Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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293 Best Practices in Endodontics with Rick Schwartz : Dentistry Uncensored with Howard Farran

293 Best Practices in Endodontics with Rick Schwartz : Dentistry Uncensored with Howard Farran

1/19/2016 6:20:32 AM   |   Comments: 0   |   Views: 1619

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AUDIO - DUwHF #293 - Rick Schwartz

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VIDEO - DUwHF #293 - Rick Schwartz

Learn about:

  • New book from Quintessence: Best Practices in Endodontics, a Desk Reference
  • Interdisciplinary endodontics
  • The endo-restorative interface
  • The endo-implant interface
  • Management of resorption
  • And more!


Dr. Rick Schwartz was a restorative dentist for 19 years prior to entering post-graduate training in endodontics.  He attended a 2-year general dentistry residency, and then did a combination of private practice, teaching and dental materials research before entering endodontic training in 1996.  He has authored over 100 articles and abstracts and was a cover author on 3 editions of “Fundamentals of Operative Dentistry” by Quintessence Publishing Co. He is first author of the book “Best Practices in Endodontics, a Desk Reference”, recently published by Quintessence, and is a cover author on “A CBCT Primer for Endodontics “, soon to be published.  He has lectured to a wide variety of audiences on topics related to endodontics, in the US and 14 other countries.  For the past 17 years he has been in full time private practice limited to endodontics in San Antonio, TX. 

Howard Farran: It is a huge honor today for me to be podcast interviewing Rick Schwartz. He goes by Rick, unless he's in trouble by his mom. Then he goes by Richard. He's in San Antonio, and he is a legend in endodontics. I am so honored to have you today. You really are amazing. 

Dr. Rick Schwartz was a restorative dentist for 19 years prior to entering post-graduate training in endodontics. He attended a two-year general dentistry residency, and then did a combination of private practice, teaching, and dental materials research before entering endodontic training in 1996. He has authored over 100 articles and abstracts and was a cover author on three editions of "Fundamentals of Operative Dentistry" by Quintessence Publishing. He is first author of the book "Best Practices in Endodontics: A Desk Reference", recently published by Quintessence, and is a cover author on "A CBCT Primer for Endodontics", soon to be published. He has lectured to a wide variety of audiences on topics related to endodontics, in the US and 14 other countries.  For the past 17 years he has been in full-time private practice limited to endodontics in San Antonio. Rick, seriously, dude, this is an honor to have you today. How are you doing?

Rick Schwartz: I'm doing great, thanks. 

Howard Farran: I want to ask you the most off-the-wall question. Why do you think of all the general dentists I know half of them hate molar endo, and then the other half, when we look at the online CE courses on Dentaltown, endo is always ... Every single month, it's first or second in online CE views. It's just a really difficult procedure, isn't it? 

Rick Schwartz: Sometimes it is. I think that a lot of general dentists, what happens is they come out of school and they attempt some of the difficult cases, and things don't go well. Some of them continue to do it, but a lot of them back off. The simple straightforward cases, probably a general dentist can do them just as well as an endodontist. The complicated cases, it's harmful to your practice if you get bad outcomes. After a while, most dentists come to the conclusion that it's better for their practices if they don't do everything themselves. 

Howard Farran: My jealousy towards you is, when I look at my friends from dental school that went into specialty, their whole life they get to focus on one area. Then, as a general dentist, we have to keep up on root canals, fillings, crowns, bonding, veneers. You just can't do it all. 

Rick Schwartz: It's impossible, really. 

Howard Farran: Look at implants, just the bone grafting alone would be a full-time job in continuing education, and spinning blood, and platelets. Gosh, where does it end?

Rick Schwartz: It's a funny thing. When I started as an endodontist I had been a general dentist for a long time. My plan was that I was going to focus down on a few procedures and hopefully become very good at those. What's happened over the years is actually I'm doing more and more stuff again. I wasn't planning to do any restorative after I graduated my residency. My plan was that I was going to put cotton and Cavit in all of the teeth and not have to deal with that. We started seeing problems coming back after a while, and we decided that it was important that we start doing the foundational restorative. Basically, my partners and I restore all of the teeth now, the initial restorative on all of the teeth that we do endo, just for a variety of reasons, but mainly because it's the best thing for the patients in the long run. 

The other thing is, I'm doing some extractions now, depending on the situation, just because most of my referring doctors, they just want things taken care of. They don't care so much who does them, they just want things taken care of so they don't have to deal with them, so that what's most convenient for their patients. I used to do a lot of IV sedation in my general practice. I wasn't planning to do that particularly, but we've gotten back into that. I do crown prep sometimes for some of my restorative dentists. It's funny how, I don't personally do implants, but some of the endodontists I know have gotten into implants. It's funny how it's expanded out into not at all what I expected.

Howard Farran: Let's talk about the buildup, because a lot of people say that when a root canal fails it's from coronal leakage down. It's not from leaving infection in the tooth. What percent of root canals do you think fail from restoration leakage?

Rick Schwartz: Actually, I could tell you fairly authoritatively on that topic just in general. First of all, nothing good happens if you don't restore the tooth right away. Only bad things happen. The tooth breaks, you get contamination, it doesn't get restored and they get carries. We actually did a little study in our practice about five years ago. We recalled 100 patients who we'd done endo on at least 10 years earlier, which is a big job, let me tell you. We had to call about 250 patients to get 100 to come in. Then, the ones that had failed, we tried to get a hold of the old charts from the restorative dentist and see how they failed, because endodontists rarely get to see their own failures. 

We're fat and happy. We sit in our office. We think we did our job and everything is great. When a tooth gets extracted, we don't usually hear about it unless we happen to see the patient later on for another tooth. Out of those 100 patients that had been treated, 20 of the teeth had been extracted. I was ready to kill myself. I couldn't believe how many failures that I'd had. What we found was only four of them we could really say were endo failures. The other 16 were either the tooth had cracked, or the crown had snapped off, or they had developed carries and had been extracted. The vast majority of the teeth that fail, it's because of structural integrity of the tooth or because of restorative issues. That's part of it. 

Actually, there was an article that came out about a year ago, a little less than a year ago, from Scandinavia. The primary author was a guy named Kvist, K-V-I-S-T. They found exactly the same thing. Almost all of the failures were structural failures of the teeth. They had a little bit more carries than we did. They had hardly any endo failures, either. This was in a public health clinic. The bottom line is that you need to start out, first of all, with teeth that are structurally strong. Then, second of all, they need to be restored well. The best way to do it is to restore them right away after the endo is complete. The tooth's isolated. There's no opportunity for contamination. Of course, not all endodontists are well-versed in restorative. The ideal situation is complete the endo, have the endodontist restore it if they know what they're doing, and then have the restorative dentist take it from there. Nothing good happens if the restoration is delayed. 

Howard Farran: Rick, we've seen in dentistry where, in 1950, average overhead was about 40%. Now, in 2015, it's nearly 64%. These bonding agents are $250,000 for a barrel of bonding agent when you're down there, in Texas, where today I think crude oil opened up at $35 a barrel. What about the old-fashioned just $1 capsule of amalgam? The reason overhead's gone up is because insurance companies have pretty much held the price. Every time the earth goes around the sun, inflation goes up. We've really eroded our margins about 25%. Is an amalgam a low-cost alternative buildup after a root canal in a molar, or would you just want to only do adhesive dentistry?

Rick Schwartz: We like amalgam. We would like to do amalgam a lot more than we do, actually. The problem is that some patients don't like it, and some of our restorative dentists don't like it. We use it, I don't know, probably 25% of the time, something like that. Amalgam is strong. The seal improves with time, as opposed to composite, where the seal breaks down with time. If it's not in an aesthetic area, that's oftentimes our first choice, is to use amalgam. 

Howard Farran: Why is that so controversial among dentists? I want you to address this. I could split the dentists in America in half. Half of them say, "Amalgams are horrible because they fracture teeth, and that when you place MOD amalgam it's doomed to fracture and fail." I see the research showing that these things can last 35 to 40 years. Then other people say, "Well, you know, endodontists love posterior composites because they irritate the bulb and they cause a lot of endo." Then, I look at a lot of research that says these posterior composites are only lasting six to seven years. Forget looks and aesthetics and all that, because you're talking to a short, fat, bald guy, and you don't see any of my teeth. What do you think would last longer in a MOD restoration on a first molar?

Rick Schwartz: Let me just say, first of all, that amalgam is much less technique-sensitive. It's easier to use successfully. Composites, when they're placed really well, do pretty well. Oftentimes, there's not good isolation. If you get contamination, you get very poor bonding, and that makes it more susceptible to leakage and breakdown later on. Here's another little study that we did in our practice a few years ago. We looked at 100 patients who'd had composite buildups that were at least five years old according to the patients that had crowns on them. One of the things we do when we make access is we paint the inside of the preparation with carries detectors. We did this on 100 consecutive patients with five-year-old composite buildups. Let me ask you, what percentage of them do you think had carries underneath?

Howard Farran: I would say 80%.

Rick Schwartz: 37% had frank carries, where it's stained along the margins and when you poke at it with an explorer it was soft. Another 22 of them had staining but we couldn't detect any softness. A lot of these things are leaking. Some of those, probably, they didn't remove all the decay originally. It's not all because of leakage. A lot of these things have leakage underneath. My feeling about composites is that done well it's about a 15-year restoration. To answer your question, an MOD posterior is probably about a 15-year restoration if it's done well.

Howard Farran: Amalgam or composite?

Rick Schwartz: Composite. I'm sorry, did I say amalgam? Composite. 

Howard Farran: You're saying that a posterior composite done well is about 15 years?

Rick Schwartz: That's my feeling, anyway, all things being equal. I can tell you, I have a friend of my wife that I follow that had some concern of MOD amalgams placed in 1958. What does that make them? 57 years old now. I can promise you that you're never going to see a 57-year-old composite.

Howard Farran: Absolutely not. You're saying probably the average posterior composite done well maybe 15 years?

Rick Schwartz: That's my opinion. 

Howard Farran: What would that be if it was amalgam? What do you think? 100 MOD amalgams done well. 

Rick Schwartz: I think that you, from what I've seen, anyway, and this is not research-based, it's just my opinion, but I see lots of old amalgams that are 20 and 30 years old that are doing just fine. They're discolored, and maybe the margins are just a little bit, but they're doing fine. I'm an amalgam fan. Like I say, a lot of my referring doctors are not. I'm obligated to do what the referring doctors request. Of course, when I place access restorations or I place buildups they're done well, they're isolated well, and they're done following the instructions by the manufacturer. Many of them are underneath crowns. I think those, when they're protected by a crown, I think they last more than 15 years. The other thing with composite is if you've got enamel margins all the way around, those have good longevity. The problem with an MOD is that you don't have much, little if any, amalgam at the gingival margin, and that's where the problem is. 

Howard Farran: What percent of the dentists in San Antonio that you work with accept insurance, would you say?

Rick Schwartz: Most of them accept some insurance. 

Howard Farran: If the insurance is setting the market price, and the market price is not been going up, then you have to lower your costs. If there's going to be a crown over that tooth anyway, I just don't understand why you just wouldn't go to amalgam. When these doctors, the same doctors that say, "I'm amalgam-free," the next question is, "Why is my overhead so high? How could I lower my overhead?" I'm like, "Dude, you're paying over $1 million a barrel in bonding agent." I could go on and on and on with that forever. Show me the book to the left, there. Is that your bedtime reading?

Rick Schwartz: Yeah. This is a book, can you see it?

Howard Farran: Yeah. "Best Practices in Endodontics: A Desk Reference". Tell us about that journey. 

Rick Schwartz: We have this online discussion group of endodontists from around the world and we discuss all these things. We discuss literature. We post cases. We sometimes have ... 

Howard Farran: The TDO community? 

Rick Schwartz: TDO. It's a software users group. 

Howard Farran: Who's that guy out of California? TDO?

Rick Schwartz: Gary Carr from San Antonio. It's his company. 

Howard Farran: It's endodontists only.

Rick Schwartz: There's a few general dentists on there, but it's mostly endodontists. 

Howard Farran: How many endodontists would you say are on there? 

Rick Schwartz: Maybe 500, something like that. We, over the years, we've discussed all these interesting cases and how to handle different situations, and that sort of thing. We got the idea a few years ago, why don't we put these things down in writing and do a book? I have a relationship with Quintessence from my restorative days, and so I approached them about it. They were interested in doing it. This book has, I don't know, about 40 chapters, or so. Some of the chapters, the initial ones, are more geared towards endodontists. They're like how to set up your operatory properly to utilize the microscope, how to do things ergonomically with the microscope, how to train an assistant to work under the microscope, how to document your cases, how to set up to do photography through the microscope, and video, and how to document your cases. Those are things that primarily are of interest to endodontists. 

The rest of the book is about mostly how to do a single procedure. Let me just flip through, here. I'll tell you what some of the chapters are on. Also, there's a couple chapters on cone beam CT in endodontics. Then, for example, there's chapters on access preparations, how to obtain working length, how to prepare the canals, how to deal with calcified teeth, severe curves, a couple different methods for obturation, managing C-shape configuration. There's a couple chapters on retreatment. There's actually two, four, six chapters on restorative: evaluating restorability, pre-endo buildup, customized resin matrices, just things related to ... There's a chapter on bonding to ceramic materials, because there's several different ceramic materials now. You have to be able to identify them and know the proper bonding procedures for them.

There's several chapters on how to deal with resorption. There's several chapters on trauma management. Then, a few other things, horizontal fractures, how do you deal with those, perforations. Let's see, how to do just a quality intraoral radiographs, how to take quality PAs for doctors. How to effectively communicate with patients, and just a few other things. The idea is that if you haven't done a procedure before, or maybe if you have and you want to bone up on it, you can just look at one of these short chapters. It tells you a little bit of background, what sort of armamentarium that you need, how to actually do the procedure step-by-step, that sort of thing.

Many of the people that contributed to this, there's about 30 different people that contributed to this from five different countries. Many of these people are some of the best endodontists in the world, some of the best and the most skilled endodontists in the world. Many of them are people you've never heard of, actually. Probably most of them are people that you've never heard of.

Howard Farran: I know you're a busy man, but Dentaltown Magazine goes to 125,000 general dentists every month, and 100-page magazine. If you ever have time to write an article summary of your book, I would love to print it if you give away some ... 

Rick Schwartz: I'd be glad, too. I'd be glad, too. 

Howard Farran: Where can our listeners order that book? Quintessence Publishing, do you know the website address?

Rick Schwartz: If you just go to Amazon, that's probably the easiest. They sell it at a little bit of a discount. If you just type in "Best Practices in Endodontics" it will take you to the proper page. 

Howard Farran: "Best Practices in Endodontics" and then also "A Desk Reference". Is that part of the title, too?

Rick Schwartz: "A Desk Reference", yeah. 

Howard Farran: "Best Practices in Endodontics: A Desk Reference" by would it be Rick or Richard? 

Rick Schwartz: Richard. 

Howard Farran: Richard?

Rick Schwartz: Yeah, Richard. 

Howard Farran: Your mom's yelling at you from that book that you're in trouble. You must have left a chapter out if you put Richard Schwartz on there. There's got to be a typo in there, since you didn't go with Rick. I want to ask some questions that I always see on the endodontic threads on Dentaltown. The website's got a ... By the way, what's the website address to that TDO website for endodontists only?

Rick Schwartz: It's 

Howard Farran: TDO4Endo. TDO4Endo. Will Gary let just a general dentist join, or is that just by invitation only for a general dentist?

Rick Schwartz: You have to either use his software. He also has some image management software, which is a lot less expensive, which you can buy, and then you're allowed onto the website. 

Howard Farran: Is he still doing endo. 

Rick Schwartz: Oh yeah. Three days a week. 

Howard Farran: Three days a week he's still doing endo. Near San Diego?

Rick Schwartz: Yeah, in San Diego. He's a pretty remarkable guy, actually. 

Howard Farran: Does he still collect horses?

Rick Schwartz: I don't think so. I haven't heard about that, anyway. 

Howard Farran: I remember back in the day he was into horses. Hey, I want to ask you some questions that I see. I was looking on the endo forum today on Dentaltown. How should a dentist be thinking when the apex locator measurement doesn't really look like the radiographic image? Who are you to trust when those two don't look like they agree? 

Rick Schwartz: When you look at working length, there's four methods for getting working length. Some people can say they can do it by feel, so that's the worst method to use.

Howard Farran: Is that the Stevie Wonder method?

Rick Schwartz: Some people claim they can do it by feel. The next most accurate is radiographs. They're misleading, a lot of times, because the [IOPA 00:21:43] frame is not necessarily at the apex, and plus sometimes it's just hard to see. The apex locator is the next most accurate, and it's pretty good. It's pretty accurate most of the time. Actually, the most accurate method, and there's a chapter in the book about this, is to use paper points. Most people actually use paper points the wrong way. The best way to use them is, first of all, you get an initial idea, either from your radiographs or from your apex locator as to the proper length. Then, you prepare the canal to that length and dry it. Then, go at it with a paper point and see where you get a wet spot at the tip. Do that a couple times and see what sort of length you get. That's actually going to be a little bit short, because of wicking that you get in the paper point from the moisture. 

Then go back with paper points a little bit shorter than that, let's say a half a millimeter shorter. If the tip is dry, then go a little bit farther. If the tip is still dry, then go a little bit farther. You want to use the longest length where you can get a dry paper point. That's going to be very accurate. You're going to be right on every time if you do it that way. You can't have weeping into the canal. You have to have a dry canal, obviously. If you prepare the canal, if you get patency, you prepare the canal, and then you're able to dry it with a fairly consistent wet-dry line, then just back off and use the longest length you can get with the paper point. Like I say, you'll be right on every time. The times when an apex locator doesn't work that well, like if you have apical resorption or if you can't get the canal dry, but this paper point method actually is the best method to use in all different situations. 

Howard Farran: Now you have your paper point dry, you have your length, really feel your length, then what would you do next, then? What sealer would you use, and how would you apply that? Would you apply that with a paper point, or do you like to use the [inaudible 00:23:41] and spin it down into the canal?

Rick Schwartz: First of all, I do almost no single-visit. I know probably most endodontists and most of your listeners, or your readers, probably do it mostly in single-visit. I do it almost no single-visit treatment. The reason for that isn't that necessarily it's more successful doing it that way, at least the literature's not very clear on that. The reason I do it is that the doctors that I refer to, the biggest thing I have to offer them is success. There's a certain percentage of cases that endo just doesn't work. If you look at the literature, about 5-10% there's persistent problems with them. I can't be sending cases back to my referring doctors with problems. 

The only way that I can tell for sure if I've eliminated their problems is to start treatment, put calcium hydroxide in, see how it goes, see if the symptoms go away, if the sinus tract heals, if swelling goes away, if deep pockets reduce. I don't finish the cases until all of those things have been resolved, which is usually at the second appointment about a month later. Then I finish the treatment, send the patients back to the referring doctors. In San Antonio, most of the best restorative doctors refer to me or my partners. The reason is because they don't get cases back with problems. We don't ever get phone calls from them saying, "Hey, the patient's in here. I'm getting ready to do the crown prep and they say the tooth's still symptomatic." We've eliminated all of that by this multi-appointment process. That's the first way that I would answer your question. Then usually we put calcium hydroxide in. 

Then, when it comes time to obturate, I recheck my working lengths to make sure that they're still good. Then, I just dip some sealer on the tip of my cone, and seat my cone, and then go through with the obturation process. I do a warm vertical technique. Honestly, the sealer that you use is probably the least important aspect of endodontics. The obturating technique that you use probably doesn't make any difference, as far as success and failure go. People always ask me when I lecture, "What sealer do you use?" I use AH Plus from Dentsply. The reason I use that is that, since I'm going to go ahead and do the restorative, I don't want to have to deal with eugenol and with bonding issues. Plus, it cleans up nicer than the eugenol-based sealers. Honestly, the sealer you use just doesn't matter that much.

Howard Farran: What about the calcium hydroxide? Does the brand, or potency, or any of that matter?

Rick Schwartz: I don't think so. I don't know for sure. I use UltraCal by Ultradent, just because it's very simple to use. You can inject it in there, and then spin it a little bit with the [inaudible 00:26:51] to get it down to the apex. Honestly, I don't think it matters. 

Howard Farran: Back to that sealer, what do you think of some of these general dentists that are using a gutta-percha carrier, like a Thermafil, a plastic carrier gutta-percha device? Does that make it harder for you to retreat, should 5-10% fail? Are you a fan of these, or you wish your referring dentists stopped using them? 

Rick Schwartz: I don't have a problem with Thermafil at all. I think as long as you do everything else right ... Here's the thing about endo, as long as you locate all the canals, you clean them reasonably well, you're going to have a lot of success with endo. I think Thermafil is fine. I don't have a problem with it. A lot of the restorative dentists use Thermafil in San Antonio, and so we have a lot of experience retreating them. I wouldn't say never, but I rarely have a problem getting them out. I have no problem at all with Thermafil. I think it's as good as any other method of obturating. Usually they look better, at least radiographically, the ones that have been treated with Thermafil than the ones that are obturated with Thermafil versus other methods that we see.

The other thing I like about Thermafil is that if the obturating material is sticking out of the end of the root, if it's gutta-percha you have no chance of getting it back in, very little chance, let's say. With Thermafil, you just snag the carrier and pull it out. You can pull everything back in. Whether that makes a difference in success or failure, I don't know. I know my retreatments look nicer if I can get everything out. 

Howard Farran: I am so old. I could remember flying to Ben Johnson's office in Tulsa, Oklahoma, and watching him make these by hand. He would get gutta-percha out of his operatory drawer and a flame and a file, and I would watch him roll these things, kind of like watching your old uncle roll a cigarette. He would just roll a Thermafil. He was just a wild man. He was so interesting and smart and fun. Back to Ben Johnson's company, Tulsa Dental Products, when you're seeing these teeth, 100 teeth, 20 got extracted, do you think those rotary files, do you think the 0.04 or 0.06, do you think we're removing too much structure in the root and this is contributing to final failures? Do you think that our tapers are too big? Back in the day, we used to use Gates Gliddens. What was the other one, besides the Gates?

Rick Schwartz: Piezos. 

Howard Farran: The piezos. Man, you would just take out Frosty the Snowman tooth structure. There would be like you were cutting a board.

Rick Schwartz: I most definitely think that we should be as conservative as possible on our access preparations, as conservative in our shaping. There's a lot of resistance to this, actually, in the endo community. The idea is that if you don't make a big access opening you're going to miss things or you're going to have more problem with broken instruments, and that sort of thing, procedural accidents. Then, if you don't prepare the canals to a big size that you're not going to have as much success with endo. There's really not anything in the literature that says that. There's really no outcome studies that have compared small preparations to big preparations, as far as success and failure of the endo. 

What we've found in our 10-year recall thing was that we didn't see very many failures at two years or three years, hardly any. Most of the failures we saw were in the seven-, eight-, nine-year time frame. The most common failure we saw, actually, were premolars snapping off. It changed the way we practice in a couple of ways. One is that we're trying to do everything much more conservatively now, preserve as much tooth structure as possible. Another thing is that premolars and anteriors we put fiber posts in them now, virtually all of them, which is getting off on a little bit of a tangent. There's an idea, again, in the endo community especially, and the dental community in general, that posts don't make teeth stronger. That's based on two studies, one that was done in the '80s and one that was done in the '90s.

If you look at the restorative literature for the last 10 or 12 years, there's overwhelming evidence that fiber posts make teeth stronger. There's at least 16 studies that show that. There's hardly anything in the dental literature where the evidence is so strong, and yet nobody in the endo community pretty much has read that literature, and not very many people in the restorative community either. It just makes sense. A fiber post is something that has more or less the same properties as dentin. Instead of putting gutta-percha in, you're putting another piece of dentin in there. It just makes common sense that it would make them stronger. The literature is overwhelming in supporting that.

Here's the key to longevity in endo: start out with teeth that are substantial and are strong, not teeth that are just gutted with decay or where there's no coronal tooth structure left; be as conservative as possible in your access preparation; be as conservative as possible in your canal preparation; then, restore the teeth immediately with sound restorations. Of course, too, everything right restoratively, crowns that fit well, proper occlusion, that sort of thing. Those are the keys to longevity in endodontically-treated teeth. It's funny, there's a lot of resistance to this idea of doing things more conservatively in the endo community. 

I lecture a lot to restorative groups, to prosthadontic groups, to what I call sophisticated restorative dentists, like implant study clubs and skeletal study clubs, and that sort of thing. They're all over this idea of conserving tooth structure, because they have to see the teeth that fail. If they have a tooth that has endodont and the tooth breaks in five, or seven, or eight years, the endodontist doesn't suffer for that. The endodontist already has put the money in the bank and spent it. The ones that suffer are the patients and the restorative dentists. The restorative dentist has to deal with an unhappy patient. Those are the keys to longevity in endodontists. It's not so much how the endo is done. It's really the structural integrity of the tooth and how the restorative is done.

Howard Farran: I would so love to get one of your courses on Dentaltown. We have 205,000 members. We put up 350 one-hour minimum length courses, they're one to two hours. They've been viewed over half a million times. If you put up that course, you'd be teaching dentists in India, Asia, Brazil, around the world. Any chance you think we could ever get a course from you? 

Rick Schwartz: Sure. I would like to. There's probably about four or five things I do that would work well with your program.

Howard Farran: I think that it sounds like the most important course would include talking about a fiber post buildup, because there's a lot of general dentists who believe the only thing a metal post does is fracture a tooth, or you're removing too much tooth structure. It sounds like the fiber posts ... What brand of fiber posts? Does that matter in these 16 studies? 

Rick Schwartz: 90% of them are made by, what's the French company?

Howard Farran: Septodont?

Rick Schwartz: No. I'm blanking. 

Howard Farran: That's the anesthesia. Myers? Mylar?

Rick Schwartz: I can't think of it right now. 90% of them are made by the same company in France. 

Howard Farran: Is that the one that Dentsply bought?

Rick Schwartz: No. No. They're an independent company. I'm sorry, I'm blanking on the name right now. That seems to happen to me more and more these days. 

Howard Farran: I have four boys and I feel sorry for them, because every time one comes to my house I always call him the wrong name. Is it Micromega?

Rick Schwartz: No. 

Howard Farran: Not Micromega? 

Rick Schwartz: It will probably come to me after a little while, and I'll tell you what it is. They make them for Bisco, they make them for 3M, they make them for almost all the companies. Here's the key with any kind of post, whether it's metal or fiber, is that prepare the canal, do the endo, prepare the canal as conservatively as possible, and then don't remove any more dentin to put the post in. Don't take out a twist drill and make it bigger. You need to pick a post that fits the canal that you've already prepared. Don't make the canal fit the post. That's the key to ... 

Howard Farran: Is it RTD Dental? RTD Dental?

Rick Schwartz: Yeah. That's it. 

Howard Farran: That's it. 

Rick Schwartz: That's it. 

Howard Farran: RTD Dental. They're making a lot of these posts for other companies. They're an original manufacturer. 

Rick Schwartz: They make almost all of them that are sold around the world. 

Howard Farran: I'm sorry to interrupt you on that. Continue on about these fiber posts.

Rick Schwartz: Do the endo, fit a post to the existing canal. If you do that, you're strengthening the tooth. The evidence is just overwhelming. As far as the metal posts, it's about 50/50 now. There's a couple of studies that have come out that show that metal posts make the tooth stronger. The advantage, at least the theoretical advantage of the fiber post is that they distribute the forces better, and so you don't get concentration of forces like you do with a metal post. You get a concentration at the end of the post. Force is concentrated in a root two places. If there's nothing in there, they concentrate at the crest of the alveolar ridge. If there's a metal post in there, they concentrate at the end of the post. The worst thing you can do is put a metal post in where the end of the post is right at the crest of the alveolar ridge, because then you're just setting yourself up for failure. 

One of the problems with metal posts is that they're parallel. Almost all of them are parallel. What I do when I use metal posts is that I take a Diamond Burr to it and I make it tapered so that I can fit it into the existing canal. One other thing with metal posts is we're making these canal preparations more and more conservative, fiber posts are not as strong as metal posts. For some of the really conservative ones, like on lower anterior teeth for example, I'll use a metal post instead of a fiber post. 

Howard Farran: How do you cement these? Are you using the kit from the fiber post company?

Rick Schwartz: I don't, actually. The way I cement them is that I like to have my posts cemented with the same material that I use for my buildup. I like to do it all in one step. The way I cement the post is I use a dual-cure bonding agent first, etch and rinse and apply the primer and adhesive. It's dual-cure because the light's not going to penetrate all the way deep into the canal, obviously. Then I'll use a dual-cure buildup material. The particular one I use is LuxaCore, which is made by DMG, a German company. Any dual-cure buildup material will work. I inject that into the post space, I seat the post, and then I do my buildup and light cure everything. 

Howard Farran: You were talking about LuxaCore from Germany. Do you see much variance of how endo is done between North America and Europe and Japan, or is it pretty consistent around the world? I'm talking among people who do this all the time, endodontists. 

Rick Schwartz: I'd say it's very consistent. I think there was a time when America had pretty much of a monopoly on the best clinicians and the best endodontists. That certainly is not true anymore. There are just some amazing clinicians in other countries. The top people in all the countries are just outstanding. 

Howard Farran: Speaking about the most controversial endodontists of all time, Angelo Sargenti from Italy. How would you remember him by? How would you sum up his career?

Rick Schwartz: He was hated in the endo community, but I don't know that we have strong evidence that there was a ... He was in favor of very conservative preparations of the canals. Here's what I would say, is that, again, if you locate all the canals and you prepare them well, it probably doesn't matter very much how you obturate them. Probably Sargenti would be fine. The knock against Sargenti was it contained formaldehyde, and if you got a dont in the mandibular canal it would cause damage, it would cause numbness. Honestly, the same things are true if you get eugenol down in there, if you get calcium hydroxide down in the mandibular canal, you're going to cause damage to the nerve and numbness. I don't have that much of a problem with Sargenti. 

Howard Farran: You're talking to several thousand general dentists. When they go to a dental convention, there are so many different rotary endo files for sale. Do you have any recommendations? How should a general dentist look at all these? It seems like the taper would be a big factor, an 02 versus an 04, an 06. What advice could you help a general dentist in looking for an endo file?

Rick Schwartz: First of all, pretty much all of the files that are on the market are fine. They've all been tested and they've all followed the ... They all can be used successfully. I'm inclined, again, to use the less tapered ones that remove less dentin. Doing things more conservatively makes the procedure more difficult and more fraught with danger. It requires more skill and it requires more time. Those are all negative, to some extent. As far as what's best for the patient, what's going to last the longest, I would use the less tapered instruments. I've gone through a process. I initially did everything with 06 tapers, back when we did our recall, back in 2000 and earlier was when I was treating those patients. Pretty much everything was 06. Then I went to 04. 

I've actually gone now to some files, the primary files I use are called V-Tapers. They're relatively new. They're made by SS White. They're very conservative. They have taper at the apex, but then very little taper the rest of the way. You're removing relatively little dentin. Just in general, I guess, the one recommendation I would give is to, whatever system that you use, use the heat-treated ones, the ones that they're coated and they're heat-treated. They're very flexible. My experience with the V-Tapers is that they're almost impossible to break. I've only used them probably about six months, or so, so it's too soon to say, but so far I haven't broken a single one. I unfortunately have somewhat of a propensity to break files. I would use the heat-treated ones. All the different companies make them now.

Howard Farran: Do you single-use your files, or do you ever autoclave them and reuse them?

Rick Schwartz: Generally speaking, I single-use them. I occasionally, if the file's not stressed very much when I use it the first time, and there's no unwinding, or anything like that, then I'll use it a second time. 

Howard Farran: Do you think that increases the fracture, if you use it a second time?

Rick Schwartz: If you use them routinely more than once it probably increases the fracture. It's more the clinician. You know the old saying: it's the Indian, not the arrow. All of these things, it's more the clinician than it is the-

Howard Farran: I have never heard that. It's the Indian, not the arrow. I love that. I'm in Arizona, where 25% of the state is Indian reservation. I'll tell all my Indian dentist friends that. 

Rick Schwartz: Almost all the things in dentistry, it's not so much the materials you use, it's not so much the instrument. The clinician is a much more important factor.

Howard Farran: In fact, I just had dinner last month with the first Native American Indian dentist in the United States, with him and Jack Dillenberg. 06 was too big. You were with 04. You've gone smaller. Would the next logical file be a 0.03? Is that where the market's headed?

Rick Schwartz: I think this variable taper, actually, is the best, because you'd like a little more taper in the apex. You'd like the apex to be a little bit bigger, and you'd like to have a capture zone down the apex to help, especially with these really thin preparations, to help avoid overfills. I think variable taper is where we're going to be, probably, going forward. I think the V-Tapers, I can't remember, I think they are something like 02 or 03 taper once you get away from the apex. 

Howard Farran: Let's jump to your other book, where you're a cover author on "A CBCT Primer for Endodontics". Has CBCT, was that a game-changer in endodontics?

Rick Schwartz: About every 10 years or so another game-changer comes along, and that's the most recent one. I would hate to practice without it. It just provides so much information ahead of time before you pick up a hand piece or start giving people injections. You just have so much more information about the problems that you might run into, first of all, and also sometimes you see things that you decide not to do treatment. You decide it's better to extract the tooth and do a regular implant. 

Howard Farran: What percent of the teeth that you endo do you get a CBCT before you treat it?

Rick Schwartz: It's getting to be more and more. Honestly, I'd like to do it on every patient, but it's just not possible to do that. Simply, at least in my practice, it's not. I'm there most nights till 6:00 or 6:30. I'd be there till 8:00 every night if we did a scan on every patient. The reason being that we're obligated when we take these things not to just look at them quickly and say, "Oh yeah, this or that." We're obligated to look at the whole volume in all three dimensions, and it takes time to do that. It takes me about 10 or 15 minutes with each one to look at the whole volume. That's one reason that we don't. We take them on the patients that we think we're likely to get valuable information. 

We take them on virtually every retreatment, because we want to know if there's any untreated canal space. We do it on all of our surgeries. We do it on any case where we just can't seem to see things clearly on the PA, or we have some question about how many canals there are, or something just doesn't look right. We probably miss some things because we don't do it on every patient. It's just not practical for us to do it on every patient. 

Howard Farran: What CBCT would you recommend if someone wanted to improve their molar endo? Is there any name brands, any better for endo as opposed to the other spectrum like ortho? 

Rick Schwartz: You want a small field that just takes images of a few teeth. For one thing, it makes it much easier to review the whole volume and you're less likely to miss something else that's on there. Also, they have very low radiation. The small-volume ones expose the patient to an amount of radiation that's approximately comparable to about three or four PAs. It's not very much. The particular machine that we use is from Carestream. I have a lot of friends that use the Morita machine, which is also a very good machine. Those are the two that most endodontists have, but there's lots of others on the market that are probably just as good.

Howard Farran: I hear Carestream's very, very, very popular. That's the one I got. When you see a general dentist do a misdiagnosis on a root canal, where does the misdiagnosis usually come from? 

Rick Schwartz: We see all different kinds. That's one thing that I think most dentists don't come out of dental school with a very good understanding of diagnosis, and I'm sure I was the same. We see things missed, teeth that are obviously cracked, canals that have been missed. 95% of the time it's easy to make the diagnosis, but 5% of the time they're very difficult. A lot of it is just they don't get exposed. We deal with it all day long, as endodontists. Most general dentists only really have to make a difficult diagnosis once a week, or a couple times a month, or something. Part of it is the initial training. 

Howard Farran: I want to paint you a scenario that I hear, when you're watching a football game at a bar and there's some young dental students. They say one of the things they hate the most about molar endo is when you know it's in the lower right, but you can't for sure tell which tooth it is. What would you tell that young dentist to do? They're not sure. Is that the second molar? The first molar? The second [bico 00:49:48]? They all seem sensitive. They all seem to hurt. They're trying to zero in on the exact tooth. 

Rick Schwartz: I would say in anything, when in doubt, I would say refer them. Refer them to their endodontist, because they're probably going to be able to make the diagnosis. We get these cases in where we can't make it easily initially, either. In most cases, we just wait. Usually with time it becomes more clear. If the patient's really in severe pain and we have to do something, this is going to sound funny, but all things being equal, when in doubt, treat the second molar. 

Howard Farran: When in doubt, it's usually the second molar. Speaking of pain, here's another painful soul-searching question a lot of dentists go to. A lot of dentists, when they do a root canal, they were in pain, they want to get them out of pain and they want to give them hydrocodone. Then, there's a lot of dentists on Dentaltown that says, "You know, dentists and physicians are the ones causing all these opiate addictions." There are a lot of dentists who just won't ever prescribe it. How do you, personally, because you're in a conservative state of Texas, I don't know if it gets any more conservative than San Antonio, Texas ... Do you prescribe opiates judiciously, or do you know these are bad and go ibuprofen? What are your thoughts on opiates and opiate addiction?

Rick Schwartz: We hardly ever prescribe them. When I say "hardly ever", it's maybe once a month, or something like that. It's usually because the patient specifically wants that. The vast majority of the cases ... It's a complicated question, actually. Initially when you see the patient, number one, you've absolutely got to get them completely numb to do the treatment. Patients that come in in a lot of pain, they're more likely to have pain after the numbness wears off. We'll give them a block with marcaine at the end of the procedure to try to keep them numb for four or five hours. That's really the critical period where they're going to tend to have a lot of pain. That gives things a chance to settle down. That's for a block on the mandibular arch. 

If it's severe pain in the upper arch, we can't keep them numb that long. Marcaine only works about the same as lidocaine, or any of the others. An hour, or maybe two hours max, for most patients. Then we'll give them an injection of ketorolac, which is a non-steroidal anti-inflammatory, which provides really rock-solid analgesia for about, again, about five hours, or so. It gives the tooth a chance to settle down. 

Howard Farran: You inject that at the tooth?

Rick Schwartz: Yeah.

Howard Farran: Really?

Rick Schwartz: They have to be numb, because it's painful otherwise. We just inject it in the vestibule where we were working at the end of the procedure.

Howard Farran: It's like a liquid ibuprofen? 

Rick Schwartz: Yeah. It's stronger, though. It's stronger than ibuprofen. We just keep some in the office. We keep some ampules of it. We don't have to do that very often, but, again, probably once a month, or something like that, we'll give an injection of that. It just gets them through that first five hours, or so, where they tend to have a lot of ... Where people who have a lot of pain when they came in are more likely to have a lot of pain after the numbness wears off. Then, after that, we can usually manage it either just with ibuprofen or with a combination of ibuprofen and Tylenol. That's usually all they have to take, just alternate those every three hours. If you look at the studies of analgesics, that combination is actually just as effective as the narcotics.

Howard Farran: Same question. We hear the same guilt about antibiotic resistance. I personally know dentists who, every single root canal they've ever done, they always give a prescription of pen-VK or amoxicillin. Then, there's other dentists that they will not do that unless there's some type of swelling. 

Rick Schwartz: First of all, the literature shows that, and this has been pretty well-documented, that giving antibiotics ahead of time doesn't make any difference, as far as postoperative pain, postoperative swelling, those sorts of things. It doesn't make any difference. The times that we give antibiotics, there's really only two times. One is patients that need to be premedicated for heart issues, or that sort of thing, and patients who have systemic signs of infection, so swelling, big swelling, fever, any other systemic signs of things. Those are really the only two times we give it. 

Howard Farran: I'm going to keep asking you these controversial questions. A general dentist is looking at this patient that has a root canal, it's failed, and they're thinking, do I send this to the endodontist for a retreat or to the oral surgeon for an extraction implant? What are you thinking on these close calls between to retreat or treat with forceps? 

Rick Schwartz: Number one is, what's the structural integrity of the tooth? What's the restorative prognosis for the tooth? If it's not so great, probably they're better off having the tooth extracted and having an implant or a bridge put in. The reason being that the retreatment process, if it's a compromised tooth to start out with, the retreatment process is going to compromise it more. It's going to weaken the tooth more. That's just a fact. That's probably the biggest factor. Another important factor is, is there ... Let's say it's a structurally pretty strong tooth, is there untreated canal space? The retreatments that are most likely to be successful are the ones where there is an untreated MB2 or there's obvious untreated canal space. 

Another big factor, for me, because a lot of the doctors refer them to me, and I cut the crowns off, and I'm the one that makes the determination of restorability, the really big factor for me is who's going to be doing the restorative after I'm done with them? Who's going to be doing the crowns, and so forth? If it's somebody that's really skilled, then I'll push the envelope more to more compromised teeth. If it's somebody that's not very skilled at restorative, probably the patient is better off with an implant or a bridge.

Howard Farran: When you're doing the diagnosis, and you cut off the crown, and you decide that this needs to be extracted, do you see yourself in the future extracting it and placing the implant single-visit? Some endodontists are doing this. Do you think that's a growing trend?

Rick Schwartz: It's definitely a growing trend. I have quite a few friends that do. I think especially among the younger endodontists they're doing it more and more. It's a nice service for the patient. The patients don't want to be referred here and there. Again, as long as the endodontist knows what they're doing and does a good job, the restorative dentists generally don't care one way or the other. About 10 years ago, or so, I was thinking, as implants became mainstream, I was thinking that we were probably going to get less busy. I took some courses on implants. My partner and I took some courses on implants thinking at some point we were probably going to start doing them as things slowed down. Things actually never slowed down. If anything, they've gotten busier. We never made that move.

If I was a young endodontist, I would definitely get trained in doing implants, I think. I did some, actually, when I was a general dentist, years ago, back when we didn't really know what we were doing, back in the '90s. Interestingly, during that time about 10 years ago I went around and talked to some of my restorative dentists telling them we were thinking about starting to do implants. I went and talked to some of the oral surgeons and periodontists that we dealt with. The general dentists, they've generally said, "That's fine. As long as you do a good job, I don't care who places the implants for me." The oral surgeon and the periodontist said, "That's great if you want to do them. We don't want to do the single units, anyway." Nobody had a problem with it.

Howard Farran: That's true. They do a lot of big cases, and a single unit is ... It's like an oral surgeon wants to pull four wisdom teeth, not one extraction. Gosh. You could order that book, your second book, "A CBCT Primer for Endodontics", or is that not published yet? 

Rick Schwartz: It's not. We're trying to get it finished by the end of the year, actually. I have, actually, a fairly small part in that. John Khademi, an endodontist in Colorado, who I think goes on Dental Talk quite a bit ...

Howard Farran: Absolutely. 

Rick Schwartz: He's the primary author. He's doing probably 80 or 90%, probably 80% of the work on it. Then, Gary Carr has contributed to it, and then I've contributed a little bit. I actually told him he didn't have to put me on the cover, since I didn't contribute that much. 

Howard Farran: How do you spell Khademi? John Khademi?

Rick Schwartz: It's K-H-A-D-E-M-I. 

Howard Farran: K-H-A-D ...

Rick Schwartz: E-M-I. 

Howard Farran: E-M-I. Where is he in Colorado? 

Rick Schwartz: He practices in Durango, just this little town. He's another amazing guy, one of the best endodontists in the world. He practices in this town of, I don't know, 5,000, or something. 

Howard Farran: That's only about four hours from my house. I'm in Phoenix. That's near Four Corners. That's the only place in the United States where four states touch. I love going up there. That's the most beautiful part of the country. I often say this to patients, and I only got you for one minute left, I say this to patients all the time, and sometimes I wonder, I hope I'm saying it right, but most people who study our race, our human race, say that basically it's about 50,000 years old, and that from 50,000 years ago to 4,000 years ago the average human only lived about 17 years. From 4,000 to 2,000 years ago, it went to 36. Now it's up to 74 for the planet. 

A lot of the times a 50-year-old lady will be sad, and she'll say, "Why did my tooth die?" I say, "Well, you know, your tooth probably was only designed to go about 17 years." If you lived long enough, I'm sure, if you lived to be 100 or 200 or 300 years old, they're all going to die. Is just the tooth dying because we live so much longer than the design elements of the tooth? For 50,000 years it was designed to go 17 years. Do you think just being 50 years old and living, and this aging population, that they just outlive their designed life expectancy? 

Rick Schwartz: There's definitely some of that. There's definitely some of that, just wear and tear. Bruxism is a big issue, and teeth cracking, and that sort of thing. It's interesting, though, our average patient that we see is probably 65 or 70, something like that. We see a lot of old patients. I guess getting back to this implant endo thing, that reminds me of another little story. In this old patient population that we see, we see them up into their 90s. I don't know if we've seen anybody in their 100s. That's part of that decision process, too. Let's say that they're 70 or 72, and we're trying to decide whether to do endo or do an implant. As they get older, they have more and more carries, because their mouth dries and they take more drugs, and all of that. 

If they're having a carries problem, we'll push them in the implant direction, because implants don't get decay, of course. The other thing is that if they're going to have a surgery and we're worried that we if do endo in 10 years there's going to be carries and they're going to lose this tooth, they're much better-suited to deal with surgery, and that sort of thing, when they're 72 than they're going to be when they're 82. That's another big factor in our old population when we're trying to make that decision on implants versus endo.

Howard Farran: I'm in Phoenix, which is a lot of retirements. I'll tell you, the root surface decay, it's one of the most ... I feel more helpless treating root surface decay. I can't tell you how many times you treat it and in one year you're back to square one. That is a vicious decay process. 

Rick Schwartz: I see some of these patients that some of the old prosthedontists in town treated 30 years ago, did beautiful gold work, and pin facings, just beautiful work, really nicer than we see, for the most part, being done today. These old people, they've got carries everywhere. It's all failing now. It worked great for 30 years, but they have carries everywhere. Gosh, what do you do? These patients are 75, or 85. It's really a difficult problem. 

Howard Farran: To you younger dentists listening, probably my first diagnostic mistake trend that I did for the first five or 10 years, I was so wrong, a lot of times those older people, older men, I was trying to patch things up because I thought, this guy's not going to live five more years anyway. God, 25 years later they're still alive. I call it the Keith Richards syndrome, Keith Richards of the Rolling Stones, just people who you know were on so much drugs and a wild lifestyle that they should have died decades ago and they're still alive. I can't tell you how you have to diagnose more aggressively, because these people just stay alive forever. 

Rick Schwartz: Earlier in my career, I had dealt with patients, some patients, who had radiation, who had big carries, or in even younger patients. The only thing that stops rampant carries are fluoride trays. I tell the patients, "You have to have fluoride trays. You need to use them twice a day every day religiously for the rest of your life. That's the only thing that's going to stop this for you." 

Howard Farran: Too often when you tell someone to use it religiously they just use it on Christmas and Easter. Hey, Rick, I know you're a busy man, and I'm so honored that you spent an hour with me today. Thank you so much for all that you've done for dentistry, for endodontics. I'd give anything to have a course from you on Dentaltown, as many courses, short, long, as you want. I'm really interested in these fiber posts. I think you could really help leading the way from metal posts to fiber posts. Again, thank you so much for spending the day with me. 

Rick Schwartz: Thanks, Howard. It was fun. Listen, I have the information about doing the courses. If you want to send me the information now, I'm writing an article, I'll do that. 

Howard Farran: Howard Goldstein is the director of the website community and the online scene, but the editor of the magazine is Tom Giacobbi since 2000. He's been doing it for 16 years. He's a great guy. Everyone's probably wondering, are you a big Spurs fan, San Antonio Spurs basketball fan?

Rick Schwartz: Absolutely. Absolutely. I've treated a bunch of them, actually, and they're just great guys. They just get such great human beings, besides being great athletes. 

Howard Farran: I think the funniest thing about basketball and the Spurs and the Suns is the basketball people, they say, "We're a non-contact sport." I've never treated a knocked-out tooth from a football player. It's always an elbow and a basketball. I always say, "I thought that was a non-contact sport?" 

Rick Schwartz: Not anymore. [inaudible 01:05:29]

Howard Farran: Thanks for spending an hour with me. I really, really appreciate it.

Rick Schwartz: Thanks. 

Howard Farran: Bye bye.

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