those dentinal tubules, EDTA doesn't move through it. Calcium hydroxide, which is an intracanal medication for infected teeth, will take weeks to get through the dentinal tubules. Chlorhexidine moves through very effectively.
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When you have an infection in the [apical 00:32:50] part, there are many bacteria which are deep inside the dentinal tubules, which the chlorhexidine is able to get to. I only use it for infected teeth, and also we use EDTA between sodium hypochlorite and the chlorhexidine because you mentioned that someone said it creates an oily precipitate. That's a combination of sodium hypochlorite and the chlorhexidine. If you wash it out with EDTA in between those two medicaments, you don't get that precipitate.
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Howard:
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You mean I'm going to have to go back and tell my buddy Tim that he was right?
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Martin:
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Unfortunately. You should have checked with me before the interview.
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Howard:
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What do you say to these dentists who, when they see a [inaudible 00:33:37], they want to take a really small 6, 8, file or 10 file and go out the apex of tooth, 2 or 3 millimeters to cure out that periapical lesion, thinking that that would bring in a blood supply, more white blood cells, and increase their success rate?
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Martin:
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Yeah, that's been categorically disproven as effective means. Basically, we still from a clinical perspective ... If you have a electron microscope, and looking at periapical lesion, you'll maybe see some microbes. From a clinical perspective, with bacteria or the microbes in the root canal are causing an inflammation in the periapical tissues. Inflammation is generally non-infected and inflammation has the potential to heal. You take away the microbes by treating the root canal, and only the root canal, and periapical inflammation, if the patient is reasonably healthy, will heal. It's as simple as that.
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Going into it can only ... If you go into a lesion, you're pushing microbes into the periapical tissues. You go into a lesion, you're just causing more inflammation. There's really no value to it, and I think that's been proven categorically.
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Howard:
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What percent of the time do you, when your solutions down there, do you put ultrasonic agitation inside the canal?
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Martin:
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Until the 3D file was available, and it's not available in the US, but even so, it's been available only for a very short amount of time. I would agitate with the ultrasonic at the end of each irrigation, so if I was talking about sodium hypochlorite, I would irrigate throughout the procedure. Then I'd fill the canal with sodium hypochlorite and use an ultrasonic file to agitate for 60 seconds. Then I'd place EDTA, agitate for another 10, 15 seconds. Chlorhexidine, not agitate as much because there's a little bit of controversy with agitation causes this precipitate, this oily precipitate, et cetera. Agitation is just an adjunct in order to move the irrigant and to cause turbulence in the irrigant.
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|
|
What we know also is laminar flow of irrigant is not as effective as a turbulent flow. Anything that can agitate and move, and force the irrigant against the wall is positive in terms of getting rid of microbes.
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Howard:
|
There is a reason to bang the patient's head up against the wall a couple times during a root canal, to agitate the ...
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Martin:
|
Yeah, and many of the patients [crosstalk/laughter 00:36:34].
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Howard:
|
Where could my dentist listeners in the United States buy this file online, overseas and get it UPS-ed or FedEx-ed to their office? Is that legal, or do they have to wait?
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Martin:
|
I don't know. I don't know. I probably shouldn't answer that, but if you go through XP Endo Online, you probably will get the information there that you need.
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|
Howard:
|
Does vital pulp therapy fall under the definition of endodontics?
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Martin:
|
Absolutely. There is no better root canal filling material than a vital pulp, because if you have a vital pulp, you do not have microbes and if you don't have microbes, you don't have periradicular disease. In fact, and after this podcast, I'm giving a lecture in New Jersey this evening, the expanding role of vital pulp therapy. Anything you can do, or the dentist can do, to maintain a vital, healthy pulp, is the best endodontic therapy that is available.
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Howard:
|
Okay, well these guys ... Dentaltown was going to use the internet so that no dentist ever has to practice solo again. You're sitting there in your office, you're all by yourself, you're removing the decay, and you've nicked the pulp. Talk these young dentists, what are they looking at? Or they say, "Nah, you got to do a root canal," or "No, we can manage this pulp exposure." Will you talk about that?
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Martin:
|
Yeah. I'm going to be dogmatic and emphatic about a asymptomatic case. Okay, because even though I think what I'm going to say is valid for a symptomatic case, I'm not ... The literature is not very clear on that. Let's assume the patient does not have symptoms of irreversible pulpitis. This is just a deep carious lesion, mild pain to cold that doesn't linger for hours, et cetera, et cetera. Removing the caries, and as you mentioned, you nick the pulp.
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Now, what we used to think about very recently was that the inflamed pulp of the caries was the thing that made the procedure generally unsuccessful. We now know it's the seal above the pulp that is the critical factor for success. We now have bioceramic materials which seal as well as anything in the literature, in dentistry. MTA was the first bioceramic material that came to the market and is very, very well researched, is a wonderful material. It's a bioceramic, expands slightly on setting, becomes rock hard, and then you can build on top of it.
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Howard:
|
What was the guy's name? He's out in Southern Cal? [Torridont? 00:39:47]
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Martin:
|
[inaudible 00:39:48].
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Howard:
|
[inaudible 00:39:49], is he a friend of yours?
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Martin:
|
Yeah. Well, he's a colleague.
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Howard:
|
It was Portland cement, I noticed it from his swimming pool, right? Wasn't that the inside came from a swimming pool to a tooth?
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Martin:
|
Basically it was from a ... When you have a leak in your shower, or your bathtub, the best sealer is Portland cement, which is the classical bioceramic. Now, MTA, in this pulp capping situation, is not ideal because it discolors. MTA is gray, even when they've tried to make it white. When the [inaudible 00:40:29] gets in with moisture, it discolors.
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|
Now there are new bioceramics. The best one is the one from Brasseler, which is the ready mixed bioceramic, which you place on the pulp, plus a [perimital 00:40:53] sound dentin. Then, build on top of that. There's been very, very good data showing that-
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Howard:
|
Is this a powdered liquid that [zinc oxide used 00:41:03] on?
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Martin:
|
It comes out in the consistency of [cavete 00:41:09], or [crosstalk 00:41:09].
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Howard:
|
Okay.
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Martin:
|
You place it on the pulp ... Actually, there are 3 mixtures. One, you could get the putty, or you could syringe in a little bit of liquid and then cover it with the putty, and then after it's set, you build on top of that. That will give you the seal necessary for a successful pulp cap. It's the seal that is the difference.
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Howard:
|
What about the size? What about if it's bleeding? Talk more about that pulp, what if you nick and then does it have to stop bleeding a certain amount of time, or? What would you do if you nick it? Try to play a scenario in their head more.
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Martin:
|
Basically the epinephrine in the anesthetic should take care of most of the bleeding. You can rinse it with the chlorhexidine, or with sodium hypochlorite. Some people rinse it for 5, 10 minutes. Actually, if it's bleeding very, very excessively, you should actually cut the pulp a little bit lower. You do that with a diamond [bur 00:42:13] at a very, very high speed, with a good irrigation, water irrigation, and you can just very, very easily cut down the pulp. Then that top layer, which is extremely inflamed, will bleed less. Generally, epinephrine in your anesthetic, plus rinsing for 5 minutes with sodium hypochlorite.
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|
The good thing about the bioceramic is that it loves moisture. The Portland cement, you take to your bathroom, they tell you 'add water, add water, add water.' The more water that you add, the better the seal. That's a great advantage. It's hydrophilic. As long as you can get reasonable moisture control, even if it's bleeding a little bit, the material will seal very, very well.
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Howard:
|
Basically, the point is that if you went in there, and the tooth was asymptomatic, and you went in there to do a filling and not a root canal, and you get an exposure. The best root canal is the pulp cap.
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Martin:
|
Yeah, I mean a successful pulp cap. If you do it correctly, one is ... A lot of people, when they get a pulp exposure, they think all of a sudden the professor that they haven't seen for 50 years is standing on their shoulder and going to shoot them in the head. They've become very conservative and they just close it very quickly, et cetera. You could come quite aggressive and get rid of every last bit of carious dentin, even if you get an exposure, doesn't really matter. Control the bleeding, and then cover it with the EndoSequence putty, and you wait for it to set. It takes 20 minutes. Some people will cover that with a active bonded material, and the moisture will set it from the inside. Then, you can restore the tooth.
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Howard:
|
You can buy that at Brasseler?
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Martin:
|
The putty, yes.
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Howard:
|
Yeah. What's it called?
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Martin:
|
It's called EndoSequence root repair putty, I think.
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Howard:
|
EndoSequence root canal putty. You get that from Brasseler.com?
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Martin:
|
Yeah.
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Howard:
|
Do they sell direct, or do they go through dealers?
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Martin:
|
Both, both. Or no, they are the dealer.
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Howard:
|
They sell direct.
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Martin:
|
Sell direct, yes.
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Howard:
|
Okay. Right on.
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Martin:
|
Sorry, when it comes to the commercial aspect, I'm not too strong.
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Howard:
|
I never know if I should ask this to an endodontist, and a pediatric dentist, but same thing with a pulpotomy? Do you like this?
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Martin:
|
Yeah, absolutely. Absolutely. The pulpotomy, I would be at this particular time, in a symptomatic tooth, the inflammation is generally pretty high. If you've got a pulpotomy, you're generally on sound, healthy-ish pulp. Or, in a patient who have got very wide, open canals and you don't want to do a root canal, the pulpotomy is exactly the same. You cut the pulp at the orifices, place the bioceramic material into the chamber, and you're home free.
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Howard:
|
This is a very weird question. I feel a little strange asking it, but who should these general dentists be listening to on a pulpotomy? Pediatric dentists, or endodontists? Is it the overlap between a pediatric dentist doing a pulpotomy, and a endodontist? Do endodontists think pulpotomies?
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Martin:
|
Well, I mean the endodontist who ... Yeah, I think so. Some endodontists feel that they're getting more money from root canal, and it's more sure, and rather do it and get it over with. It's a hard argument to argue with, except that if you believe that the best root canal is a vital pulp, and if it doesn't work, you can still do the root canal. It doesn't seem to be a very strong argument not to do it that way.
|
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Howard:
|
What are the most difficult technical challenges in performing successful endodontics?
|
|
Martin:
|
Basically what I had mentioned before. The most difficult technical part is that our instruments up until very recently, haven't met the shape of the canal. If you wanted to clean the canal, ideally or adequately, you were by definition, weakening the root. Of course, when we talk about success in endodontics, one aspect is periradicular health, but the other aspect is survivability. It's not good having periradicular health if the tooth is going to crack and fracture. That balance has always been a problem. We always have been compromising on cleaning in order not to over shape and weaken the tooth. These new files allow us to clean while maintaining root structure. In other words, the root canal and the root is becoming part of the restorative continuum. That is only good for the lifespan of the tooth.
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Howard:
|
I know every tooth is different, every patient is different. Do you think you can generally say that these .06 tapers are just a little bit too aggressive?
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Martin:
|
Absolutely. I never use an 06 tapered file more than a third the way into a root canal. I will never go to the apex, to the working length with an 06 taper in a reasonably lengthed tooth because by the time you get to 21 millimeters, et cetera, you've removed so much unnecessary dentin, it's just not acceptable today.
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Howard:
|
Well help me out, because again, my motto is that with Dentaltown, the internet, podcasts, no dentist should have to practice solo again. I'm telling you, Martin, when you go to the Cologne meeting in Germany, how many different file systems are there? I mean, how many would you guess? 100?
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|
[00:48:32]
Martin:
|
I don't know, 40, 50? You know what's very interesting is most of them come ... the comes from 2 factories in the world.
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Howard:
|
They're both in Tennessee.
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Martin:
|
Well, one's in Tennessee. Basically, it's the same instrument. It's the design of the instrument that makes a difference.
|
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Howard:
|
What I want you to do is ... There's so many file systems out there. You say you don't like the 06 taper all the way to working length. This dentist doesn't want to own 5 different systems. There's 20 different advertisements in every journal. Pick a file for him. How should he think about a file system? How big of a taper? You said you don't want a 06 taper going up more than a third of the root.
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Martin:
|
Yeah, so basically there's ... Our rule is very simple. Let's say you don't have the 3D file now. You don't have them now. The small canal, which is [mesial 00:49:27] of a lower molar, [buccal 00:49:28] of an upper molar, any root that has two canals is a small canal. We would like you to go to at least a 35 at the apex. That's for a number of reasons.
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|
|
That gets you to the biggest size available that is safe, but just as important, it allows you to get your irrigant right to the working length with your 30 gauge irrigation needle. Then, no more than an 04 taper, and for anything that has an excessive curve, or excessive length, because the longer the root, the more effect the taper has, right? If you've got a tooth that is 26 millimeters long, you've got to worry about the taper effect in the coronal aspect. If you've got a tooth that's very, very curved, you've got to worry about the taper effect.
|
|
|
If you're going to compromise, you will compromise on the taper. If it's a long tooth, or a very curved tooth, you'll go to a 35 02, not a 25 06. What a lot of people don't understand is if you started at 25, the 06 catches up quite quickly. If you stay at a 35, but go 02, it never catches up. That's one of the misconceptions, that if you have a curved canal, you must use a smaller tipped file but stay with the 06. No, you can stay with a bigger tip file, but compromise on the taper.
|
|
|
Now, if you have a central incisor, or a palatal of an upper molar, distal of a lower molar, you should go to about a 50 or even 55, but again, with an 04 taper.
|
|
Howard:
|
Right.
|
|
Martin:
|
Now, come to 3D files. The XP finisher, for example. This allows you to go to a 30, 35 maximum, because that's the minimum diameter. Then, the finisher takes care of the rest of it. That allows us to go even more conservative, and we can go definitely no more 04 taper, but I imagine in the future, we'll be going no more than an 02 taper. We'll be leaving very, very thick root. We'll be able to clean the third dimension, if you will.
|
|
|
Then, the fill comes in and we'll fill this again with a bioceramic sealer, which does not have to be very thin. The problem with the sealers of the past is they shrink and they wash out. You needed maximum gutta-percha, and minimum sealer. The bioceramic sealers are like Portland cement, they're stable, they don't wash out, and they expand slightly. Actually, you just use the gutta-percha in those cases as the hydrolic pump to move the cement into these third dimensions, if you will, and then one [cone 00:52:45].
|
|
Howard:
|
This is an extremely interesting discussion. What file system works best with your XP ENDO 3D file finisher?
|
|
Martin:
|
Well, in full disclosure, I promote the BioRace system, and the BT Race system.
|
|
Howard:
|
Say that again, the BioRace?
|
|
Martin:
|
BioRace system.
|
|
Howard:
|
Bio-R-A-C-E?
|
|
Martin:
|
Yeah, and the BT Race system. These are 2 different systems, that get you to the sizes I talked about.
|
|
Howard:
|
These are sold at Brasseler?
|
|
Martin:
|
Yeah.
|
|
Howard:
|
Did you ever meet Peter Brasseler, the founder, before he passed?
|
|
Martin:
|
No. I actually ... My main connection is with the people who make the files in Switzerland, FKG. Then, Brasseler sell FKG files in the US. I [don't like 00:53:42] the XP ENDO, this 3D file, I was part of the team that developed it in Switzerland, and then it's going to be sold by Brasseler.
|
|
Howard:
|
FKG, do you know what that stands for? Is that the 3 initial zone, like IKEA?
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|
Martin:
|
I'll have to find out, I forget.
|
|
Howard:
|
It's funny, I've looked up IKEA. I've looked it up 10 times. The first 2 letters are his first and last name, and then the last 2 letters are the city and state he grew up in, and I can't remember anything. Was that a company founded by an endodontist?
|
|
Martin:
|
No. This was a company that grew out of watch making, these micro-instruments. It's in the watch making district of Switzerland. All the technicians are ex-watchmakers, and they are absolutely fantastic in creating small devices and small instruments, if you will.
|
|
Howard:
|
I just found on my iPhone, that said the website's FKG.CH.
|
|
Martin:
|
Yeah, Switzerland. Yeah.
|
|
Howard:
|
So CH is the internet code for Switzerland?
|
|
Martin:
|
Yup.
|
|
Howard:
|
Very interesting. The sealer, you said a bioceramic. What sealers, what's out? The [H26 00:54:59], the Grossman cement, those are the ones that contract and wash out?
|
|
Martin:
|
Yeah. Every sealer ... The older sealers, Grossman cement washes out horribly. The zinc oxide [eugenol 00:55:10] cements wash out horribly. There are a number of ... AH plus, for example, washes out. It would be untruthful to say horribly, but it does shrink, and it does wash out. The bioceramic sealers do not wash out, and they actually expand a little bit. This is their major, major advantage and this allows us to change our philosophy completely so that the sealer is doing the work, and not the gutta-percha.
|
|
|
Before, we used to use maximal gutta-percha in order to keep the sealer thin in order to minimize wash out, et cetera, et cetera. Now, we don't have to worry about that. We just have to find a way to get the sealer into place, if you will. We use the gutta-percha point as our hydraulic mover. You only need one of those points, so the single cone technique that we all used to really never consider as endodontists, is now a technique but not because we only use one cone. We're just using the gutta-percha to move the sealer, and then use the gutta-percha if we need a post, or something like that.
|
|
Howard:
|
What's your favorite sealer?
|
|
Martin:
|
It's this EndoSequence sealer.
|
|
Howard:
|
The EndoSequence.
|
|
Martin:
|
Yeah.
|
|
Howard:
|
It's made by FKG.CH?
|
|
Martin:
|
No. The files are made by FKG.
|
|
Howard:
|
Okay, who makes the sealer?
|
|
Martin:
|
The sealer's made in Vancouver somewhere, and also sold in the US as EndoSequence BC Bioceramic sealer. It's sold all over the world as [TotalFill 00:56:58], which is the same product, TotalFill.
|
|
Howard:
|
Is that Vancouver, Washington, or Vancouver, Canada?
|
|
Martin:
|
Vancouver, Canada.
|
|
Howard:
|
Vancouver, Canada. Okay.
|
|
Martin:
|
Then, it's sold as iRoot, I think, in Asia. These are all the same product, and it's 3 different consistencies of the bioceramic material.
|
|
Howard:
|
You are a wealth of information. You've done your root canal. It's all done. How important is the final restoration. Does it need to be a crown? Will you talk about the importance of the final restoration?
|
|
Martin:
|
Yeah.
|
|
Howard:
|
In fact, let's say an endodontist did the root canal, and now it's back in your office.
|
|
Martin:
|
Yeah.
|
|
Howard:
|
How important is the final restoration?
|
|
Martin:
|
It's essential. It's absolutely essential. At least the access cavity should be sealed the same day as the root canal. If you're a general dentist, you must schedule enough time to do the root canal, and the at least access permanent seal. If I'm an endodontist today, I work only with general dentists that allow me to do a bonded resin in my access cavity. It has a major advantage. It stops leakage, if the patient doesn't go and get the coronal restoration immediately. The disadvantage, of course, if you need to do a post, and things like that, you have to drill it out rather than just taking a cotton out and having everything there. It's absolutely essential.
|
|
|
In terms of what restoration to place, ... First of all, the literature tells us that the vast majority of root canal teeth are successfully maintained in the mouth for 10 or more years. 97% of teeth are still in the mouth 10 years later. Of those that are lost, if you don't have a cuspal protection of the posterior teeth, you have a 6 times greater chance of losing those posterior teeth. Cuspal protection of posterior teeth is important. Very, very importantly, if you have a tooth that does not have a mesial or a distal contact, in other words it's a solo tooth in the jaw, that has a 12 times greater incidence of being lost.
|
|
|
When I say to my patients is ... Ideally we'd like to have your posterior teeth crowned or at least cuspally protected after we do the root canal, certainly it's not a tragedy if they can't do it because the vast majority of them still will survive. The only one I have a real discussion with is that tooth that is freestanding, and I really want a commitment from that patient that you're going to do something with that space after the root canal. Otherwise we have to discuss whether it's worth doing the root canal, because that's the tooth that really has a 12 times greater incidence of being lost if you don't create a contact, either with a partial denture or with a bridge, or with an implant, or whatever.
|
|
Howard:
|
Martin, you were talking about how an 06 file to length is just too much dentin removal. We're removing too much tooth structure. Couldn't you say the same about most posts being placed? I mean, I see so many posts where you just think "Was that even necessary?" They just reamed out, so much even more tooth structure. What percent of posts do you think were too aggressive, not necessary, removed too much tooth structure?
|
|
Martin:
|
Well, first of all, most posts are not necessary. That's point number 1.
|
|
Howard:
|
What percent of the posts do you see in modern day America that probably weren't even necessary? Give me a percent.
|
|
Martin:
|
The vast majority. I'll tell you why I say that.
|
|
Howard:
|
Give me a number. Give me a number though.
|
|
Martin:
|
80%.
|
|
Howard:
|
Okay.
|
|
Martin:
|
85%, and very interestingly, I find that if I have to redo a root canal, and take out the post in order to do a re-treatment, the crown never falls off.
|
|
Howard:
|
Right.
|
|
Martin:
|
The post is supposed to be there to maintain the crown, right? Otherwise, there's no reason for a post. But I can't tell you the last time I took out a post, and the patient came in the next week and said "Look, my crown came off." It almost never happens.
|
|
Howard:
|
It's like restorative dentistry, every advertisement lecture you see talks about wear rates. It's like, okay, I'm a dentist for 28 years, I never had a patient come in and said "Hey, that filling you did? It all wore down."
|
|
Martin:
|
Right, right.
|
|
Howard:
|
Every wants to talk about wear rate, and then they want to talk about adhesive strength. It's like okay, the fillings aren't falling out! Those aren't my issues.
|
|
Martin:
|
Right, right. The posts, first of all, they're not necessary in the first place. Secondly, I agree with you totally. They're too big, and when you do get a fracture due to a post, it is at the base of the post, at that fulcrum where the post is moving. It should be with the shape of the post, the shape of the canal, and again, with bonding and fiber posts, and things like that, you probably can make it very, very conservative.
|
|
Howard:
|
I agree. I agree, agree. I want you to ... We're in overtime, we're past an hour; but I just got to ask you one last question because I get this asked so many times. It's seen on Dentaltown all the time. Young dentists, they've only been out of school 2 or 3 years. Say the patient's our age, and they see a molar and it had a big MOD amalgam, by the time they take out the amalgam, there's hardly any tooth left. They don't know ... Martin, should I have done the root canal, build them a crown, or should I extracted it and done an implant and a crown? How does your amazing mind ... What are you looking for to decide root canal or treat it with forceps and replace the whole thing with titanium?
|
|
Martin:
|
Well, it's not an endodontic issue, because if you go through the endodontic part, the root canal, if done correctly, is 90% successful. Then you can do a re-treatment, then you can do surgery. A root canal is going to fail very, very ... Failed by meaning extraction. It's a very rare thing. First of all, by definition, you have a dental degree, that is save teeth. It's not just because of your certificate, it's because natural teeth are better than implants because they erupt and they can be used in the way God intended, whoever that is.
|
|
Howard:
|
That's my ex-wife, actually.
|
|
Martin:
|
No, that's your current, anyway. That's number 1. Number 2 is if you look at the outcomes and the survivability data, they're very similar until very recently. Now, the implants, now that they've been in for 15 years, 20 years, you're starting to get a lot of studies on peri ... implantitis? Is that what it is? All of a sudden, implants aren't as great as they used to be. I could even make the basic argument that even if you get 5 years, or 10 years out of that natural tooth, they're going to know so much more about implants in 5 or 10 years. Probably, you'll never need the implant. If you go back to the periodontal data, heavy sections, root resections, all of these things, were amazingly successful. It's just not that convenient, and the implant ... I can only go back to [Yan Lindy's 01:05:27] original statements, 'Implants are to ... replace missing teeth, not to replace teeth.'
|
|
Howard:
|
That's well put! "Implants are to replace missing teeth, not to replace teeth."
|
|
Martin:
|
I hope I've got that quote correct, it's [Yan Lindy's 01:05:46] quote, but if you have a space, an implant's a wonderful thing. If you can save a tooth, and unless you've got serious periodontal problems, I cannot see a reason why you shouldn't attempt to replace a tooth, of course with the patient's consent and things like that.
|
|
Howard:
|
Well Martin, we are 6 minutes past our end date, and I just want to say, seriously, you are 1 of my first idols in endo all the way back to Freshman year of dental school in '83. The endodontists at University of Missouri, Kansas City, thought you walked on water. Thank you so much for all that you have done for dentistry, for all you have done for endodontics. Thank you so much for putting an online course on Dentaltown. Everybody tells me they absolutely loved it, and the fact that you spent an hour with me today was humbling. Martin, thank you so much for all your wisdom.
|
|
Martin:
|
Great, thank you. I enjoyed it. Thanks a lot.
|
|
Howard:
|
All right, have a great day, buddy. Good luck on your lecture in New Jersey.
|
|
Martin:
|
Thank you. Bye-bye.
|
|
Howard:
|
Okay, bye-bye.
|