Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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260 Evidence Based Dentistry with Liviu Steier : Dentistry Uncensored with Howard Farran

260 Evidence Based Dentistry with Liviu Steier : Dentistry Uncensored with Howard Farran

12/17/2015 2:00:00 AM   |   Comments: 0   |   Views: 632

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• Evidence based dentistry in decision making

• Actionable tips for your practice

• Protocol specifics



For many years, dentist Dr. Liviu Steier has been successfully practicing a comprehensive and holistic dentistry with a specialty in implantology.


Furthermore, Dr. Liviu Steier is a specialist in prosthetics as well as a specialist in endodontics. Through his active professorships in Italy (Florence), England (Warwick) and the USA (Boston) he has a constant direct exchange with colleagues around the world.




Dr. Steier received his Doctorate in medical dentistry from the University of Medicine and Pharmacy Faculty of Dentistry in Bucharest, Romania in 1982. He is a specialist in Prosthodontics and in Endodontics, has supervised several doctoral theses, and has lectured internationally. He has been Program Director and Co-director of over 200 CE programs around the world and has published extensively including referred chapters in textbooks. He is a Fellow of different international dental academies as well as having memberships in several societies. Currently, he is on the Faculty at Warwick Medical School and has been elected Visiting Professor to other European and US Dental Schools. He is Editor-in-Chief of REALITY ENDO and maintains private practices in Mayen, Germany and London, UK.

Howard: It is a huge honor today to be interviewing Dr. Liviu Steier all the way from Germany where it’s 10:00 at night. It’s only 2:00 in the afternoon here. Thank you for staying up late. Tonight, I’m going to definitely put you past your bedtime, keep me on the phone for an hour, but I was so excited to get to talk to you and interview you, I told my listeners, because evidence based dentistry is something new, it’s something that’s coming about, it took off more in the United States with oncology and cancer years ago, but it’s coming to dentistry. You have a lot of thoughts. You’re very well into evidence based dentistry. What do you think of the evidence based dentistry movement?

Liviu: For the moment, one of the biggest problems with evidence based dentistry is the fact that clinicians are requested to join decision making protocols based on evidence base while critical appraisal of the evidence has not been taught so far in universities. It is more an issue and a topic of postgrad education.

The evidence we have today available is in dentistry, especially, for example, the one in endodontics is more based up on in vitro studies. The clinicians are misled to believe that application of the results from in vitro studies can be taken one-to-one and it leads to a bias in clinical dentistry especially here in decision making protocols in endodontics.

Howard: Can you give an example of that?

Liviu: Sure. For example, one of the simplest decision which clinicians has to take is to understand today, in endodontics, for example, single file systems. Industry is pushing extremely heavy the clinicians to believe that using one single file, they could solve all the cases in daily practice, a fact which is almost proven by the studies, by the in vitro studies as well that one single file cannot solve not all the cases and surely should be reserved to a very restricted number of cases. A single file technique is not available at all, you will always have to use additional files to the one which is presented and pushed by the industry.

Howard: You’re saying that not all the advertisements we see in dentistry are true?

Liviu: Correct.

Howard: I think evidence based dentistry could have taken off a long time ago because all these dentists are entering digital computers that they did the treatment. If we would have been entering what materials we used, we would have samples that when over a million samples right out of the gate, but we don’t seem to capture this data as an industry, do we?

Liviu: It’s absolutely correct. The problem which we will be facing which started already is, of course, the high level of litigation based on this misbeliefs or biased decisions. The dentists are losing the confidence. I believe this is also very bad from an ethical point of view for our patients.

Howard: I think it’s crazy in the year 2015, I just read a study that said that if you were treated for cancer, the really famous cancer institutions like Mayo clinic or something like that that you got a 10% higher survival rate than if you were treated like a Medicare or Medicaid clinic. Gosh, you would think that the absolute, best protocol for a cancer should be mathematically based on all the data, there wouldn’t be much thought involved, you know what I mean?

Liviu: Yes, you are talking now ... You’ve very correctly brought in the topic of statistics, based on the statistics, the calculation of probabilities. If we try to make a parallel and to identify case studies which … Well, in vivo studies for the survival of root canal treated teeth or survival of other topics in dentistry, we would like to build a probability calculation, decision trees, a mark of model for decision, it would be almost impossible because we do not have sufficient data to support this probability calculation.

What we do today is we make a lot of shortcuts. These are shortcuts, ad modum, we are all familiar with the book of Daniel Kahneman, Thinking Slow, Thinking Fast and we are doing coloristics[ph] and all our decisions are [inaudible 00:06:55], gut feeling. We are supposed also to go into this shared decision making with our patients. We do not know the data, what the evidence is. To call it a shared decision with a patient, it is quite difficult, not to say it is not real.

Same if you go into cancers, well I’m a little bit familiar due to the fact that I have oncologist in my very close family from the U.S. and I know, for example, that a lot is done to replace with this new proton therapy and there are no facts to prove that they do prolong life more, it is only the fact that it will give probably less side effects. Evidence based, the way it is presented currently, it is misleading. From an ethical point of view, it is somehow cheating and destroying the relation, the credibility of the profession and the relation between patient and professional.

Howard: I think Germany is at least 10 years ahead of the rest of the world and definitely the United States because I see it in oral surgery. Oral surgeons in Germany is [inaudible 00:08:45] on whether or not they should pull wisdom teeth and they hardly pull a fraction of the wisdom teeth that the Americans pull, whereas the Americans, insurance covers it 100%, they just pull everyone’s wisdom teeth.

I’m a victim of this. I’m 53, so the first time I went to the doctor with a sore throat, they yanked my tonsils and adenoids out. They pulled everybody’s tonsils and adenoids in the ‘60s. Now, in 2015, they don’t pull your tonsils just because the insurance will pay for it. Do you think the United States extracts too many wisdom teeth, prophylactically, and don’t have the evidence to support the need for doing it?

Liviu: I would like a parenthesis here, the Kokin Library has already brought or made the statement that coronectomies for wisdom teeth are indeed a viable alternative to wisdom tooth extraction. Yes, I believe all around the world extraction of wisdom teeth is overemphasized due to monetary reasons.

Howard: Are there any other things that you see in the same boat as treatments that are over-utilized that don’t really have the science to back it and it probably is done more for economic incentives as opposed to scientific research?

Liviu: You may be familiar or the listeners might be familiar with the old Gold Cast Academy founded by Dr. Tucker in Seattle. Well, this was a very conservative and still continues to be an extremely conservative and long-lasting treatment. What we have today are just pushed into CAD/COM, just pushed into ceramics, into the CAD/COM technology of ceramics has already changed tremendously, for example, the fitting and the request for fitting of margins compared to the old gold restoration. Now, suddenly, these margins, bigger margins are acceptable simply due to the fact that they are glued in with resins. Yes, there are a lot of changes which are not all to the absolute benefit of the patient.

Howard: You’re talking about the difference in the pros and cons of gold going to ceramic, continue with amalgam silver mercury filling versus composite. I know that Europe has had some different views on the use of mercury because it seems to me the research is clear that amalgams last longer than composite. Do you agree with that statement or not?

Liviu: I personal have stopped utilizing amalgam restorations. My last amalgam restoration I placed was back in 1994. Sweden and Japan were indeed among the forefront fighters to abolish the utilization of amalgams. I do not see the toxicity of the amalgam restoration as such, what I do indeed recognize is that aging of amalgam restorations indeed lead to, based upon the mechanical properties like quick and flow to more [inaudible 00:13:11] fracture if not correctly placed.

If the indication is overstretched meaning that the width of the [inaudible 00:13:24] of the restoration is indeed more than just 1/3 of the width of the tooth. I would say, correct indication and correct use of amalgam restoration does, for sure, still support the use of amalgam restoration.

Howard: Where do you think evidence based dentistry is going? What do you think will be the changes that we’ll see over the next 5, 10, 20 years with evidence based dentistry? Do you think it’ll get more important and grow or do you think it will be marginalized to the side?

Liviu: If we look a little bit aside and we consider what’s going on with artificial intelligence, with decision making based on this artificial intelligence like we already have this in [inaudible 00:14:29], then yes, I believe that the decision, what approach, what to say, what we extract to crown or not crown, to post or not to post, root canal or not to root canal, to whatever, the decision making will be based upon other criterias than the empiric criterias we’re using today and we’re applying to day.

More of the decision making will be taken away from the clinician and it will be implemented in software, it will be implemented in other tools being taken away from the practitioner who will just become, more or less, the executing machine of this decision making, artificial intelligence decision making.

Howard: Who will be leading the way? Will this be led by certain countries, government or the private sector? Who’s leading the evidence based dentistry movement today?

Liviu: For the moment, it is quite confusing. In medicine, the Cochrane Library and Cochrane is, more or less, the highest level of evidence, of acceptable evidence, you have this pyramid of evidence, so systematic reviews and better analysis is among the highest level of evidence currently.

We cannot really apply Cochrane criterias or, for example, critical appraisal tools like the PICO tools for dentistry. We do not have … There is [inaudible 00:16:50] evidence for clinical studies. New materials, new instruments, new techniques are introduced into dentistry and there is no evidence … Evidence is build up once the instrument, the technology, the material is already in the market and not prior.

You do not have study Phase 1, 2 like in pharmaceuticals. It is currently very, very misleading. If you look into the Journal of American Association of the ADA, American Association of Dentistry, then you will see that they are talking and they are bringing new papers on how to implement evidence into clinical practice, but they do not help you by offering the studies and the tools to apply, the available data for your clinical case.

For the moment, everything is very misleading and confusing. I would suggest to allow and to teach the clinician and the clinicians more in regards of appraisal of scientific data to teach them. I would like to see also on the different forums now available more than just the presentation of how I solves this case and how I solved of herodontics, as we call it, to see more discussions on the decision and the choice for a technique, for an approach, for a restoration, for whatever, the choice how you came to the result, based on what criteria have been based for that approach chosen. This is what we are lacking.

Howard: Yeah, you still hear dentists all the time say, “Well, this is what works for me.”

Liviu: Yes.

Howard: I say, “Well, if it’s not …”

Liviu: Is this evidence?

Howard: Yeah, “Is this repeatable?” How do you think … Back to the advertisements, like you’ll get an implant, they’ll say, “Well, I have a 97% success rate with this implant,” but all the implants were placed only in the lower anterior mandible. There were no implants placed on the maxilla or with people with periodontal disease. Yeah, I see it all the time. How do you think a dentist could, you’re talking to thousands of dentists, how could a dentist listening to you become a better critical thinker and have better critical appraisal skills? How could she develop these skills better?

Liviu: [Inaudible 00:20:03] the recipe is not in self-education, the recipe lies in comprehensive educational programs. Universities should offer open courses, online is fine, to allow the clinician to continue his activity. I believe this MOOCs like Coursera and Audacity will manage to enter also the market and will open doors for this kind of education for our fellow colleagues.

In Europe we have, in U.K. for the moment the Learn Forum, so yes, this is the way … Online education is changing the face of the universities. You may be aware that, for example, open universities in U.K. have almost closed down 2/3 of their capacities due to the big competition by online courses, open online courses, massive online course. Yes, this is the way, I believe, it should go.

Howard: You said MOOC, the OCs for Online Courses, what’s the MO stand for?

Liviu: Massive Online Open Courses.

Howard: Ha! Interesting. Do you think some countries are using evidence based dentistry more than others? If so, why do you think some countries … Why do German oral surgeons extract less wisdom teeth than American oral surgeons? Which countries you think are leading that and why do you think they’re leading that?

Liviu: It is difficult, I do not owe[ph] the data on the topic of oral surgeons. As you know, here in Germany, we do have 2 different ways of qualification for oral surgery. There is the simple oral surgeon, meaning the dental school graduate who continued residency in oral surgery. He will perform the minor surgery. We do have the Max-Fac surgeons who graduated medical and dental school. In addition, they have this Max-Fac residency and education.

The clinicians or the general practitioners are referring youngsters and adults for wisdom tooth extraction to Max-Fac surgeons. This is performed under anesthesia and a full sedation which is a problem. We do see a lot of post-surgical trauma of TMJ due to the fact that the ligaments are overstretched because all 4 wisdom teeth are removed in one session. This is quite traumatic for the TMJ.

I do not really owe[ph] the data to make the difference and to say in one country there are more wisdom tooth extraction than in the other. I believe it is a problem also due to the number of professionals out there. It is difficult to compare numbers. I’m not sure we do have the numbers which compare the outcomes and the cases in the different countries.

Howard: You’ve been published so many times, especially in endodontics and ozone. What could you share about all your extensive endodontics knowledge? What’s hot, what’s not? What should people doing root canals be thinking about today?

Liviu: Number 1, do not believe that by using rotary files, you have solved the case. The root canal, the shaping mechanism either manual or rotary is just a tool to help and allow for irrigation. There should be the [inaudible 00:25:32] of endodontics, the [inaudible 00:25:33] of endodontics success should be chemical disinfection, number 1, and number 2, sealing coronal and apical sealing. Number 3 is understanding the coronal restoration in terms of forces, of mechanics. If you follow this 4 points, then you’ll be able to raise the success rate in your clinical practice.

Howard: You said number 1 was chemical disinfection. 2 was epical sealing?

Liviu: Coronal and epical sealing.

Howard: Okay, what was 3?

Liviu: The coronal restoration, yes.

Howard: What was 4? Was there a 4 or just 3?

Liviu: Just 3, yes.

Howard: Okay, so you’re saying that it doesn’t matter if it’s manual file or rotary file, the only thing the file is doing is opening up a space to get the chemical disinfection down there. What …

Liviu: Root canal restoration material, yes, the sealing.

Howard: What should they know about chemical disinfection? What chemical disinfections do like, how long does it need to be in there? Is there …

Liviu: If we go back into what we discussed at the beginning when we said that this concept of single file is not true as a concept because you’ll always use more files, this concept of saving time by using just one single file cannot be validated.

If you have a vital case, the chemical disinfection protocol will be completely different than in a non-vital case. You have to use other irrigant protocol, the different irrigant protocol. You will use different instruments and materials to help and increase the efficacy of the irrigant in the root canal. The timeframe will be longer as such, so it is a complete different … You have to divide and to split between simple anatomy on one side and complicated anatomy on the other side.

Number 2, you’ll have to divide between vital cases and non-vital cases. In the non-vital cases, you will have again to divide … We do know there is, for example, data that 86% of upper molars have somehow an involvement in MSGOs. Are you prepared for this case? How are you performing this case? How will you solve the case?

Irrigation, chemical disinfection is not … It is not a topic which has been completely elaborated. When we discuss about sodium hypochlorite, you will find the ones who will tell you, “Just use up to 1.5%” due to the cytotoxicity. Other ones will tell you, “No, use 5.5% then heat it up.” Then you’ll have the ones who will tell you, “Don’t use sodium hypochlorite in those and those areas due to cytotoxicity and possible emphysema.”

There is so much going on. This is exactly coming back into what we were talking, the evidence, there is no final evidence for that. It is still a problem I the decision making protocol and we have to help support the clinicians out there in building this decision making protocols and in helping them deciding and appraising what kind of case they have, what would be the best solution for their case based on evidence, based on their own expertise on their knowledge, on their technology and so on.

Howard: Where do you think the evidence lies now on those 3 areas, chemical disinfection for vital versus non-vital, coronal ceiling, apical and the coronal restoration, where do you think the evidence is overwhelming that we should be doing something, a certain protocol?

Liviu: Let’s start with the easiest, I would say coronal sealing, in the coronal sealing, I will definitely say adhesive seal.

Howard: You’d say what seal?

Liviu: Adhesive seal, adhesives.

Howard: Okay.

Liviu: In the apical seal, we still have big leaks. For the moment, we know that a three-dimensional root canal obturation is the best way to go. We do not have the perfect material for a root canal obturation. We cannot have a perfect adhesive seal in the root canal due to the configuration factor, so on shrinking and other shortcomings which are material based.

In the disinfection, the best way to do is, for sure, time, take your time. Use fresh sodium hypochlorite depending on the case, vital or non-vital, you may use different concentrations. You may want to energize the solution to make sure that the penetration capacity into the dentinal tubules is granted.

There will be other additional disinfection mechanism which you will want to use like from photo-activated disinfection to ozone, from a variety of irrigants, from a negative apical pressure to the cone technique. There are many ways which you could help and enhance the penetration of the irrigant in the canal. Make sure, number 1, that you give the needed time. Yes, basically, these are best tips I could give a clinician for his practice for tomorrow.

Howard: Will you go back and talk more about how you irrigate differently for a vital versus a non-vital? You’re saying that it takes a lot more to kill the bacteria in a non-vital infection, so do you use a stronger sodium hypochlorite and how much longer do you use … What is the difference in your protocol between vital and non-vital?

Liviu: We have to understand that in a vital case, the infection is more in the coronal part. This is probably the biggest difference. Then in a non-vital, indeed, I use a higher concentration, I use 5.5 heated, 50°C heated sodium hypochlorite. I build up my shaping, I have a shaping protocol. This is what we also teach. We have the shaping protocol complimented by continuous irrigation with sodium hypochlorite. Then there is a final phase of chemical disinfection.

Here, of course, you have to address organic and non-organic components meaning sodium hypochlorite versus EDTA. Do not forget that the combination of sodium hypochlorite and EDGA will reduce the efficacy of the solutions. Then there is indeed, in addition, I prefer today to use photo-activated disinfection in the last part of the chemical disinfection protocol.

Last but not least, the application of chlorhexidine, not so much for its chemical disinfection, but for the inhibition of the matrix metalloproteinase or the MMPs which can induce the so-called [inaudible 00:36:25], the collagen [inaudible 00:36:27] in the structure.

Basically, this is the extended irrigation protocol for a non-vital case. Time is, of course, very important. In a vital case, I will not use adjuvants like photo-activated disinfect like PAD or ozone, I will just stick to a classic chemical disinfection protocol as already discussed.

Howard: What is this photo-activating disinfectant? I think a lot of our listeners have never heard of that before.

Liviu: Photo-activated disinfection, you are using a dye, different dyes, and you are bringing in some energy, light energy, and this will, in addition … There is a very good penetration of the solutions into the dentinal tubules. The energy you’ll bring, you can bring … There are different dyes and different solutions, you are basically producing, for a very short period of time, an O3 which manages to act as a very good disinfectant. Photo-activated disinfection is not new and it is not particular to endodontics. You may find it paleontology already, its application in [inaudible 00:38:13] is well established.

Howard: Do you have any brand names? How would a dentist purchase this? Where would they find photo-activated disinfectants?

Liviu: For example, here in Germany, you’ll find it under the brand name of Aseptim, HELBO, H-E-L-B-O, are probably the 2 biggest brands here in Europe.

Howard: You’ve been published so many times in endo, but also ozone, what are your thoughts on ozone?

Liviu: Ozones, the problem was … Well, I still, to make it short, I still believe in the excellent ability of ozone in disinfection. The only problem, we did a lot of research with the product manufactured by Cabo[ph] which was the halo[ph] zone, we did a lot of research within cardiology or cavity disinfection as well as in endodontics, I believe the way it was marketed that time was, again, lacking adequate[ph] evidence and it was misleading.

We have seen that applying ozone to sodium hypochlorite, it will activate much faster, the sodium hypochlorite for its tissue dissolution ability and one could reduce the concentration of the sodium hypochlorite used for disinfection. We had results proving that 1.5% solution would be sufficient.

Number 2, the time needed for ozonated sodium hypochlorite would half, so it would speed up the treatment as well. Sadly, technology, so it would speed up the treatment as well. Sadly, technology, adequate technology for manufacturing and to support the studies and the research performed were not adequately spread and available. This is why probably the big hype around the use of ozone chilled down massively.

Howard: Do you think lasers will be used to clean, sterilize and disinfect the inside of endo? Do you see lasers now being used in a lanap peridontal disease protocol where they’re using the laser to disinfect? Do you think lasers are good at disinfecting the endodontic canal?

Liviu: Personally, I’m not an advocate of the application of lasers with the exception of lasers used for the photo-activated disinfection. I also have not done sufficient research on the topic. The evidence we have on the market is not yet satisfying, also in vitro studies, to support, but chances are very good that lasers as a supporter adjunct disinfection could be a valuable … Especially, for example, in non-vital cases, in cases with chronic apical periodontitis and so on. If you would ask me today, “Would you invest in a laser to improve the outcome or would you consider investing in a laser to raise the success rate of your root canal treatments?” I would say no.

Howard: How is your mind thinking when you see a failed root canal and you got to decide, “Should I redo the root canal or should I extract and go to an implant?” What are you looking at to try to make that critical thinking, that critical analysis?

Liviu: Number 1, we know already that these are facts that implants seen as natural teeth are affected by time and by the changes available within the body. There is this bone modeling and remodeling process within the body. Due to that, we know that the chances for disease with implants are higher than what we thought at the beginning when implants were placed only in the area, as you correctly mentioned in the beginning, in the interforaminal area.

Predictability of regeneration in implant disease is much lower than the predictability of regeneration of protocols applied in natural teeth. The replacement of a natural tooth by an implant requires, indeed, consideration of different other factors.

Number 1, which I would like to emphasize here is to stay within your limits of knowledge skills and abilities. Do not be worried if you have to refer, as a clinician, a case out to a specialist. You know the statistics in the U.S. show that the vast majorities or more than half of the root canal treatments are performed by clinicians, same as secondary root canal treatments, also the vast majorities performed by the general practitioners.

If you have a non-vital case, do not be worried to refer the case out. The specialist will send you the case back and you’ll be able to build, continue the treatment and the care of your patient in your practice. The consideration which has to be given when the decision making has to be performed to save or to extract, much more teeth can be saved than it is the case today.

Implantology is there, just not as an alternative for the decision making protocol to treat or not to treat or to extract the tooth, but the implant has been established or has been introduced as a tool in a case where teeth are indeed missing, in the case where the support for the restorative dentistry is not given.

Implant dentistry is not a competitor for endodontics. It is a complete, different instrument in the armamentarium, in the hand of the dentist. Dentistry has sufficient work to be granted for the clinical practitioner, for the specialist, either for specialist in endodontics or the implantologist for paleodontogy, so the work together will be much more beneficial for the patient out there. Basically, what we owe, we owe the service to the patient because we are privileged to be allowed to heal and to treat. We should fulfill this task and not made the choice as simple to save or to extract.

Howard: A lot of times, a kid will learn something simple in dental school like the final restoration of every tooth for the root canal should be a crown. That probably makes sense on a lot of the molars, but when you get into the lower incisors, when you get down performing a root canal and then with a constricted singular [inaudible 00:48:22], you prepare that for a crown, there’s just literally nothing left to the tooth, you’ve cleaned it out for the root canal, you filed it on for the crown, do you really think the mandibular 4 incisors after a root canal should be crowned? What would your coronal restoration advice be for the 4 lower incisors?

Liviu: Understanding mechanics, understanding forces available, diagnostic of the chewing patterns of the individual patient, habits like parafunctional habits. All these are the criterias which have to, first, analyzed prior to deciding the kind of restoration given or got chosen for the anterior incisors, lower incisors.

I believe that also oral hygiene has to be considered. I’m not among the advocates of those advocates of saying that every root canal treated tooth requires a [inaudible 00:49:55] coverage. I believe that the tools available today in our hands with adhesive dentistry are superb and they are granting excellent long term success rates if correctly chosen, correctly applied.

You can even use prepped or non-prepped veneers for the restoration. Yes, I’m in agreement with yourself when you say, “I would prefer to be paid for the amount of tooth structure I saved than for the amount of tooth structure I removed.”

Howard: Well said, “I would rather be paid for the amount of tooth structure I saved, than being paid for the amount of tooth structure I removed.” It’s true. You’ll see people with a worn down dentation and to save their worn down dentation, they file a nullity for the crown. Sometimes you wonder if money is the answer, what is the question?

Liviu: Correct.

Howard: What other advice would you … You talked a lot about chemical disinfection, the coronal sealing, the apical sealing. On the apical sealing, what is your favorite sealer? You said adhesive sealers, do you have brands that you like? Is there some brand better than others?

Liviu: Now, this is a question which … I will answer this question honest. I know I expose myself tremendous by answering this question honestly. I have participated from the beginning … I worked with the first prototypes and I was asked to evaluate the first prototypes of a material which is now, the verdict has been, “Kill it,” it was [inaudible 00:52:04].

Howard: What was the company that sold [inaudible 00:52:10]?

Liviu: The first, the manufacturer of [inaudible 00:52:13], the manufacturer, the initial manufacturer of [inaudible 00:52:17] was Pentron. Then it went to [inaudible 00:52:21]. Basically, [inaudible 00:52:24] was, over the last couple of years, a product produced, manufactured and distributed by [inaudible 00:52:34]. Other companies as well have the product were allowed on their own names to sell it, but the manufacturer basically and the patent were owned by Pentron, a company which was then bought by [inaudible 00:52:58] and so on.

Howard: Then that’s owned by Danaher, Danaher, then it’s Kerr going Sybron.

Liviu: Yes, but sadly, the company has decided, due to the fact that the sales were not satisfactory, the material has been now taken off the market. For me, this material, and I’m not the only one who … Well, from the beginning, the protocol of use which I have suggested was somehow different to the protocol of use suggested by the manufacturer and by the U.S. opinion leaders.

Interesting wise, I will not give any names, but I met some of those opinion leaders in the last 2 years. I enjoyed when they came to me, they approached me and they said, “We should have followed your application or your protocol. That way, we wouldn’t have killed the material.”

It was said that there was this monoblock idea which, of course, you cannot have a monoblock in the root canal, but indeed, the tribology of this material especially in the three-dimensional root canal obturation approach was a fantastic material.

Sadly, it is taken off the market today. Everyone is trying to jump on the bandwagon of bioceramic MTA light materials. I’m still not convinced that this is the solution, so basically, we are now at the limit where … At the border where we are looking into new technologies, new materials, new approaches. It is a challenging time for the root canal obturation, currently.

Howard: Well, if there’s some kid listening to us right now, she’s 25, she just got out of dental school and she’s asking you what brand of sealers should she use, what would you tell her?

Liviu: I cannot answer with just suggesting 1 brand.

Howard: Can you give her a class of brand or multiples or … What advice would you give her?

Liviu: I can’t …

Howard: Let me ask you this, when I got out of school, pretty much, they only had 1 sealer, it Grossman cement. Then the next big thing was AH 26. First of all, what do you think of the ancient Grossman cement and then the next generation AH 26 … She’s asking the question, what sealer would she use? You got to answer her somehow.

Liviu: Yes. Number 1, I would suggest don’t trust single-cone technique. I would suggest a three-dimensional root canal obturation. Lateral condensation, imagine an ashtray and you are putting your cigarettes into an ashtray. You can put a lot of cigarettes in this ashtray and you’ll still have gaps in between.

This gas now, you will want to fill with a sealer. You will still have porosity and you will still have gaps. Lateral condensation, I wouldn’t suggest. Single-cone technique, again, this is an approach where in a curved canal, you will have areas where you will have direct contact of the cone with the root canal and no sealer in between.

Now, if you have a three-dimensional root canal obturation material, what you will have, you will end up, for example, if you are using the classic epoxy resins like AH+ or similar, your intention is to have an adhesive joint. There is no adhesive joint between gutta-percha and an epoxy resin.

If you go and do your vertical condensation technique, you will end up with a mixture of gutta-percha and sealer. If you do the very same using the gutta-percha and an MKA light material, you will again end up with a mixture of a hard cone with implementing sealer in between.

As you can see, we do not really have an optimal material. Of course, the new MKA light materials have the big benefit of a very high biocompatibility. If biocompatibility is your main goal, then yes, stick to a MKA light material in combination with gutta-percha.

Howard: Some dentists still like the warm gutta-percha like the obture system, they like the [inaudible 00:59:41] instead of a cone, instead of a lateral condensation. Do you think warm gutta-percha, condensing warm gutta-percha is better than a single-cone and lateral condensation? Do you recommend that?

Liviu: The answer is definitely yes.

Howard: What percent of the endodontists, I believe there’s 4,000 endodontists in the United States, I don’t know how many are in Germany and in Europe, but what percent endodontists do you know use warm gutta-percha as opposed to lateral condensation versus single- cone?

Liviu: I know, for example, that in Germany, some universities continue to teach lateral condensation at undergrad level. In the U.K., there is a university where I know that lateral condensation is taught even at a postgrad level. In the U.S., warm vertical condensation is probably the tool or the technique used by specialist on endodontics. I believe that it is just an estimation, I do not owe[ph] any numbers, but probably more than half of the specialists will use a warm vertical condensation approach.

Howard: Okay, our hour is up. I want to stay close to the hour because now it’s 11:00 pm in Germany. You’re probably going to be mad at me in the morning when you wake up being tired, but I want to say that I’m a big fan of you. Ken Zoroda[ph] is a big fan of you. I have so many of my endodontist friends cannot believe that I was lucky enough and fortunate enough to be interviewing you all the way from Germany.

Your resume, you can’t even your whole resume, it’d be like reading a book. I just think, thank you so much for all that you’ve done for dentistry around the world from roots, ozone and all the things you’ve published. You’re a legend and it was an extreme honor for you to spend an hour with me today on my podcast, thank you so much.

Liviu: Thank you very much, indeed, as well.

Howard: All right …

Liviu: I’m honored to have been interviewed by you.

Howard: I’m sure you’ll sleep well tonight after this late interview. Good night.

Liviu: Thank you, good night.

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