Dentistry Uncensored with Howard Farran
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203 Conventional Endodontics with Jeffrey Krupp : Dentistry Uncensored with Howard Farran

203 Conventional Endodontics with Jeffrey Krupp : Dentistry Uncensored with Howard Farran

10/22/2015 12:00:00 PM   |   Comments: 0   |   Views: 767





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AUDIO - HSP #203 - Jeffrey Krupp



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VIDEO - HSP #203 - Jeffrey Krupp



Jeffrey Krupp, DDS discusses his inspiration to spend 5 years producing his vast volume of information, conservative diagnosis, and patient comfort, and self care.

 

 

Dr. Jeffrey Krupp, a Board Certified member of the American Association of Endodontics, brings to the continuing education world “Success In Endodontics” a CE course developed from his 33 years of private practice experience in the field of clinical endodontics. Over the last five years Dr. Krupp has developed “Success In Endodontics”, as a comprehensive technique course incorporating HD microscopic clinical footage, 3D animations, graphs, and detailed diagrams. The course is certified by ADA CERP and accredited for 16 CE units by the Academy of General Dentistry - PACE.

 

Dr. Krupp obtained his DDS from UCLA in 1979, his MS degree and specialty certification in endodontics from Marquette University in 1982. He has been in clinical practice at the same location in San Jose, California since 1982 and is full-time practice today.

 

 

Success In Endodontics

http://www.successinendodontics.com

 

Facebook

https://www.facebook.com/pages/Success-In-Endodontics/669357016447995

 

email - support@successinendodontics.com

 

Phone - 1 (855) 762-ENDO





Howard: It is a huge, huge honor today to be podcast interviewing my buddy, Jeffrey Krupp. That's how you pronounce it, right? 

Jeffrey: Yeah, Jeffrey Krupp. That's right. 

Howard: Just a month ago, we were having a beer in San Jose and I wanted to podcast you so bad. I think you're the coolest endodontist I've ever met.

Jeffrey: Oh, thank you. 

Howard: These podcasts, seriously, they're mostly devoured by the kids. They're all either juniors or seniors in dental school. I've been [crosstalk 00:37] 5 years.

Jeffrey: Good for them.

Howard: Every time someone sends an email telling me they love my podcast I always reply back, well, tell me about you. Are you a boy, a girl, how old, whatever. They're all kids.

Jeffrey: Right. 

Howard: You've been an outstanding stellar endodontist for what, how many, 30 years? I don't want to [crosstalk 00:00:56] your age.

Jeffrey: I started practicing in San Jose. I've been at the same location since July of 1982, and I joke around the fact that Ronald Reagan was president, America was strong, the dollar was actually worth something. I really can't believe I've been at that same location [inaudible 00:01:12] 33 years, yeah.

Howard: Was your favorite song of all time written by Dionne Warwick? Not one listener, there's 7000 listeners, not one person gets that joke. What's the joke? 

Jeffrey: Do you know the way to San Jose? 

Howard: That was a great song, and Whitney Houston ended up being her niece or sister's daughter or something like that.

Jeffrey: Some tie-ins.

Howard: Yeah, unbelievable but you know what, when I talk to the younger dentists, they're really not freaked out about implants because they're not doing them. They're not freaked out about 3D CB CTs because they're not doing them. What they're really doing is fillings and crowns and that's manageable. You can't get in too much trouble during a filling or crown but you know what's really kicking their butt is molar endo.

Jeffrey: Yeah.

Howard: From the diagnosing, the treatment planning, the whole 9 yards. My first question to you I want to ask you is ... This is a thing that no one wants to talk about with endodontics is that, being a fireman, you want to put out the fire or being a policeman, you want to catch the bad guy. A dentist wants to save a tooth and sometimes ... I had this old gruff endo instructor at UMKC from '83 to '87 and he'd hold the PA at arm's length, and he'd say, "At arm's length, [inaudible 00:02:32] and do the root canal." We don't sit around and love pulps and Dycal and [inaudible 00:02:37]. We don't worship pulp. If it's dead, kill it. Sometimes they get burned because they're in their high speed, they switch to a slow speed, they're down to hand instruments, then they think is it affected or effected, then they put some Dycal, then the thing blows up. 

Jeffrey: Right.

Howard: If you were a young kid ... If you were talking to me and I was 25 years old and just walked out of dental school, how much should I worship the pulp, and when do I just say, "The hell with this thing. I'm going to kill it." 

Jeffrey: I'm a very conservative endodontist. My diagnostic protocols are centered around the fact that pretty much I believe we could always do the root canal tomorrow. I am not aggressive. In fact, I get accused being not aggressive in the slightest. I'm very comfortable sleeping at night with that position. I like to be able to absolutely verify the symptoms in the chair. If I can't get that patient in the chair ... They can have subjective symptoms but I can't duplicate them in the chair, I am not going to numb them up and start a root canal. I'm again, very comfortable with that. 

I have seen far too many patients treated that didn't need endodontics. I had a patient today, as a matter of fact, came in, she was in last Thursday, really beautiful British lady. She had an amalgam that was probably so heavy, the right side of her face was [inaudible 00:04:00], and it was old and it was on tooth number 2. I looked at it last Thursday. You could almost say for sure there is recurrent decay around the mesial or the distal, and it's cracked. I don't see how they were able to keep such a large alloy in that tooth for that length of time. 

I did some percussion testing. We did some cold testing. We did some vitality work-ups. We took a PA, and as a matter of fact, she just wasn't having the subjective symptoms. Duplicatable is a hard word to say in my chair. Well, she showed up this morning and she was in a lot of pain, and it was tooth number 30 with a recent PFM that had just been done this last spring. I went, "See, that's why we wait," because patients do not like multiple procedures for a single tooth problem.  

Howard: You just opened up Pandora's box talking about a crown. 

Jeffrey: Yeah. It was a beautiful PFM. It was gorgeous. 

Howard: There are people that say a third of every tooth we crown within 5 to 10 years will need a root canal. What do you think of that number? Is that right on, too high, too low? 

Jeffrey: Well, I don't really know the numbers on those things. As a practicing endodontist, I would say, it's a little bit around who's doing the preparation. It's a little bit how fast are they running those burs. You know Howard, I see a lot of crowns. I'll take a temporary off, do a root canal, and I'll see an old alloy underneath it. I'll say, "My goodness, the patient was anesthetized. How do they know there's not diseased dentin underneath that existing alloy that was placed when they were 14 or 15 years old?" 

If you're going to go ahead and prep something out, remove everything. Get your caries stain out, stain it, make sure you're good before you build it up and then go ahead and prep your tooth. I just think that there's no excuse in my book for leaving an old alloy as part of your core for a new existing crown. You don't know what's underneath it.

Howard: Yeah, I always ... If I'm going to work on a tooth, take everything out.

Jeffrey: Just go back to solid dentin. 

Howard: Yeah, I completely agree. What do you think ... Doing this for 3 decades, what do you think the young kids ... What do you think the low-hanging fruit is? What were the mistakes you were making when you were in your 20s that now you don't make that you're 39? 

Jeffrey: I started when I was 28 as a full-time endodontist. It seems like a long time ago and it seems like it wasn't so long ago but I would say that probably one of the biggest problems that endodontists have and I would go ahead and extrapolate that a general dentist has is in getting teeth numbers 18, 19, 30 and 31 numb. Those patients come in and they have a blistering. In dentistry, we call it the hot tooth. They have a blistering problem and it's legitimate, and they are not anesthetized. 

At that time, I didn't have the armamentarium that I use now for numbing teeth up. I just didn't have it. Oh, my god, the blood we use to sweat trying to get these poor people numb when they had just such an acute irreversible pulpitis and just a terrible problem, terrible. I would say that was ... Now I can sit down with a high degree of confidence, almost cocky confidence and say, "You're going to be numb. If you're not numb, we're not working on you." It's a black or white issue, and I do not work on people-

Howard: Is it because you've changed anesthetics or you changed your technique? 

Jeffrey: Well, you get better. You just get better. Numbing people up is a little bit of an art form. Everybody's jaw, everybody's ramus, everyone's internal pterygoid muscle, there are different ways to go around it. I utilize a protocol that brings in a Gow-Gates injection. I'm using a lot of Septocaine and we get people numb. 

So many people come in, I couldn't get numb. I can't get numb. These poor people have been so afraid of the dentist for so long. I'm sure you've seen them in your office. They come in and they're just mortified but generally, discomfort and acute pain is what's brought them in, and their poor teeth are just wretched. Things are broken and things aren't repaired because they're just freaked out.

Howard: Speaking of freaked out, some people are freaked out of using Septocaine on the lower because they think they're going to get some nerve paresthesia.

Jeffrey: Yeah, yeah. 

Howard: What do you think of that? 

Jeffrey: I use it routinely. In fact, there was just an article in the Journal of Endodontics a couple of months ago. They were talking about the attribute of using 2 carpules of Septocaine as a block injection over 1. I think that's what, 3.6 cc's of articaine. You know what? I do it routinely. Find some [inaudible 00:09:00] around here. I have not had any problems. I administer it slowly. I administer it carefully. I administer them one at a time generally and the stuff works.

I saw an article. I don't know how long it was, 17, 18 years ago in one of the Thrill magazines that came across our office. An article out of France says, oh, we have an anesthetic that has little lipid [inaudible 00:09:28] on it and it actually floats into the neurologic tissue and it really gets people numb. Of course, at that time, I was like, I'm trying anything. At that time, I was punching little holes back with ... Remember that little perforator bur hoping that there was an extraction socket that wasn't too ossified. We could get our little plunger in there. That worked pretty well but that made me nervous. 

I went ahead and tried this Septocaine product very soon after it's introduction and went, "Oh my goodness gracious. This stuff is better." I spread the word all around my referring community and now I think it's become pretty well [crosstalk 00:10:12].

Howard: Some people when they've got a hot tooth on a lower molar, after they give their block, their inferior alveolar block, after about 3 or 4 minutes, then they'll go take a ligament jet and start ligging all around the tooth. Do you ever do that? 

Jeffrey: No, I don't usually ... Never have. I don't like to use ligament jet. It looks too much like a gun. It's too scary. I've never really had much success with it. I typically will use a Wand and I'll use a Wand and I'll use a Gow-Gates approach. I will use Septocaine and I will use prior to that a compounded topical that I leave on the tissue, which is ... I don't remember the exact ingredients but 3 different type ingredients that are in there, works very, very well. We add a little bit of the commercially available topical to increase the flavor profile of the stuff because it doesn't taste very good. In fact, I think we get it out of a pharmacy down there in your neck of the woods. That works very well.

Then just slow by easy, easy by slow just anesthetize them slowly, slowly. I cannot stress that enough. The Wand really will allow ... It has a little computer chip in there and it allows for an even flow of the deposition of the anesthetic into the tissue and it's really us picking up our anesthetic carpule and going ram. That's really what brings the discomfort in. It's not necessarily the needle per se as the flow of the solution being injected quickly into the tissue. 

I joke with patients, "Yeah, remember when you were a kid?" I don't think any of the kids listen to this, remember this but doctor would have you drop your pants and he'd load up how many cc's of penicillin and load them right in your butt as fast as he can. You go, "Yo!" That's what it is. It's the tearing of the tissue by the solution going in. I use a Wand and it works very, very well and I use it slowly. 

Howard: That would be a good Seahorse ... I remember right, is SmartPractice here in Phoenix, are they the ones selling The Wand now?

Jeffrey: I'm not exactly sure who The Wand ... I have my manual here. I could look it up but The Wand is a wonderful tool. I'd like to say that I got it for the patient's comfort but I didn't. I got it because I was starting to get some discomfort in my thumb. One of my office people said, "Hey, Dr. Krupp, check this out." The Wand is manufactured by Milestone Scientific.

Howard: Do they sell it direct or do they sell it through a distributor?

Jeffrey: I don't know. I don't buy anything in my office.

Howard: Yeah, same here. I have no idea. I don't think a successful dentist spends all their time trying to save 12 cents on gauze in a catalog or online. I think they missed the whole boat. Really, if you're buying anesthetic and gauze online, I think you missed the whole boat. 

Let's go to radiographs. My job is trying to estimate the questions. I've got about 7000 listeners for show and I believe they're all 5 years out of school and under. One of the big stressful things they're having is they come out of school with $250,000 of student loans and some people are telling them, to do a root canal right, you need to buy a $100,000 3-dimensional CB CT x-ray. Can I do quality molar endo with 2-dimensional x-rays or do I really need to suck it up, buttercup and get me a CB CT?

Jeffrey: No, you do not. If you're a gentle dentist ... I had recently digitized my office just this last spring. In fact, I was one of the very first clinicians in Silicon Valley if not the first to buy myself a digital imaging system back in 1992. I had this fancy digital imaging system and the sensor was about as big as a brick. It was bad. The fidelity of it was marginal. I'm an older guy. I was raised on film. If the film is properly angled, it's developed properly, it's fixed properly, it's dried properly, yada, yada then it's going to work very well for you.

The younger people listening probably don't even know what film is. There also used to be something called vinyl records, which also sound really cool. Analog film works really well. I went ahead and I'm always looking at the new stuff that's out there. I'm always interested to see what is being developed. I kept my eyes on the digital system. Needless to say, my first digital imaging system has been up in my attic for a long, long time and I went back to the exclusive use of film. It was just too uncomfortable and the fidelity wasn't good enough. 

I was the first went out of the box with that and I ate it. I spent a lot of money and I did not enjoy the ... Now, the fidelity of these digital imaging systems are fantastic. I have now a digital imaging system. I use it routinely. Patients still complain a little bit about it with trying to have it placed underneath the rubber dam because it's still a little uncomfortable. Film is still thinner. Obviously, the attributes to your image quality is just as good as film if not finer. Your ability to manipulate the images is wonderful. Storage and then of course the reduced exposure time, it's terrific. 

As far as going out and getting a CB CT machine to do endodontics, no. I just got one. I got on in the spring. I use it, and I've heard you interview other guys and other gals, we use them primarily to evaluate re-treatments. 

Howard: What machine did you get?

Jeffrey: Carestream 8100.

Howard: That's what I got too. That seems to be a pretty popular one. 

Jeffrey: Yeah, I got it. I want to say I did a whole bunch of research around it but I didn't. I had my eye on him again. I keep my eye on a lot of stuff and I see them come around. Years and years and years and years ago, I went to a lecture and they said, "Oh, there's going to become a technology when you're going to be able to 3-dimensionally evaluate your tooth or your jaw." I was, "Yeah, sure. Beam me up Scotty." I had no idea that I was going to live and practice long enough to see this technology. 

We had a junk room. We cleaned it up. Used to be an old operatory. It worked beautifully. We put it in there, the Carestream. You enjoy your machine? It's wonderful. I don't do implants in my office. I don't use it for that purpose but for evaluating re-treatments. You do see cases where you're having trouble perhaps finding a canal and you can take them over there, explain the situation to them and then run a cone beam on them and go, "Well, you know, I just need to go a little bit there. I need to go a little there," and saves removal of unnecessary dentin down the root [inaudible 00:17:17]. It helps you [crosstalk 00:17:19] conservative.

Howard: Some of the kids ... I watch them talking on the message boards and I watch them bantering back and back. A lot of I think that was stressing them out is when one would tell the other and they say, "Well, the number 1 cause of root canal failure is missed anatomy." If you would have had a 3D x-ray, you would have seen there was an MB2 or you would have seen another canal. Do you buy that argument?

Jeffrey: To a degree. There's a study by a guy named [inaudible 00:17:44], came out years and years and years ago. He says that 90% of all upper first molars have MB2 canals and they probably do. He's probably right. They do. Do you need a cone beam to know that 90% of teeth have MB2 canals? No. Do you need a cone beam to find 90%? Not really. What is best is to take a very careful, calculated look in that area where you suspect the anatomy might be. If you're not looking for it, you're not going to find it. 

The one constant though in endodontics, and you've heard other endodontists talk about this too, is variation. Not only to root morphology but also to canal anatomy. That is the one constant that's not going to change in our business ever. God's throwing curve balls every day at us. 

Before I came home to do this interview with you, I was working away on this British lady's tooth number 30 or 31. I forget what it was. It presented anatomically as though it had one little dark line running right down mesiodistally, had a nice distal canal, had a nice mesial canal. I thought oh, this is one of those unusual, although you see them, two-canaled lower molars. I was working away, working away, getting ready to fill it. I got my scope out because I generally push my scope away after a period of time on my procedures. Brought my scope back in to take a look at it and sure enough right there ... I was working down the mesiolingual canal. The MB canal was right there sitting right next to it like the Twin Towers and I was like, "Oh, well. There you go." They're there and they're constantly trying to fool you. 

You want to do a very thorough evaluation visually for any further anatomy. Any further orifices. You need to open the tooth up. You need to see what's going on. You need to get through and give yourself a chance to get light into that tooth and give yourself a chance to find that anatomy because by and large, it's going to be there. 

Howard: You said this lady was from Britain, Great Britain. 

Jeffrey: She had a beautiful British accent. 

Howard: I assume she was a foreigner because I assume that all endodontists only treat foreigners because when I talked to the 120,000 general dentists doing root canals, I asked them, what is your failure rate? Every single one will say, "You know, well, knock on wood. I've never had one fail yet." Then you go talk to the 4000 endodontists and they're either only doing immigrants from other countries or these general dentists don't realize some of their root canals fail.

I want to ask you, of the 4000 endodontists in America, what percent of your work or cases is re-treats done by a general dentist that failed earlier? Seriously, go ask 10 general dentists how many molar root canals they've done that failed, and most of them will say, "You know what, knock on wood. I haven't done one yet and I've done it for 30 years." What's the beef? Who's right or who's wrong? Do these guys never fail or are you guys only working on immigrants? 

Jeffrey: No, no, no. Teeth fail. That's part of why I produced what I produced. Teeth fail. There certainly is probably historically been some very large studies around endodontic success and I would say that probably in large numbers, the success rate is ... I recall about 82%. Over what length of time, I can't tell you, but 82% seems pretty darn reasonable. 

It doesn't seem as though because there's only an 82 chance of success, we're just going to take the tooth out and do an implant. I don't think that that's a reason. The root canal might fail so let's do an implant? No, no. God put the tooth in there for a reason. 

Howard: Yeah, the dental elf just had a ... His monthly deal this month was that implants are failing much higher rates than anybody's reporting. I think what the implant companies, they all do, they always show their success rates based on implants in the lower mandible, where basically a nail from Home Depot or Lowe's would work. You're sticking titanium in oak wood but they don't seem to incorporate in their studies posterior mandibles, the maxilla, sinus lifts, bone grafts. Basically, what everybody's critical research is saying that implants fail much higher than anybody's reporting.

Jeffrey: Obviously, implants are wonderful restoration. It's a wonderful advance in dentistry and I'm not trying to malign implants at all. I don't place them. I respect the guys that do. I see beautiful results from ones that are done. I see results that aren't so good also as I'm sure you do in your practice. 

I saw a lady the other week that had a beautifully placed tooth number ... She was edentulous. She had the implant in the 31 area. It was beautifully placed. It was integrated. It had been unloaded for 5 or 6 years because it was pushed so far distal that there was no way they could get a distal margin down on the crown and so it shall remain as her implant without any function. 

I believe I read something recently in the CDA Journal that they were talking about 60% of implants had cracks in them. I'm not sure how serious those cracks are. I'm not maligning implants. I think it's a great restoration. I think they need to be done with ... Like any other aspect to dentistry, they need to be done properly, treatment plan, probably put in with some surgical guides and restored by guys that really know what they're doing.

Howard: Let's give some father-son advice. I want you to talk to all these [inaudible 00:23:37] listener here because one of their stressful things they're saying is, what does someone like you, who's been doing this for 3 decades thinking between when you're looking at a re-treat or extract and implant? How do you frame that diagnosis and treatment plan?

Jeffrey: Again, today, I got into a tooth of a wonderfully beautiful lady, 5 months pregnant. She waited until her middle trimester for me to after her failing tooth number 30 and I was like, okay great. This is going to be interesting. I think every endodontist, and I can speak for a lot of endodontists on this, do not like to open up a tooth and see little circles of gutta percha with a black-eye in the middle, which means that we've just run into one of these gutta percha on a stick obturator systems that [crosstalk 00:24:25] oh my goodness.

Howard: You're talking Thermafil?

Jeffrey: Whatever nasty event you want to call it. I call it gutta percha on a stick. Yeah, that's a Thermafil.

Howard: What percent of gutta percha on a stick would be Thermafil?

Jeffrey: Well, I'm not sure what percentage but they've gone to gutta core now to try to get around that. For a while there, these Thermafils were getting stuffed into teeth with ... They are very difficult to treat. They are very difficult. They look like gutta percha on a radiograph. You can't see the difference on a scan. I just am not comfortable re-treating those things. I would rather see silver cones in there. At least the silver cone I know if I can get it out. I pretty much got the cone out. A Thermafil leaves residue of gutta percha or this and that. It's not a good prognosis with a Thermafil.

I would say that by and large, I am not one of those guys. I'm conservative. I'm not one of those guys where someone presents with what appears to be a reasonably well done root canal and say, "Yes, I can fix that. I'll give it a try." I'm patient-centric. I will definitely try to do what the patient wants to do but I will give my clinical advice and I will explain the different parameters and for sure, the options to what they're considering.

Howard: That's something that dentists have to think about. Of course, a root canal is going to fail because we're all going to die. 

Jeffrey: Right.

Howard: I'm not sure anybody's made it past 115 years old. If every tooth we touch is eventually going to ... Every time we touch a tooth, we condemn it to re-treatment if they live long enough and you need to be looking at treatments that are reversible. Sometimes we're wondering about this with these new zirconium crowns. You bond on these zirconium crowns and sometimes you got to cut them off. It's literally almost impossible to remove.

Jeffrey: Oh, yeah. I accessed through quite a few of those to the [inaudible 00:26:25]. I'm not sure why porcelain needs to be so hard. I don't think the human dentition really requires that but they are some mighty, mighty, mighty strong pieces of porcelain.

Howard: I think that's why-

Jeffrey: Maybe even they're calling them metals. Zirconium is a metal, I guess.

Howard: That's why a lot of surgeons are telling me that porcelain cosmetic implants are dead on arrival because when porcelain glass fractures under the jaw, oral surgeons and periodontists say, "That's a mess." They would rather grab on to a solid piece of titanium and get it out not some breaking piece of glass.

Jeffrey: Yeah.

Howard: Humans love lists. The top 3 this, the top 5. They love top 10, even the 10 Commandments went with the top 10 even though it's not even 10 Commandments because there seem to be a lot of duplicating thou shall not commit adultery, thou shall not covet thy neighbor's wife, thou shall not steal, thou shall not covet they neighbor's goods. There seems like a lot of repeats in the 10 Commandments. 

If you had to have a list of the top 3 or the top 5, what do you think a 13 under ... Kids that just got out of dental school. They haven't done 50 molars yet. What do you think will be the top 3 or 4 or 5 reasons ... Their mistakes and solution. 

Jeffrey: Where are they going to find their mistakes? 

Howard: What will be the mistakes they'll have [crosstalk 00:27:44].

Jeffrey: That's a great question, Howard. What I discussed earlier. Making sure that patient is numb. That is absolutely paramount. It seems like a given but make sure they are numb and that they are not feeling this procedure. The patient needs to have confidence in the clinician so that they come back and you do not want to scar that patient into the future for their inability to walk back in the dental office. We want to make sure they're numb.

Another very key ... I don't want to call them mistake but let's just say a clinical challenge that I see, is they're not opening up the roof of the chamber. They're not getting these things open. They're not truly allowing light to come in to the chamber and evaluating the floor of the tooth for any further anatomy orifices. That's another key problem that I see.

Another problem that I'll see is they're not removing restrictive dentin. There's a whole debate going on in endodontics. You might have heard some of these terms ninja accesses and let's be conservative and let's be open. Oh, my goodness gracious. I had a professor many years ago, a very wonderful endodontist, who told me when I was a resident that there really isn't anything conservative about an endodontic procedure. Not that you need to rip open stuff needlessly.

I use the term ... When I teach, I use the term maximize your minimums, minimize your maximums. Try to make sure that you're open just enough to make sure that you're not hiding ... That no orifices are hiding there but at the same time don't take it out the expensive solid dentin. Between numbing people up, opening up the chamber and evaluating for any further orifices, that's two. 

The third one I would say would be do a little pre-flaring to your preparation prior to getting your measurement. I was measuring down to 22.4 mm or 22.5 mm with my number 20 instrument on the mesiobuccal canal and they weren't numb enough and I didn't know what to do. I'll get long notes on my referral cards about how they were so careful with this and so forth. God bless them. I think they were trying really hard but then I go and I open up the tooth and I take the temporary out, and I've got a mesial shelf of dentin just going [inaudible 00:30:14]. Hanging right over here. I'm going like, "Whoa, what's going on here." 

The first thing I’ll do is take a carbide fissure bur that's tapered, round-ended and I'll just open that thing up and flare it up so we can get in there and see what's ... Give yourself a chance going in to these [inaudible 00:30:29]. People are working through a lot of restrictive dentin in the coronal third and even in the mid-third. You want your working length of the instruments to drop nicely to the root end so you can get a proper root length evaluation.

If you have the luxury, you're not working through a new porcelain crown, an old alloy or some other type of crown, you have the luxury of flattening off that cusp so you have a predictable measurement point for your further instrumentation, do it. Take advantage of it.

Howard: I can’t ever interview endodontists so I'll ask you the million-dollar question, where does the root canal stop? Are you an apical barbarian? 

Jeffrey: I've heard you use that term.

Howard: You like to get a puff sealer out the end and you love it or are you a pulp lover and you like to stop before the apex.

Jeffrey: I'm just me. 

Howard: You're just you?

Jeffrey: I’m just me. 

Howard: Would your wife call you a lover or a barbarian? We'll just assume that it's a root canal.

Jeffrey: Yeah, right. She’d probably call me a little bit other things.

Howard: Where does the root canal end? Do you want to puff a sealer out the end?

Jeffrey: If you get it, you get it. If you don’t, you don’t. It's not something I’m shooting for. It depends I think how long-standing that lesion is ... They call them LEOs, lesions of endodontic origin. It depends how long that tooth has been infected. It depends what the body is trying to do with that contaminant. If you're finding yourself getting a nice puff of sealer through some [inaudible 00:32:03] anatomy that you had no idea was there and most likely is there in most of your cases, I cannot stress that point more strongly. 

There's some wonderful diaphonizations that are going on these days. Go online, look at some of these clearings. The root anatomy particularly as you get to the middle and especially into the apical third is extremely complex. Herb Schilder had it right. He brought the word root canal systems into our dialogue and he's absolutely right. 

In dentistry, we were working with the concept ... I don't know, you're probably even a little too young yourself. The Washington Monument theory. We're just going to get down and we're going to carve out this trapezoid, apical seal and we're going to [inaudible 00:32:50] ... I think that came from [inaudible 00:32:51]. I'm not sure. That's what they're going to look like. They're going to look like the Washington monument. Well, wake up dentistry. That's not the way it's going down. 

God has thrown tremendous variation. No talk on endodontics needs to begin or end without an amazing discussion or certainly amazing pictures of what’s really going on. Like I said, I've got some pictures here in my program but you can go online and look at these diaphonizations that are coming out now. This was exposed early in dentistry, 1913. Hess showed this in Dental Cosmos. We're dealing with amazing variations. 

As far as going how do I treat the apex, I like to just make sure that I’m getting an extremely accurate root length measurement. That's where the game starts after they are numbed up and you've identified canals. Clearing out the restrictive dentin, getting an accurate root length measurement and creating a glide path, and maintaining patency. It's not a complicated concept in endodontics. It's technically very hard. It can be challenging. 

Howard: When I saw the Internet came out, I thought the Internet solved an amazing problem. I thought dentists were all professionally isolated and lonely. Not really many people they can talk to. They're shy, introvert people and when they go to a dental convention, when they go to CDA up there in San Fran, there is more file systems being sold than they could name cousins and relatives. There's just so many and they're all alone so I want you to give some guy ... Think about this 30-year-old woman walking into the CDA and everybody is trying to sell her a file system and you’re her dad.

Jeffrey: Mine's the best, mine's the best. Yeah, you hear that from everybody. It's just amazing.

Howard: I don’t want her [inaudible 00:34:46] alone and she feels like it's hard to trust. The research we see is, dentists about 94% to 97% would rather take the advice from a colleague than a sales person. They think the sales person is trying to sell them their deal. They're not going to sit there and say ... Help her out. What file system? Are all files file? I'm sure Tiger Woods could golf better than me with a used set of clubs from a garage sale.

Jeffrey: I used to caddy and I got to be a really good caddy. I would see these guys go out on the golf courses, and oh, my goodness what a difficult sport that one is. That's supposed to be for fun? I like to walk the golf course but I won’t play it. As far as file systems go, it’s how you use them. So many people are putting so much thought. I received ... I think it was John McSpadden. I'm not sure exactly when it was. It might have been 1990, 1991. 

Howard: I love that guy.

Jeffrey: Great guy and I've met him and he doesn’t know me real well. I don’t know him but I've met him. I got a little card with this file. It was a 0.02 nickel titanium. Flexibility with martensitic and austenite properties. This baby would ... You could bounce this right back and I went, "Whoa!" I'm hand filing with stainless steel K-files at the time and doing different things. I was just amazed. It was incredible. It almost seemed unworldly. 

Dentistry and the manufacturers that are out there, God bless those guys. They are out there really trying to make our job easier but at the same time, they're inundating us and this one's got this file system and this one's got this file system. It's how you use them and what point in the procedure that you use them. I read an article just last week and another new file system was coming out. This was an article ... It was about a half page article and it was written by a dentist and he was extolling the benefits of this next new ... I think there are 60 or 70 file systems out there.

Howard: Isn't that amazing?

Jeffrey: Yeah, it's crazy. Now they're heat treating them and I kind of like the fact that they're heat treating nickel titanium. Anyway, this file system was being extolled by this dentist and I read the article. I read a lot of these articles. Part of the praise of the instrument was he mentioned the word quick 8 times. He mentioned  the word irrigate 1 time. That's why I think the culture of dentistry needs to change in endodontics. 

The file, yeah, we pick up some pulpal debris and we probably get some bacterial contaminants. We get this and that side of teeth and we've all seen them but really when the rubber meets the road, it comes down to activating your irrigants and getting into all these amazing anastomoses, all these tertiary, anatomical variants that are just everywhere on a daily basis. They're out there. These roots are complicated. 

In my endodontic program, we were laterally condensing. We were K-filing and we were laterally condensing. Every now and then we would get with our Grossman seal that we would get a lateral puff out the side. I have this one endodontic professor that swore that tooth was going to fail because that's evidence of a broken root. Come on. I saw Herb Schilder. I'm not a student of the Boston program but I saw Schilder interviewed probably about 1980, 1979 and a wonderful speaker. He's given so much and his students have given so much to dentistry. Like I said already, he brought out the concept of root canal systems. 

They are systems and I'm going to say it again and every endodontist will tell you, these are complicated roots. Morphologically maybe it's a single root but anatomically they are complicated. Morphologically, they may be more complicated than you see like you expressed on a mesial distal 2D radiograph but no, I don't think you need a cone beam to show that necessarily. 

Howard: That was really the problem with Thermafil is that people didn't spend any time cleaning and shaping because with that carrier they could shove it to the apex.

Jeffrey: You work faster.

Howard: It looked great on a x-ray and it's like the whole deal of endodontic success is what you take out of the tooth not what you put in. Since irrigation is so important, let's talk about that. Is your main irrigant bleach, sodium hypochlorite.

Jeffrey: Sodium hypochlorite. 

Howard: Do you use EDTA or or chlorhexidine gluconate or any others?

Jeffrey: I don't use chlorhexidine. I use EDTA, ethylene diamine tetra-acetic acid. I use it towards the obturation portion of my procedure. I believe that for me, what works best is activating using ultrasonic activation of the sodium hypochlorite and used to be activated in that-

Howard: To save money, what I do is I just shake the head.

Jeffrey: Yeah, or have them bounce up and down. 

Howard: Fill up their [inaudible 00:40:05] and have them go around the block. Another big question that I hear the kids asking a lot is, when do you use antibiotics and furthermore, what is your go-to pain med? Will you talk about antibiotics and pain meds, the pharmaceutical side of endo?

Jeffrey: I'll be happy to. There's a reason women have the babies because they tend to be a little bit more pain tolerant. It's not up to us. Us men, we're physically stronger but we tend to be a littl wimpier when it comes to pain medications. If I'm seeing a man ... This is a gut level feel. I don't want to make splashing generalizations although I just did. As far as pain medication goes, I tend to write for Percocet. I will tell them that you can break them in half. You can break them in a quarter, take them in quarter doses. 

I find that now there are other medications out there. Tramadol seems to work. The people are using Vicodin. I guess it's called Norco. We write for that. Tylenol with codeine, I will use a Tylenol with codeine medication more for an older patient. 

Howard: Do you always give pain meds just in case? Do you give an interim policy? 

Jeffrey: Absolutely. 

Howard: If you did a 100 molars, how many would get a prescription for a pain med?

Jeffrey: One hundred.

Howard: One hundred.

Jeffrey: Absolutely. 

Howard: You just coach them, if you don't need it, you don't need it. If you do need it, cut them up in quarters.

Jeffrey: Absolutely. You want to over prepare people for any eventualities. My staff is very well trained and they spend a long time with them at check-out making sure that they completely understand what is being prescribed and in what manner to take it. I tell patients all the time, if you have it, you don't need it. If you don't have it, you need it. 

Howard: What about antibiotics? 

Jeffrey: Antibiotics I use fairly frequently. I don't want to misrepresent that. I write a lot for Augmentin. I'll use it in the 875 strength. I’ll use in the 500 strength if their body weight isn't quite as [inaudible 00:42:11]. When I started out in endodontics, Howard, there were 30 40 different bacterial colonies that used to infect teeth. Now, through metagenetics and all the increased genetic testing they're finding that no, in fact there is 300 to 400 different species of bacteria that are infecting these teeth along with various yeasts, molds, viruses and god, we didn't even talk about biofilms back then but yuck, talk about nasty stuff. This is bad stuff.

A lot of times, these things have been cooking in these teeth for months and months. There is this study years ago by a guy named Morris. He used to say that anytime there’s a radiographic lesion then, you want to pre-medicate that patient with an antibiotic prior to initiating a root canal procedure. I think that’s a little aggressive but that’s been discussed by other endodontists. I do use a fair amount of Augmentin and then I'll back that up with metronidazole.

I was one of the first guys in my area coming on board with metronidazole. That was, oh my goodness, that was back in 1990, 1989 and that stuff works fabulous. It works well in conjunction with an amoxicillin type clavulanic acid combination but that’s what I like to use. The same British lady that we're discussing that I saw today, she was having a lot of problems and she was starting to be a little swollen so I wrote her a prescription for 875 Augmentin and I gave it to her for 5 days. I don't [inaudible 00:43:46] for 10 days or anything like that. 

Then I went ahead and gave her a prescription for metronidazole, which is 500 mg t.i.d and I told her that you can’t even look at alcohol on that stuff. That is an Antabuse medication and will make you violently sick if you have any residual alcohol in your system. I tell them, they'll be praying to the porcelain gods and see parts of the toilet they didn't know existed but I will give the metronidazole as a back up and then she was instructed today, Thursday, Friday and if she is not better come Saturday, she is to add the metronidazole, which seems to work well in conjunction with the Augmentin after a blood level of the Augmentin or the amoxicillin/clavulanic acid combination has been reached.

Howard: I think it was very interesting what you said about access about when someone sends over a root canal they couldn't finish and the access. It's funny because my oral surgeon friends, they all tell me that every time some dentists tries to get out a tooth and they can't get it out, and they send them over their office, they look at the flap and they're like, "I couldn’t get it out either."

Jeffrey: Yeah.

Howard: That's all I could see and all they do is double the size of the flap until they can see what’s going on, then they get it out in 10 seconds. Most of them say, yeah, I couldn't do it. I want to ask you another thing that’s very, very confusing. You do a molar, it had an MOD amalgam and you do a root canal, you crown it. That's an easy diagnosis but sometimes it's very confusing when people are taught that all root canals need to have full covered restoration when they do a root canal on an incisor. Then when they get done with that cingulum constriction, when they get done prepping a mandibular incisor for a crown, you basically only have the gutta percha, it looks like a grain of rice.

Jeffrey: Yeah, I would say that you're looking at wooden end of a toothpick.

Howard: Yeah, so-

Jeffrey: Yeah, God bless them. I'm not going to sit here and pretend I'm a restorative dentist. That's one reason I went to become an endodontist because I thought your guys job is just too damn hard. It's a tough one. I also joke around the fact that lower anterior teeth are just too small to do dentistry. My goodness gracious, what was God thinking giving those lower anterior teeth. Go ahead, your question, I’m sorry?

Howard: Your question, if you did a root canal on lower four incisors, and you sent it back to the dentist and they're like, "If I file that down for a full coverage crown, it's going to be a grain of rice. I'm just going to put a composite in your endodontic access." 

Jeffrey: Yeah.

Howard: What do you think of that?

Jeffrey: I think that’s probably reasonable. I think that's probably reasonable or else, that patient's coming back in 18 months and they've got their crown in their hand and we’re looking at gutta percha sticking out of a fractured tooth that has been section at the gingival crest.

Howard: I want to go completely off topic and I hope you’re okay going to this but when you grow up in Kansas, everybody will tell you, everything starts out in the coast. It's either California or New York and it gets to Kansas 10 years later. It seems like growing up in Kansas 25 years and now I've been in Arizona 28 years, it seems like there's a lot of anti-mercury, not just patients in California, not just government but there is a lot of dentists out there. Sometimes on Dentaltown I always notice that if someone has any question about mercury ... The older dentists in the mid west are rolling their eyes. Hippie freak from California, go eat your kiwi and your kale.

Jeffrey: Meditate. 

Howard: Go to yoga and eat kale and meditate but do you think mercury needs to be looked at again. Do you think it’s changing? You're out there on the ... San Jose, you're in the middle of Silicon Valley. You probably have the smartest, most highly educated ... That's where Google and Facebook and Twitter-

Jeffrey: They're all here. 

Howard: Those are some of the smartest people out there and you hear not just them but some dentists out there saying, "I don’t like mercury." What do you think about that?

Jeffrey: Well, I know you get the ADA Journal and there's 2 distinct discussions around mercury. One discussion is, is it a proper restorative material. Okay, I think what I heard there's 30 million tons in patients [inaudible 00:48:12] worldwide or has been or something. Some huge number. We've all seen it. I've had them in my mouth. They're not in there now. It's a wonderful material. It's time tested. It's inexpensive. They also say that 30% of the mercury in the San Francisco Bay comes from dental offices. 

If you look just I think this recent September issue of the ADA ... That's one discussion. Is mercury a restorative material that we should be using in dentistry. I don’t really have opinions one way or the other on that. I think there's probably wonderful restorative materials now that can be used without picking up an amalgam triturator and putting a mercury-based filling. It's 50% mercury, an alloy is 50% mercury. 

The other argument is, and this is the one that I'm a little bit passionate about is, is mercury an occupational hazard? There is the front page issue September 2015, just this couple of months ago, where they've got an opinion from the American Dental Association on us. The occupants who are in our operatories, us picking up high speed hand pieces, and drilling out those mercury fillings. When you drill out a mercury filling, first of all, it's bound organically with silver, tin and other metals inside the tooth but when you pick up a high speed hand piece, you've just weaponized that mercury. It goes into mercury vapor and bang, it just assaults that operatory. 

It is nasty stuff. Mercury is, I believe, the most toxic non-radioactive material on the planet and we’re working around it everyday by taking out old fillings. Is the occupational risk to mercury great in dentistry? You bet it is. I have absolutely a 100% belief that as dentists, we need to be taking precautions for ourselves. Now, as a patient, do I need to come running into the local, I'll remove all your fillings in one sitting dentist? No, I do not believe that. I do not believe that mercury fillings are contaminating the patient who has them residing in their mouth. That is a completely different issue as I've already said. 

The issue of, well, I'm taking out this filling. Do I need to take some precautions? Do I need to inform my patient that maybe I’m going to use some accessory evacuation procedures? Do I need to take that grey sludge of mercury that I wipe off my hand piece and maybe not take that 2 x 2 and throw it into my trash can so that at least mercury vapor all day long around my fertile bearing assistants and myself? Yes, absolutely without a doubt.

Howard: I got to tell you a mercury story. My son Ryan, I don’t know if he remembers this but when my boys were about probably 1, 3, 5 and 7, one of my very good friends bought a 65-year-old man's practice of 40 years or whatever. We got in there, the first thing he wanted to do is he wanted to take out the carpet because he ... Going back, the AIDS issue had just surfaced and disinfection and OSHA.

Jeffrey: Oh, yeah.

Howard: You couldn't really have carpet. He asked me if on a Friday after work, if I'd go help him pull up this carpet and pull out all the carpets. I said, "yeah." Brought all my boys over and he had kids that age. We pulled up all the carpet. There were balls of mercury underneath the carpet that the boys started kicking around and they would get to the size of a ping pong ball and there is all of our children playing, kicking these balls of mercury and it hit the walls [inaudible 00:52:07]. Oh my god, look at all the mercury in the air that had solidified, fallen to the carpet and we were just looking there like, unbelievable. 

It wasn't like he was some weird dentist just throwing mercury on the floor. He was a normal dentist but the carpet showed the story. It was a ton of mercury. 

Jeffrey: Yeah, I consider it this ugly relative in dentistry. Mercury's out there and occupational hazard. You can take some precautions. We're speaking to a lot of young dentists, listen up guys and gals, if you can take some precautions pretty straightforward. I have a protocol I call it Dr. Krupp's mercury hygiene protocol. It's not-

Howard: Do you really?

Jeffrey: Yeah, I just make it up myself but yes, I do. I have a high speed 4-inch hose that vents outside. I of course use rubber dam routinely but after we've cut that alloy, I will wear a mask and I'm not a spiritual freak but I do meditate. This is a real problem and I will have my assistant wear a mask and the patient will have a slow speed evacuator in the back and then once we cut that alloy out, we'll rinse everything down. We'll take off that rubber dam but I do not tell the patient to swallow and have them ingest that mercury residue. 

I'm very meticulous about suctioning out the back of their mouth, making sure we look under the tongue, back of the mouth, everywhere and then we will take and we'll put a napkin down on the patient's chest. We'll take the rubber dam, which has been contaminated. We'll wipe down the clamp and take off the floss that's holding the clamp on the patient's mouth. We’ll take out the bur. We'll take out ... It sounds like a lot of work but it takes about 3 minutes. We then take off our our gloves and we take that material and we take it out of the building into an environmentally safe box and they pick it up and get rid of it.

When we go back to complete the rest of the endodontic procedure or actually begin the endodontic procedure, we will put on a fresh clamp, fresh rubber dam, fresh gloves. It's not sitting in there leaching mercury vapor all day long. The patients, they love if you explain it to them. They love the precautions that you’re giving them and I want to say that I’m doing it for their benefit. I’m doing it for mine.

Howard: It's funny how history repeats itself because Rome had a huge problem. They were building lead aqueducts and late into their civilization, archaeologists were saying that some of the lead poisoning was 50 parts per million in their cranium. They had to be completely mentally crazy from that. There is a guy ... I'm in Arizona, in Phoenix, there was a guy at U of A who's doing some studies on premature babies lost. He was amazed at how much neurotoxicity was in these fetuses and embryos apparently only a few months old. He has shows all these radiographic neurological from mercury.

Jeffrey: Mercury vapor, you can't see it. We all went through dental school. We all went in our sophomore labs. Can you imagine the contamination with all those typodont teeth receiving MO alloys with 100 or us in there. We were getting bathed early in our deal.

Howard: There's a lot of dentists listening to this that got mad saying, "Howard, why did you switch to mercury when you’re talking to an endodontist and you never even talked about obturation?" Same thing, how many different sealers are there? Do you care if it's lateral condensation, vertical condensation? Are you a hot gutta percha squirter? Are you a squirter? 

Jeffrey: I was taught lateral condensation. I did lateral condensation for 12 years and it’s a nice technique. It's reasonably predictable. I think it's controllable. I switched over about 1989, 1990 and I do a modified warm gutta percha technique. I feel it’s far superior to anything that’s really out there. It's not rocket science. It's just a solid way to fill a canal 3-dimensionally. 

Of course, people will say, "Oh, you’re going to break a root. You're going to crack this. You need to open it up too much." You just have to be gentle with these teeth and you use your vertical condensing pluggers with a reasonable amount of force. We're not trying to lift weights here. Everything is done in a controlled fashion and you get beautiful results.

Yes, sometimes you get puffs of sealer and sometimes you don’t. Sometimes you'll get a tertiary anatomy displaying itself and we threw up our hands. I think the term has been coined the thrill of the fill. Wow, look at this. I had no idea that this thing had 3, 4 branches towards the apices. You see that kind of stuff. I've been using just regular Kerr sealer and it's worked beautifully for years and years. 

Howard: Kerr sealers, I've run Kerr-

Jeffrey: Yeah, I believe so. I think that's what they mix up for me. I love it. It's definitely sensitive to humidity. It's sensitive to air temperature. I have a ... Sealer wars, I call them. I have the assistants [inaudible 00:57:29]. [inaudible 00:57:31], "Who's going to mix me up the best sealer today?" I want something that's creamy and beautiful. It's only 83 degrees in my operatory today. Who's going to do the best. 

I'm also, like I said, I've said this a few times in our discussion that I got my nose out and I'm sure other people out there have heard of bioceramics and I think bioceramics is a wonderful sealer. I use that sometimes. It's a little more difficult. I believe Brasseler has come out with a 150 gutta percha system, where they can go ahead and warm obturate with their bioceramics. They have gutta percha cones that are coated. They have wonderful paper points in that system. Then the bioceramic material, the sealer, hydrophilic. It's extremely, they say, antibacterial, very high pH. It doesn't flow quite as nice as I like with the curves but it gets the job done. I used it probably about once a day.

Howard: Well, I think we've covered everything. I've only got you for 1 and a half minutes and one of the most exciting things that's ever happen to me on Dentaltown from 1998 to 2015 is ... You were the first one to come out and say ... Usually, the courses are 1 hour long and I don't care if it's an implant or TMJ or whatever. They always present a 1-hour show. You spend a gazillion dollars and gazillion years, and you built a 16-hour endodontic ... I think it's the first online internet curriculum ever put together that covers endo from A to Z. Talk about that. When will we see that on Dentaltown?

Jeffrey: Well, I think pretty soon. I've been talking to your people there and then I was advised, this has to be an online course because we’re in 2000 at that time. It was 2013 with animations and clinical footage through my microscope. I also filmed diagnostic procedures in the operatories. We turned it into an online course and that’s what's going to be represented on Dentaltown. It tells a story. I try to make it ... I work very hard. I was my absolute passion, Howard. 

This has been my life for the last 5 and a half, last 6 years. My wife will attest to the fact that I've been an absentee husband. I've been working on this thing for the last 5 and a half, 6 years. I absolutely am trying to pay it forward. I’m trying to have my knowledge and my expertise, not that I’ve done it. I'm so great. It's just that I've done it a long time. I don't want people to have to sweat their own individual blood. I've already sweated the blood. Here's what works. This is my technique. It's certainly not representing that is the only way to peel a pineapple. There are other ways to get through an endodontic procedure to be sure.

Howard: I've seen a lot of the [inaudible 01:00:27] and everything. It's just incomprehensible. You were able to film and your animations and your graphics, you're an endo unicorn. You really are. You are.

Jeffrey: Thank you very much. It was my pleasure, let me tell you. It was a lot of work and I loved every minute of it. We've gone through ADA CERP approval, AGD approval. Went through exhaustive applications on those. 

Howard: I think people will be watching that seriously, dude. I think a century from now, people will still be watching that. I really do. They'll be parts of that ... So much of what you did was timeless. 

Jeffrey: Thank you, yeah. Thank you very much. It was my pleasure.

Howard: Can people call you or email you?

Jeffrey: You can get a hold of me, info@successinendodontics.

Howard: Info@successinendodontics.com. 

Jeffrey: Yeah, info@successinendodontics.com and we have a web site and we have a Facebook page and we've been doing all that. 

Howard: What's your Facebook page?

Jeffrey: Success in Endodontics.

Howard: Successinendodontics.com.

Jeffrey: Yeah. I'm pleased to have an affiliation with you guys. You Howard, have done a great job. You've taken technology and you've ran with it and you've taken dentists and we're all used to being little independent entrepreneurs sitting on our little independent operatories and you've brought the community together and you've done a beautiful job on that. You are to be congratulated for what you have done and establishing your blogs and your network. My hat is off to you.

Howard: Well, it's definitely my passion too. I've been on Dentaltown-

Jeffrey: It's fun when you find your passion. 

Howard: I've been on Dentaltown 5, 6 hours a day every day, 7 days a week since 1999. I don't care if it's Sunday, Christmas, Easter, Hanukkah, it doesn't matter to me. Hey, we're in way overtime. We're 3 minutes over. Hey, really dude, I think you're an amazing guy. I had so much fun with you in San Jose. I'm glad Dionne Warwick pointed you to that town. Thank you for this masterpiece program you put together. That's really ... I think it's the only one of its kind. I don't think there is-

Jeffrey: It's the only one in solar system, Howard.

Howard: It's definitely the only one in solar system. There's nothing else like it you'll be able to find on the internet. It is truly ... Hogo and me and Giacobbi, we're just leaving stuff like damn.

Jeffrey: That's a pleasure.

Howard: On that note, damn. Thanks, Jeff for all that you've done for endo.

Jeffrey: Okay, thank you so much, Howard.

Howard: Bye-bye.

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