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VIDEO - DUwHF #764 - Bradley Gettleman
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AUDIO - DUwHF #764 - Bradley Gettleman
Dr. Gettleman earned his dental degree from the University of Missouri, in Kansas City. He finished his Master's Degree and Endodontic Residency at the University of Minnesota. He has published numerous articles of Endodontic Therapy.
He is a member of the Westside Dental Study Club (past president), American Dental Association, American Association of Endodontists, where he has just completed tenure as chairman of the Professional Standards Peer Review and Ethics Committee, Arizona Endodontic Association (past president), and the Arizona State Dental Association. He is a Diplomat of the American Board of Endodontics and has been in private practice since 1989.
Howard Farran: It is just a huge, huge honor for me today to be podcast interviewing my classmate, Bradley Howard Gettleman. He used to always go by Bradley Howard Gettleman until he met me. Then he said, "I'll never use the Howard part again," and refuses to tell anybody that's his middle name. Dr. Gettleman earned his degree from the University of Missouri in Kansas City. He finished his master's degree in endodontic resonancy at the University of Minnesota. He has published numerous articles on endodontic therapy, and I hope someday makes those an online C course on Dentaltown. He is a member of the Westside Dental Study Club, past president; American Dental Association; American Association of Endodontics, where he just completed tenure as chairman of the Professional Standards Peer Review and Ethics Committee; Arizona Endodontic Association, past president; and the Arizona State Dental Association. He is a diplomat of the American Board of Endodontics and has been in private practice since 1989. You remember a while back, we had Steven Cohen on, and Brad actually wrote chapter 8, there it is. Bradley Howard Gettleman-
Bradley Gettlem: Co-wrote, co-wrote.
Howard Farran: Co-wrote with Robert [Rota 00:01:15], a dentist up the street here too, on the non-surgical retreatment. And it is just, I gotta tell you the inside story on Brad. So he was Gettleman, I was Farran. So four years at UMKC Dental School, we sat usually about this far apart. I sort of got, if the instructor said in lab that we had to prep some extracted tooth or some, what were those, typodont teeth?
Bradley Gettlem: It was [inaudible 00:01:41] teeth.
Howard Farran: If we had to buy one of those and do a crown, Brad would do 30. I mean, all I remember is that when I got to the lab, you were already there. When I left the lab, you were still there. I don't think there was a more disciplined son of a gun in the class of '87 than you. I mean, you were just, you were always disciplined. Is that from your roots as a wrestler here?
Bradley Gettlem: Not sure.
Howard Farran: But you were-
Bradley Gettlem: [crosstalk 00:02:07]
Howard Farran: You seriously were one of the most disciplined people I remember. You did everything-
Bradley Gettlem: Thank you.
Howard Farran: Serious as. And I knew another great endodontist. When I was a [crate 00:02:19] undergrad, I was in room 915, and in room 919 was Joe Dovekin, who was one of the most intense endodontists too.
Bradley Gettlem: The difference between Joe and I is Joe probably just had to do it one time; he's a little brighter. I think I did it over and over again just to get it right.
Howard Farran: Ha. My gosh, ah. So you and I were having a discussion, and not to throw anybody abridge, but we were having a discussion that it seems like 30 years ago, UMKC, how many endodontists were in our class? How many endodontists taught at UMKC when we were there?
Bradley Gettlem: I would say there were six full time endodontists, if I remember correctly. I could possibly name them. There was on any half day in clinic, probably two part timers that worked full time private practice and volunteered or you know, came half day for the clinic. So you had six full time, maybe ten part time.
Howard Farran: Who was your favorite?
Bradley Gettlem: Ramon Aguirre
Howard Farran: Really? Mine was [Bambidiro 00:03:23].
Bradley Gettlem: Both real good guys. I have not communicated with Bambidiro. I still have a relationship with Ramon, speak with him from time to time.
Howard Farran: Ramon what?
Bradley Gettlem: Aguirre. He's up in the University of Minnesota.
Howard Farran: How do you spell Aguirre?
Bradley Gettlem: A G U I R E.
Howard Farran: A G U I R E?
Bradley Gettlem: R R E.
Howard Farran: And so now-
Bradley Gettlem: [crosstalk 00:03:42] both endodontists in Minneapolis. He was, when we graduated in '87, he moved up to Minnesota. That's where he did his residency in endodontics. He's from Mexico City. He moved up there, so he was teaching part time up there, so I can kind of, 'cause we did work together. He's part time up there in private practice. He's not teaching anymore, he's full time private practice. And his younger brother's an endodontist who went through Minnesota, but he went to Minnesota and came back down to UMKC to get his American DDS and then went back up there. I think Bambidiro did, at least.
Howard Farran: So we went to a public school, University of Missouri Kansas City.
Bradley Gettlem: Correct.
Howard Farran: Now there's private schools, and there's two of them in our city. We're both in Phoenix. You're in Glendale?
Bradley Gettlem: I practice in Glendale.
Howard Farran: But you live in Phoenix.
Bradley Gettlem: Correct. [crosstalk 00:04:25]
Howard Farran: But Phoenix has a lot of suburbs, and one of them has AT Still and Mesa, and one of them has Midwestern in Glendale. How many endodontist faculty would you say are Midwestern?
Bradley Gettlem: There's one full time and I heard just this week they hired a second. I just heard that they hired a second.
Howard Farran: Okay but the school, the school's five years old.
Bradley Gettlem: Or more.
Howard Farran: Or more.
Bradley Gettlem: They probably have five graduated in that range.
Howard Farran: But for the most part since they've opened, how many endodontists are on the floor?
Bradley Gettlem: There was one full time, and I believe they just hired one. I don't know if he's started yet or not. I heard it through the grapevine.
Howard Farran: So I guess where I'm getting at with this, it seems like when you talk to recent grads, I mean, it depends on the school and it depends on the country. But would you say that a lot of kids are graduating with very minimal endodontic understandings?
Bradley Gettlem: It's hard for me to say 'cause I'm not in academics right now. I plan on going into academics at some time. It's real hard for me to say.
Howard Farran: Brad, Brad, Brad. I mean kids who graduated from dental school, $500 thousand in debt, and never did a molar root canal.
Bradley Gettlem: Then they're definitely undereducated.
Howard Farran: They did, like, two single canal teeth.
Bradley Gettlem: Then I would consider that undereducated. You know, I'd have to go school by school to see what the requirements are, what their experiences are. But I just know what we went through, what we had at the University of Missouri Kansas City. I know what was going on at the University of Minnesota when I was there. I'm not sure how many are there now, but education is maybe different when we went through. Not to say it's better or worse, but I think it's, some schools, it's different. I know that, I know that.
Howard Farran: But what would you say in general, how do you feel in general about the state of endodontic, the state of endodontic education and the state of endodontics as performed in Arizona?
Bradley Gettlem: Right. It seems like some of the younger practitioners that come out that I work with did not have the education that we had, and the experience. You know, we were fortunate enough to go to a dental school that was located where there was a ton of patients. Patients was a non-issue. I think some of these newer dental schools are being placed in locations, nice areas where that's the not the population they're gonna serve. So I think patient population is an issue, and based on that, based on populations, you need a certain number of educators based on the educator to student ratio.
Howard Farran: Yeah, K-
Bradley Gettlem: I don't know what the ideal education ratio is.
Howard Farran: KU Med School realized that having a medical university in downtown Lawrence, Kansas is, I mean there's only 30,000 people; it's a college town. So they moved the last two years to downtown Wichita, because when kids ask me, "What do you think of this residency or that residency?" I say, "The only thing that matters in a residency is that you're in the poorest part of the biggest city in the world."
Bradley Gettlem: You get experience, you get the experience.
Howard Farran: That way, you'll see the most diseases walking into your clinic. You go to the richest part, they're gonna go to private doctors.
Bradley Gettlem: You're not gonna have the patient population to get the education.
Howard Farran: Yeah. So just find the biggest, poorest, ghetto residency you can find, and you'll see one of everything.
Bradley Gettlem: And get the experience to be a private practitioner. I think that's an issue.
Howard Farran: We read this book in dental school 30 years ago. How does it feel that 30 years after you graduate, you're writing chapter 8 of the same book we used in dental school?
Bradley Gettlem: Rewarding. A lot of work. I mean, myself and Rob wrote the last three editions. We wrote the 9th, 10th, and they asked us back for the 11th. Are we gonna do it again? I doubt it. It's a lot of work.
Howard Farran: So you wrote in the 9th? What edition did we have in dental school?
Bradley Gettlem: We had, I believe, the 4th.
Howard Farran: Really?
Bradley Gettlem: I think it was the 4th.
Howard Farran: Huh. I should ask how old it was.
Bradley Gettlem: [crosstalk 00:08:09] it's the most translative text. [inaudible 00:08:12] pulled the most translative textbook in the world on endodontic therapy, from the last I heard. And they do, the problem with textbooks versus literature versus the internet is, before it gets into ink, some of the information can be kind of old. So they continue to give new editions very regularly, which is good. 'Cause people still like textbooks, not use them as much as when we were in school, 'cause obviously you're getting online, you're looking things up, it's quicker, more efficient. It's also more present, up to date. But I like having a hard copy to look at, just 'cause I get bored. I've been able to get my hands on every edition, with the exception of the first.
Howard Farran: You don't have the first?
Bradley Gettlem: I can't. I tried to get it somewhere online.
Howard Farran: You can't find it on eBay?
Bradley Gettlem: I've searched for it, and I may have found one this morning. Just to compare it, it's just kind of fun. I'm a nerd, I like to read things.
Howard Farran: Well speaking of, things change.
Bradley Gettlem: Things change regularly.
Howard Farran: Well you know, speaking of that, I bought on, when eBay came out, when it first came out. When was that, like '94 or something? I found the first three books autographed and signed by G.V. Black and Bond.
Bradley Gettlem: Oh really?
Howard Farran: Yeah. And I have them, they're here in the house.
Bradley Gettlem: Very cool.
Howard Farran: And it was so amazing, because-
Bradley Gettlem: I'll autograph this for you.
Howard Farran: Because I want you to sign this.
Bradley Gettlem: I was just joking.
Howard Farran: I thought it was interesting, because you know, we know what we know, we know what we don't know. We have unknown knowns.
Bradley Gettlem: No, we don't. We don't know what we don't know. I think that's probably, you talk about young dentists and education. I think that's it; that's a key phrase. They don't know what they don't know. So I'll disagree with you. And that's the biggest problem with young dentists. You don't know what you don't know until you learn it, and then you realize, "I didn't know that." I mean, how can you say you don't know what you don't know? Make sense?
Howard Farran: I was quoting the, who's that guy in the ... Oh, who was, it was someone in the Bush administration, Bush 43. He said there are known knowns, those are things we know. There are known unknowns, like dark matter and what.
Bradley Gettlem: They think we don't a lot, okay.
Howard Farran: And then there are unknown knowns.
Bradley Gettlem: Don't know what we don't know.
Howard Farran: And then there are unknown unknowns.
Bradley Gettlem: That's interesting.
Howard Farran: And the point I was going with that is, when I read, I don't have Pierre Fauchard's book. He was the first dentist 200 years ago. But that stuff was just almost silly, and then G.V. Black's 100 years ago, the father of modern dentistry for the United States. I mean, they were trephinating about the teeth to let the evil spirits out, and then they drew the pictures of the evil spirits and they all look like king's jesters with little bells on their feet. And so I'm wondering, 100 years from now, how much of this will look like evil spirits with ...
Bradley Gettlem: Interesting. Let me go back 100 years. Can I go back 100 years?
Howard Farran: Yeah.
Bradley Gettlem: Do you know Ben Johnson?
Howard Farran: Yeah, the founder of [Thurmanfill 00:11:12] in Tulsa.
Bradley Gettlem: Yeah. Brilliant guy, great guy. Found a movie in their basement years ago, and he paid to have this put on video cassette, of a doctor M.L. Rhein - I think R H E I N - doing endodontic therapy in 1917, 100 years ago. And he was, he gave me this. I have this on a video, I have this on my laptop, and I'll show it to you.
Howard Farran: You do?
Bradley Gettlem: I have a copy of this. Ben Johnson-
Howard Farran: Can I have a copy?
Bradley Gettlem: I'd have to get permission from Ben, he gave it to me. Extremely generous man, he won't have a problem with that. It's the coolest thing that I've seen in endodontic therapy, and I show it when I lecture wherever I go. I do a little lecture.
Howard Farran: Let's put it at the end, ask Ben if we can put it at the end of the podcast.
Bradley Gettlem: But I can, I'll ask Ben, and I don't have one with me here, but I can get it to you.
Howard Farran: Tell Ben-
Bradley Gettlem: There's an eight minute version.
Howard Farran: Ben might not remember, but in, we go down to 1987, and when I heard of him first time, I called him from my office and I'm asking Ben, and you know what that sun of a gun said to me?
Bradley Gettlem: What?
Howard Farran: He goes, "You just asked me nine questions in two minutes." He goes, "Just fly down here and spend the day with me." So I flew down to Tulsa, Oklahoma.
Bradley Gettlem: He's a great guy.
Howard Farran: Stayed with him the whole day, and then I said, "God, I wish I could stay another day," and he goes, "Well do it."
"Nah, I'd gotta get a hotel and all this stuff.
He says, "Stay at my place."
Bradley Gettlem: He came out here to visit you once, 'cause I had dinner with him. My wife and I had dinner with him. Shortly after he saw you, like the next day he stayed in town, and I said, "Yeah, I actually know Howard pretty well. We went to dental school together." He's a great guy.
But anyway, he gave me this video of M.L. Rhein, and let me tell you about it. I'll show you the video. I think I have the long version, like an eight minute version. Number one, they're using a rubber dam. Canterbury frame, the old wrap around. You've seen those little straps around the head that pulls it back. So they were using rubber dam, which I get cases that have been started by general dentists in my office. I put a rubber dam and they go, "What the heck is that?" I mean, that's rule number one. I do a lot of extra witness work just defending dentists, and I can tell you what. Right now, if there's no rubber dam on, it's undefensable. Nothing happens, but if you don't get caught. Like running a stop sign, if nobody sees you. But the success rate goes down, you get all sorts of [cannad 00:13:21] paste and saliva and junk in the canal. It's very, very dangerous. Potential aspirating of the file. It's malpractice. You know, you usually don't get caught; use it. It's malpractice. I cannot defend a practitioner, will not defend a practitioner who does a case without a rubber dam, period, end of story.
Howard Farran: What do they use [crosstalk 00:13:41]?
Bradley Gettlem: 1917, a hundred years ago, this video, they're using a rubber dam. Has a canterbury frame, we haven't seen one of those in a long time, but they're using a rubber dam with very similar rubber dam clamps that we use today. Good isolation, I mean, it's beautiful. And the guy does a great job treating the canal. Now they do some ionization and the guy's got this welder, but they're using sodium hypochlorite. They use Johnson Johnson paper points. Last time you dried a canal, what'd you use?
Howard Farran: Johnson Johnson.
Bradley Gettlem: Johnson paper points. This is, and it says Johnson in 2000. In, I'm sorry, 1917, they're using bichloride solution. What is that? Sodium hypochlorite. It's an unbelievable video, and what's scary is how similar. Now they're using hand files, they didn't have finger files. There's no nickel titanium. They're using chloropercha technique, the Johnson Callahan method and they condense and get the little, the old boss and little puffs. They do a real nice job, but they spend a lot of time cleaning and shaping the canal. The key to endodontic therapy, cleaning and shaping under rubber dam isolation, and they do a great job of operation. It's unbelievable. Hundred years ago, 1917. I will get you a copy of the video.
Howard Farran: And do you call him? Do you call Ben, or you email him? Or what's he go by these days?
Bradley Gettlem: I see him from time, I'll get in touch with him. That won't be an issue.
Howard Farran: Yeah. Tell him I want to podcast him too.
Bradley Gettlem: He's a great guy, brilliant guy.
Howard Farran: Yeah, and he reminds me a lot of ... Who's the guy from Chattanooga, Tennessee? McSpadden.
Bradley Gettlem: McSpadden, John McSpadden.
Howard Farran: Yeah. Who I think, who told me that he was the most interested in rotary because he's like, 6'6" and had hands the size of a bear.
Bradley Gettlem: Well one of the first rotary instruments was a McSpadden compactor. Kinda thermal plasticize, they gotta approach and condense down to the canal. So one of the first rotor instruments we put in a canal. Now that was stainless steel, it was like a reverse threaded [headstrum 00:15:36]. But McSpadden compactor, I don't know if you know, have seen them.
Howard Farran: Yeah, absolutely. And we did a podcast with him to fill in on Dentaltown. I mean, if you put your hand on him, you look like you're either a newborn baby or he's a gorilla.
Bradley Gettlem: It's like shaking hands with a catcher's mitt.
Howard Farran: He said, "I had to do that. I mean, look at my hands." I mean, he's a moose of a man.
Bradley Gettlem: He's a big guy.
Howard Farran: Just a big guy, and big hands. So back to, there are known knowns; those are things that we know. You say-
Bradley Gettlem: You gotta wear a rubber dam.
Howard Farran: But you say these young kids, there are known unknowns that they don't even know what they don't, so they have unknown knowns. What do you-
Bradley Gettlem: Which I think could be dangerous. That could be related to education, possibly. Maybe they're taught well, they didn't pay attention, they didn't study. Who knows, who knows why?
Howard Farran: And the podcasters are, they're all 30 and under. So when we're talking to millennials, almost all the evidence we have is they're millennials from Kansas to Kathmandu. I mean, the distribution of these things listened to in China and Iran, but they're all under 30. 'Cause people our age, we're usually in a nursing home or reading textbooks. And so they're all on iTunes on their smart phone. Tell them, what do you think they're too young to know, and that they won't know, that they'll know after they've done a thousand molars over three decades?
Bradley Gettlem: I'll keep it simple.
Howard Farran: How many molars have you done?
Bradley Gettlem: Oh, good God. I don't know how many tens of thousands of those.
Howard Farran: Okay, so this guy's done ten thousands molars.
Bradley Gettlem: I've been practicing full time 28 years.
Howard Farran: Yeah. 28?
Bradley Gettlem: 28 years.
Howard Farran: Oh, okay. I'm 30, 'cause I didn't go to [semester 00:17:17] school.
Bradley Gettlem: But I had two years residency, so I'm 28 out from residency.
Howard Farran: So I'm two years ahead of you, that's what you're saying.
Bradley Gettlem: In private practice, you are.
You know what, I'll keep it simple. Because you spend so much time on instrumentation of a canal and obturation of a canal, it's all we talk about. When you ask somebody, "How do you do endodontic therapy?" How do they answer? Probably and obturation method.
Howard Farran: I know.
Bradley Gettlem: If you ask somebody, "How do you endodontic therapy?" They're gonna say, "I do vertical [inaudible 00:17:45]. I do thermofill. I do that." Obturation of a root canal system is probably 5% of your time put in. Would you agree with that?
Howard Farran: Yeah, it's not what you put in, it's what you take out.
Bradley Gettlem: Correct. And people say, but they answer in obturation technique. Would you agree with that?
Howard Farran: Oh, absolutely.
Bradley Gettlem: And I always get frustrated with that, and people say, "What's the most important thing?" I say, "The most important part of the endodontic procedure is whatever you're doing at that time." Diagnosis, first thing. I you make a wrong diagnosis, who cares how well you follow that curve if it's the wrong darn tooth. Right? Proper anesthetic after the proper diagnosis. Who cares, if you didn't anesthetize the patient properly and they feel everything you do, you gave them a miserable experience. Then proper isolation, proper access, so on and so forth.
So to keep it simple, what would I tell a young dentist? Learn how to diagnose pulpal and periradicular disease, and understand, that's from a diagnostics standpoint. That's the most important thing: understand pulpal diagnosis, periradicular diagnosis. And the other thing regarding actual instrumentation, the mechanical aspect of the endodontic procedure is understand anatomy. People, lower interiors, there're two canals half the time. I'll do one with two canals, send them back, and they'll go, "Wow, I've never seen one." You need to understand anatomy. Now with the use of CBCTs, cone beam computed tomography, people are understanding, "Wow, what Gettleman talked about, it's there. The NB2 is there all the time." If I do an upper molar and I don't find NB2, it's not because of. Well it's probably 'cause I couldn't find it, I missed it. I mean, you get away with some for a while 'cause they're there about 95, 96% of the time. About half of that time, they join - type 2 canal kind of figuration. So it might work for a while, but eventually it's gonna fail.
But you need to understand anatomy. If you're gonna do endodontic therapy, understand anatomy. The first thing we did when we were educated on endodontic therapy was what? We waxed canal systems on little plaster teeth. You remember that?
Howard Farran: Yeah.
Bradley Gettlem: We waxed all the canals and we learned about accessory canals, aberrant canals, multiple canal systems. Understand canal anatomy. They don't, a lot of young people don't.
Howard Farran: So let's back it up. My job is to ask the questions they're committing to work, and I know when you said that, a bunch of people said, "What's the difference between pulpal diagnosis and periradicular diagnosis?"
Bradley Gettlem: Kay. Pulpal diagnosis is plain and simple. Reversible, irreversible, necrotic. Is the pulp vital? It is inflamed, reversibly or irreversibly? Is it necrotic? Periradicular diagnosis. Is it symptomatic? Pressure sensitivity, that type of thing. Is there a lesion, asymptomatic? Asymptomatic apo periodontitis. Is there a sinus track, symptomatic? We kind of have got things into reversible, irreversible, necrotic, and symptomatic periodontitis. There's a whole chart, American Association. I'd go to the website, you can download it. Sinus track, used to call suppurative apo periodontitis. It's just at this point-
Howard Farran: So there's one chart of all this?
Bradley Gettlem: Yes.
Howard Farran: On the-
Bradley Gettlem: Do you want to put that on the thing? I'll get you a copy of that too.
Howard Farran: Yeah. Can you email me that?
Bradley Gettlem: 'Cause the terminology's changed, but you want a pulpal and periradicular diagnosis, and all this stuff that we learned. Hyperemic, we don't use those terms anymore. It's reversible/irreversible, and is there periradicular disease? A lesion that's asymptomatic is asymptomatic apo periodontitis. You remember the 'ole chronic apo periodontitis? We haven't had had. The term phoenix abscess, remember that?
Howard Farran: Yeah.
Bradley Gettlem: Where you had the lesion and all of a sudden it flares. You know, but things are pretty simple, but there's a separate diagnosis. If you get taken to the board, they're gonna want to know a pulpal and a periradicular diagnosis.
Howard Farran: I want to know-
Bradley Gettlem: I will get you that chart made.
Howard Farran: And the only thing for the electricity, the pulp tester, the electrical pulp tester. Is that only used to confirm a non vital?
Bradley Gettlem: Correct. It's not, and the most common one used is the Analytic Technology, goes zero to 80.
Howard Farran: Who makes that?
Bradley Gettlem: Analytic Technology.
Howard Farran: Analytic, okay.
Bradley Gettlem: That's probably the most common one used. There's another one that has the same frame and a different manufacturer, but anyways. If you, a molar's 50 and the contralateral adjacent molar is 30, it doesn't mean one's really. It's a yes or no thing. It's vital or it's not. But even, I mean, put an ice cube on a tooth. [crosstalk 00:22:24]
Howard Farran: But what I want to-
Bradley Gettlem: Something goes fine. Positive [crosstalk 00:22:28]
Howard Farran: What I want to do is, you do everything methodical. You know, you're methodical. When you sit down and someone sends you a tooth and says, "Look at number 30." What is your routine? When someone sends you a molar, what do you always do?
Bradley Gettlem: Introduce myself, ask the patient-
Howard Farran: You what?
Bradley Gettlem: Introduce myself, ask the patient their chief complaint. Because, so that molar may need a root canal, but that's not why they're there. I'll do my diagnosis, I'll do my thermal pulp vitality test and I'll do some periradicular test. You know, coal, EPT. You do your periradicular test, percussion, palpation. I'll periradontally probe every tooth and I'll have my definitive diagnosis, obviously ready to go out for evaluation, as a key part. But radiographs are not much more than a roadmap on things, and it's a two dimensional roadmap. I'm taking many more CBCTs than I ever used to.
Howard Farran: Okay, but I want you to just say what you said. You gotta remember, 'cause I've been in like, a dozen dental schools in Africa. I think I've been in 18 just in India. I've been to the only dental school in Kathmandu. You're talking way too fast. Just repeat just what you said. So you sit down on a molar, so you introduce yourself.
Bradley Gettlem: I introduce myself and I'll ask the patient their chief complaint. Is it, "Every time I bite down, when I have something hot, when I have something cold." Is it spontaneous pain? Is it, "When I wake up, when I lean up?" You got to start thinking about other things. Temperament [inaudible 00:23:53] issues, sinus issues. I'll ask them their chief complaint, and then what produces the pain. Then I'll try to reproduce it.
Howard Farran: So they say sensitive to the cold, then you'll go ice. If they say it's sensitive to hot?
Bradley Gettlem: Hot water. I do not believe in get a [perch 00:24:12] on a stick stuck to a tooth. Just inject hot water. And isolate with rubber dam to do the heat test with hot water. And I'll do the whole, everybody's gonna get a thermal pulp vitality test and periradicular test, percussion and palpation. You know, everybody's gonna get probed, just to be consistent. I just, be consistent with your diagnosis, but follow their chief complaint and go from there. If their chief complaint is cold, [crosstalk 00:24:39].
Howard Farran: Do you have a cheat sheet on how many canals all 32 teeth would have if they are somewhere without a CBCT that we can attach to this? That'd be all copywrited, wouldn't it?
Bradley Gettlem: It's all, buy the book! It's all there.
Howard Farran: But do you have, is there a one page sheet that just says-
Bradley Gettlem: I'm sure you could come up with one.
Howard Farran: [crosstalk 00:25:03]
Bradley Gettlem: You know, it's percentages too. I mean, in here, you get a percentage of what canal, what roots and what teeth have what percentage of canals. And you know, is it type one, type two, or type three, or type four canal system?
Howard Farran: Well regarding the CBCT. Would you say the number one cause of a failed root canal is a missed canal?
Bradley Gettlem: Yes. Or missed part of a canal. If it's not the canal, they didn't do a good job of cleaning and shaping.
Howard Farran: So I guess where I'm going with this is that-
Bradley Gettlem: So missed at least part of the canal.
Howard Farran: So if the number one cause of a failed root canal is very likely a missed canal-
Bradley Gettlem: Some sort of missed in that. If not a missed canal, missed portion of a canal not properly cleaned and shaved. Missed not thoroughly cleaning and shaping the canal system. Correct.
Howard Farran: But some people are thinking, are starting to think that a CBCT is a lot of extra radiation than a PA.
Bradley Gettlem: I think that's misinformed. You start talking to some of the guys that really have done studies and know a whole lot about CBCTs. The average dental CBCT, we have a carriage from 8500. We have high resolution, small field of view. I'm not looking at the whole arch. And it's about the equivalent of four PAs, but gives me so much more information. And I think the average CBCT for dentistry is in that range. Now I'm saying take a CBCT on everybody, by any stretch of the imagination.
Howard Farran: Well that's where I was going.
Bradley Gettlem: All front tiers have really consistent canal systems with very small variations. But if there's a concern, I won't do many retreatments without a CBCT 'cause I want to see what's missed, what's going on, why that case failed. I won't do many periradicular surgeries without a CBCT 'cause I want to see the anatomy in the whole area, not just the tooth, but the whole area regarding sinuses, intervation. But there's, in general, I think that's a miscalculation. Just like everybody says that we have digital, it's 6% of the old fashioned. No, it's not. It's probably 10% less. 6% would be 94% less. I don't think you're giving as little radiation with digital film as you are, as you think you are.
Howard Farran: So the molars are 3, 14, no. 3, 14, 19-
Bradley Gettlem: First molar is 19 and 30.
Howard Farran: And 30, 31. But it's funny. What I was saying is, if you look at a hundred million insurance claims, you see these ... Basically, you look at a hundred million insurance claims. It doesn't matter if you run it for MOD, root canal, extraction.
Bradley Gettlem: For first molar?
Howard Farran: Implant. It just, it looks like this heart has four pulses and it just beats on four first molars.
Bradley Gettlem: That makes sense. One of the first permanent teeth in the mouth, tougher to keep clean, most poorly taken care of tooth in the mouth is the first molar in a young kid's mouth.
Howard Farran: And when you see that, when you see that first molar erupt, you should shit your pants. Like, "Oh my god! That's most likely to be killed dead! Extracted, replaced."
Bradley Gettlem: Sealed and grooved.
Howard Farran: You should seal that thing the instant you see it, that tooth doesn't have a chance.
Bradley Gettlem: Absolutely. That's what I did in my kids and you did and your kids. Guaranteed, correct?
Howard Farran: Well I, that part of their life, I just kept trying to put them into foster care, and everybody kept giving them back. Just so, I really want to focus on first molars, no other tooth.
Bradley Gettlem: Probably the most common treated tooth. Not to mention also one of the most important tooth for arch integrity. More important teeth for arch integrity, don't you agree?
Howard Farran: Yeah.
Bradley Gettlem: Many people can live without second molars. You can live, first molars, you can't miss that.
Howard Farran: I got in trouble with one of my articles. I thought one of the best monthly column. I've had a monthly column every month since 1994. Can you believe that? March of '94. And so you know, you'll run good stuff for a year or two, but every four of five years, you're gonna have your little moment. But I said, one of the things I didn't understand-
Bradley Gettlem: I'm surprised for you, it's that infrequent.
Howard Farran: Oh, I know. Well I have a good editorial team. They take out all the profanity. They have five dentists read it. Tom Jeacobe, Howard Goldstein, Tim Burg, Jason [Liechtfil 00:29:17], who am I missing? They have five dentists read it, arguing about who's all gonna get butt hurt over that deal. I was telling them that everyone's afraid of second molar. I mean, I've been in several countries where they routinely pull the second molars. They don't even think they're worth saving. And I said in my deal, I said, "In my 30 years, I've never pulled a wisdom tooth that was in occlusion that someone came in and said they missed."
And whenever it was the second molar, I'd always say, "Well here's the deal. You could save it or you could pull it. You only chew about a sixth on the second molar, a third on the first molar, a third on the second bicuspid, and a sixth on the first bicuspid." I said, "What I don't want you to do is put a couple thousand dollars into a root canal building up a crown on a second molar when you got eight other cavities here and you haven't been in the dentist for three years, 'cause I'm gonna max out your insurance and then you're gonna come back for another root canal two years from now, and then another one." I said, "Maybe you should pull the second molar and put all that root canal crown money into your eight other fillings."
Bradley Gettlem: I thought that's a good thing.
Howard Farran: Oh yeah, well people do.
Bradley Gettlem: There are gonna be a lot of people that disagree with everything. There's people, and I can see the other side. It depends on the individual. I take it case by case. But if you're talking to somebody who's financially distressed and they have only so much money to go around, and they have eight other, take care of that. You'll live okay without the second molar. They win the lottery later on or they get a better job, they can always get an implant at a later date too. Implants are great. I don't do implants, I don't know a lot about implants.
Howard Farran: And I always say in my column, I've only had one patient a decade, three in my whole life, that when they lost their second molar, came in and wanted it replaced with an implant and a crown. Only one time a decade. Whereas everything else, you see someone needing it every week. So when you see all the other procedures we do, someone wants it every week your whole life, and only once a decade.
Bradley Gettlem: I completely get it.
Howard Farran: So I want to focus our whole conversation always just on the six year molars. 'Cause like I said, once you've seen the dental claims billed on a hundred million teeth on a graph, you would think-
Bradley Gettlem: And it makes sense. How many six year olds take care of their teeth?
Howard Farran: Yeah. You would think that there's only three or four teeth if you look at all the insurance data. So on those four teeth though, the question I'm going with is, do you take a CBC? What percent of molars, not retreats, molars come in your office, number 3, 14, 19-
Bradley Gettlem: 30?
Howard Farran: 30, do you take a CBCT on before you [crosstalk 00:32:00]?
Bradley Gettlem: Initial treatment, not retreatment? Not surgery?
Howard Farran: Yeah, just initial treatment.
Bradley Gettlem: Small percent.
Howard Farran: But what's small mean?
Bradley Gettlem: Single digits.
Howard Farran: Oh, so then it's not centered to care, then?
Bradley Gettlem: Not at this time. Retreatments and surgery, I'm taking one on every one. And there's also that you're talking pre-operative diagnostic. There's the other case. Let's say I'm working on an upper first molar and I'm having a hard time getting down or finding and NB2. I'll stop, take a CBCT at that time to see how it is. So I will take an inter-op, and there's occasions when you have a hard time finding the canal even with a surgical microscope and everything. So there's that that may up it a little bit, but that's not a big percent. But that ups it a little bit. And we, myself and my partners, we don't charge for inter-op CBCTs if it's for us to help find the canal anatomy.
Howard Farran: Okay. I know what they say, 'cause I get a lot of emails from them every day, and one of the biggest things they want to know is, when they go to the ADA convention, how many different file systems are there?
Bradley Gettlem: Oh my Lord.
Howard Farran: I know. So they're all gonna want to know, what do you use?
Bradley Gettlem: I use Tulsa.
Howard Farran: Tulsa.
Bradley Gettlem: I use Tulsa system. And I use the blue vortex series, and I combine it with ProFile .06's and some small Canals .04 profiles. I think many people-
Howard Farran: Now the ProFile, that's an old file.
Bradley Gettlem: It's an old file, but it's a [crosstalk 00:33:28]
Howard Farran: I mean, that came out how long ago, 20 years ago?
Bradley Gettlem: '94.
Howard Farran: '94.
Bradley Gettlem: '94.
Howard Farran: That's when we started Dentaltown magazine.
Bradley Gettlem: Then that's when the ProFile came out, and I still use some ProFiles, a lot of blue vortex. I use some WaveOnes. I think most people use some sort of-
Howard Farran: And who makes WaveOnes?
Bradley Gettlem: Tulsa.
Howard Farran: So these are all Tulsa. And Tulsa dental product is because Ben Johnson, who wasn't an endodontist, he graduated before endodontics, before it was even a specialty.
Bradley Gettlem: Had practiced a limited amount of endodontics.
Howard Farran: Yeah, practiced it. When did endodontics become one the-
Bradley Gettlem: Specialties? I think it was '65.
Howard Farran: So at that time.
Bradley Gettlem: But there was a lot of people grandfathered in.
Howard Farran: Everyone who had a practice limited to endo was grandfathered in as a specialist?
Bradley Gettlem: I believe so, I believe so. Now that, I don't use any one system solely. I use what I feel is best for that specific tooth. And I do a lot of muted systems. I'll do some ProFiles with the vortex. And I think most people do have some sort of a muted system versus. Now that's tough to understand. I mean, we'd be here all day if I told you what I did in each individual case. And the way they're sold, they work well as a system. But I like to do things my way and kinda use certain files together, and muted one system with the other. Some way one, some the vortex with ProFiles. I still like ProFiles 'cause they're a safe, safe instrument.
Howard Farran: So you mean they're not gonna break?
Bradley Gettlem: Yeah, and they stay centered really well, 'cause they have a flat rate of land. There're some things about that old file that I still like in many cases.
Howard Farran: So '94-
Bradley Gettlem: The nice thing about Tulsa, they have many different systems, not just one system. There's an old saying that if you're gonna be obsolete, obsolete yourself. And they're always doing research and trying to, and I don't work for Tulsa. I've never made one red cent from Tulsa. It's just, they're always listening to practitioners saying, "Try this." Some things don't work and they'll try to obsolete themselves and get a bigger, better file with better metal, metallurgy tech you know, as far as percentages. And I like that. I like a kind of a company that's sort of proactive versus just resting on their [crosstalk 00:35:41].
Howard Farran: I think how Ben was such a pioneer in so many ways.
Bradley Gettlem: No question.
Howard Farran: Ben Johnson lived in Tulsa, Oklahoma, started Tulsa Dental Products. But he sold Durac. Everyone else at that some sold through [crosstalk 00:35:51].
Bradley Gettlem: It was a one product company, it was thermofill.
Howard Farran: Yeah.
Bradley Gettlem: It was a one product company. Then he went from thermofill [crosstalk 00:35:57]
Howard Farran: But everyone-
Bradley Gettlem: Making them in his own oven, wrapping the files that go to purchase.
Howard Farran: But every single person-
Bradley Gettlem: Then they went titanium, they went plastic, and now they've gutter core, so they've.
Howard Farran: But every single person said, "Well you're gonna have to sell this to Shine and Patterson and Banko and Berkhart." He said no. And when he sold it to Dentsply, every one of Dentsply's divisions, caulk and all of them, sold through distributors. He said, "No, you're gonna stay dry." He wanted that one-on-one relationship, and I'll tell you what. You're ears are burning. Every time that Tulsa Dental rep, you know, when the Patterson Shine Banko Berkhart lady comes in, I mean, she sells 60,000 items and she's not using them. But when the Tulsa Dental rep comes in, he could go to a white board and draw every file system sold, and he could also tell me, 'cause I would always ask him every time I've ever seen him in my life-
Bradley Gettlem: About the competitors?
Howard Farran: I always say, "What does Gettleman use?" And he would always know! I mean, he knew. He would tell me every single thing you bought. So I really like the detailed rep as opposed to the general rep who says, "Here, I can sell you 60,000 items." Ben was a real pioneer.
Bradley Gettlem: Absolutely.
Howard Farran: Okay, so I'm gonna go to the true or false. So it seems like when they're on Facebook or Dentaltown, they think, "Ah, look at that root canal, it's perfect!" And it's always because it's obturated real pretty. But if you find all the canals and you get to the bottom and you obturate it real pretty, that's about what, 60% of the canal system infection? So you could make the prettiest root canal, but if you didn't use bleach. I mean, you could shape it and obturate it and make it gorgeous, but it's the bleach that kills about 40% that you're not mechanically removing. Would you agree with that [crosstalk 00:37:48]?
Bradley Gettlem: You have to chemo-mechanically treat the canal. You have to chemically, and files just create shape and remove some tissue, but they don't do anything to get into the aberrant to access the canals, the isthmus, the aberrations in the canal. And all canals have them. There're very few round canals. Take some teeth, clear them with methyl [inaudible 00:38:04] and couple alcohol solutions, and look at all the different canal. It's unbelievable when you look at a clear tooth, what they really look like. And you need the hypochlorite to get into all those little nooks and crannies within the canal system and clean it. All the files do is create shape. They get rid of some of the tissue, be it vital or necrotic, depending on the case. But they create a path to let you obturate. But you need to clean the canals.
I think that's the problem with some of these systems that are one or two or three step. Boom boom boom, you're done instrumenting the canal. You obturate it, but you never clean the canal. It looks good on the radiograph, but it's gonna be a failure. It's gonna absolutely be a failure. I spend more time cleaning that canal than everything. Instrumenting a canal right now with some of these great techniques and instruments that are available, it's pretty easy to shape it now. You gotta clean it, and it's all about the [inaudible 00:38:53] ...
Howard Farran: I want to key in here, 'cause whenever you're lecturing in China, Cambodia, Malaysia, Indonesia, Philippine. The Asian dentists always through the Americans under a bus, they always say this. They say, "Well you know, Americans, they only irrigate with sodium hypochlorite. But we go through four different, we do sodium hypochlorite, then we do paradax, then we do," what's the uh, HO2?
Bradley Gettlem: Hydrogen peroxide.
Howard Farran: Hydrogen peroxide, and then I think there's another one. There's bleach, hydrogen peroxide-
Bradley Gettlem: Alcohol will probably dry the canal before you.
Howard Farran: And alcohol. They say, "We do, we use all four. Americans, they're in a hurry, they only use one." What would you say to that?
Bradley Gettlem: I think a lot of people are in a hurry. I would agree to a certain extent, but let's answer it scientifically as well. All this is all good. Not cloroxing is not really gonna affect many of the bacteria within the canal system, but there's nothing negative about that. Hydrogen peroxide, kind of the same thing. Nothing real negative about it, but it doesn't gain a whole lot. But you're spending more time on cleaning, more power to 'em. I have no problem with that.
You want your irrigant to do three things. Number one, you want it to be a lubricant for your file so you don't catch up and snag and break, right? Saline would equally effective as a lubricant as anything else, agreed? So hypochlorite covers that, correct? You want it to dissolve tissue. It be nice if it dissolved little vital tissue, but most of the necrotic tissue. It's tougher to dissolve vital, but. So hypochlorite does that. You want it to be antibacterial. Well sodium hypochlorite is very antibacterial. Sodium hypochlorite covers the whole gambit of what we want. The others things, there's nothing really negative. I have absolutely no problem with it. In fact, they're focusing more on cleaning the canal; I like that, I like that a lot. The alcohol, all that's gonna do is before you dry it, and that's what we learned that in dental school. That's what we did the final flush. Just kinda desiccates and then dries it, so you can get it more well sealed. There's not gonna be any sort of less fluid in there making your seal not as well. So I have no problem with that. I actually like it, I use alcohol at the end after someone wipes [crosstalk 00:40:56]
Howard Farran: You just said sealant. You and I were taught on Grossman cement. Remember that?
Bradley Gettlem: Sure.
Howard Farran: 30 years ago. Now there's a whole new class of sealers, bioceramic sealers. Do you? So again, she's asking what do you use for a sealer?
Bradley Gettlem: I use Roth 801 elite grade, which is basically Grossman's formula.
Howard Farran: Roth what?
Bradley Gettlem: 801 elite grade. It's a nice, it's a real smooth-
Howard Farran: Elite grade?
Bradley Gettlem: Grossman's formula sealer, basically. And I have no problems with the other ones. I use bioceramics for perf repair, for retrofills. Bioceramics are great, very biocompatible, great stuff, and some of the glass out of it. But it's just, retreating, I'm not crazy about a lot of people using those, 'cause retreatment's about 40% of my practice. We talked about it in the textbook here. And some of those things, there's not a solvent for, and if you look at Grossman's original formula, original properties of root canal filling materials, root canal sealers in this textbook, it'll talk to you about the ability to go in. 'Cause I've had to retreat some of my own cases. You know, when it's surgically inoperable and it failed because of coronal microleakage, I want to retreat that, and I don't want to have something in there that I can't dissolve, that I can't get out. I think that's a negative with glass [onymer 00:42:03]. Obviously ultrasonics, but when you go in to cure, it can be dangerous, it can straighten out. So I think that's a negative with some of the, and I love bioceramics for perforation repairs, some absorption, retrofills, but I think for a ortho [inaudible 00:42:18], I'd stay away from something that doesn't have a solvent. Grossman's formula for sealers.
Howard Farran: So the bottom line is, back to the insurance data, because you couldn't get two dentists to agree that today's Saturday. I mean, I've been watching Dentaltown four hours a day since 1998. I mean, my God, I love. And they always amaze me, 'cause someone'll show something, say something, do something obvious, and then the next sentence they post. You're like, "Wow, I just love the way 100 dentists can look at something and no one sees the same thing." But you're, but when you, again back to insurance data, hundred million claims. If a general dentist does the molar root canal, a first molar root canal, in 60 months, five years, 10% are extracted. We're not talking about you and me deciding if it needs retreated, if it's failed, if it's not done right.
Bradley Gettlem: Just regardless, it's extracted.
Howard Farran: It's freaking gone. And if an endodontist does the first molar, 5%. So endodontists at 60 months, 5% of those teeth are missing, and if a general dentist does the first molar, 10% are missing. So obviously, we have to do endo so that can be reshaped. I mean, and maybe they never went to the final restoration.
Bradley Gettlem: There's so many variables on what caused it.
Howard Farran: There's so many things.
Bradley Gettlem: Was it a fracture?
Howard Farran: A facture.
Bradley Gettlem: Yeah, exactly. Looking at that whole success/failure thing if you want, but it depends on why.
Howard Farran: But the point is, you have to do a treatment based on the real possibility that it could be retreated, so you're saying bioceramics, you don't like the, it's harder to retreat.
Bradley Gettlem: It's a little bit harder to retreat.
Howard Farran: A little bit or a lot harder?
Bradley Gettlem: I haven't encountered a lot to make much of a statement. They're used more for retrofills, perf repairs. But bioceramic sealers, I'm not sure I've encountered many yet. But that's the book on 'em.
Howard Farran: When you were treating a molar-
Bradley Gettlem: They'll probably come up with some kind of solvent. They'll very well come up with a solvent for it.
Howard Farran: You think they will?
Bradley Gettlem: I think there's a good chance. If you're gonna make a seal like that, it'd be nice to have a solvent, and they should be able to. There may be some that I'm not familiar with too, so let's. I'm not familiar with everything out there on the market.
Howard Farran: When you're retreating a molar, what makes your life more difficult when you're trying to pull out what the last guy put in?
Bradley Gettlem: Some of the Sargenti paste that set up rock hard, and they don't have a-
Howard Farran: They still use Sargenti?
Bradley Gettlem: Yeah.
Howard Farran: In 2017?
Bradley Gettlem: The only thing that makes my life real hard with- Yes, there's still some of that out there. Or various pastes. Maybe it's not called Sargenti, but a paste. Something that doesn't have a solvent. And some things, you just.
Howard Farran: So you still, 2017, you still think there's Sargenti? Or is the Sargenti that was placed 10, 20 years ago?
Bradley Gettlem: That's what we're dealing with. I'm retreating a case that was done years ago. I don't think there's much out there. There are probably some paste systems, but the most difficult thing that I deal with retreatment is something that's not soluble, I can't dissolve it.
Howard Farran: I just want to say one thing on the Sargenti deal. You know, you kids come out of school, you've got an endo program, you got a board certified endodontist teaching you all this stuff. And then you get out and you go take a job for some old man who's 60, 70 years old and he goes, "I got a trick for you. They're too dumb at the dental school. Those who can't do, those who can't teach." And he pulls out a little jar of paste and he says, "I do my root canals in five minutes." And you think, "Damn, molar endo's hard, I hate it. This is really easy." But I'll tell you, 30 years as one of my very, very best and closest friends in all of dentistry believed that. It was Sargenti. And he was always in the closet with it, and he spun some out the apex and he hit the inferior alveolar nerve.
Bradley Gettlem: What happened to it?
Howard Farran: And it pickled it, and it went to court, and he lost and they took the maximum amount of the claim. So he had a disability, it's a million dollars.
Bradley Gettlem: Five million three.
Howard Farran: A million and three, three million would be lifetime total. So he lost one million dollars, but I'll tell you this. The having the society rule, the board rule against him, the trial, the loss, the newspaper. He never smiled again. He didn't like dentistry again 'til the day he died. I mean, it was just like a game changer. Same thing with an anesthesiologist. I've never done IV sedation because in every hospital in America, they don't let the cardiovascular surgeon do the IV in the surgery. In every hospital in America, they separate it. You do the IV, and every dentist you've ever met that lost a patient under sedation, they're never happy again.
Bradley Gettlem: No.
Howard Farran: I mean, how could you? But anyway, it ruined his career, and just Sargenti. What would you say to the guy? Those who can't do, those who can't teach, here's a little trick for ya.
Bradley Gettlem: Here's what I'd say about Sargenti, and we learned this, and maybe you remember this, maybe you don't. Dr. Dale Anderson ran the endodontic department when we were in dental school, remember Dr. Anderson?
Howard Farran: Yeah.
Bradley Gettlem: That came up. He said, "For those of you that go out," the exact scenario you're painting. He said, "Some of you are gonna go out to private practice. You're gonna soul sit somebody, there's gonna do a Sargenti." He says, "I'm gonna teach you in one sentence what you need to know about Sargenti." You may remember this or not, but you'll probably appreciate it. He said, "When you hear the word Sargenti related to endodontic therapy, what you should do is just turn the other way and spit." That's what Dr. Dale told us when we were probably sophomores in dental school and we were doing the preclinical endo lab. And you know what, pretty well said. I don't think I could say it better myself.
Howard Farran: We had to ... Ryan. We had to cancel a podcast yesterday, 'cause we wanted to podcast this dentist, and it would have been a great podcast. But when he sent in his talking notes, one of his talking notes was pro Sargenti. So I emailed him, or called him and said, "Okay, well we're not gonna talk about that. I'm not putting that on my program." And he goes, "No, you are. This is dentistry uncensored. We gotta tell these people the truth." And we canceled the show.
Bradley Gettlem: Turn the other way and spit, Dr. Dale Anderson, may he rest in peace. Great line.
Howard Farran: Yeah.
Bradley Gettlem: Can you disagree with that?
Howard Farran: Well I mean, and other people. The one thing that you also gotta to remember in the United States of America is that there's 211 thousand Americans who are allied with a dental license. 150 thousand of them are general dentists who practice over 32 hours a week. 30 thousand of them are specialists like Brad, who do more than 32 hours per week. But there's one million attorneys. One million attorneys. What's the chance your homies listening out there are gonna have an attorney looking at one of their charts one day?
Bradley Gettlem: You're, and like I said, I do some dental malpractice defense work as an expert witness. You know I like to stand on it if it's a certain kind of case. You really don't.
Howard Farran: And when you said that earlier-
Bradley Gettlem: We've all missed canals, we talked about that. We've all overfilled, we've all underfilled, we've all missed. But Sargenti, just the principles and fundamentals of endodontic therapy, the standard of care is not Sargenti paced, and I don't think, like the individual you were talking about who was miserable the rest of his life and he never smiled again, and the patient that had the Sargenti, the inferior alveolar nerve, may not have smiled real well again either. So there's two people from that Sargenti case that probably didn't smile a lot, agreed?
Howard Farran: Yeah. And one night when I'm having dinner, this guy who lost a patient under IV sedation, he did the IV. When he went to the bathroom, his wife told me at least every month since that happened years ago, he still wakes in the middle of the night screaming. And it's like, and then when they take you to that jury and you do your own IV sedation, they're gonna bring in a board certified anesthesiologist. What do you think the chance that some guy who learned IV sedation at a Holiday Inn is gonna take the cross examination of a board certified anesthesiologist on a witness stand? What would that look like?
Bradley Gettlem: It would, not good. I am very close with a board certified anesthesiologist that went to Yale, my wife.
Howard Farran: So you're sleeping with an anesthesiologist?
Bradley Gettlem: Yeah. I guess so. That's not as impressive as it used to be. You know, it doesn't pull as much weight as it used to.
Howard Farran: So your wife is a board certified anesthesiologist from Yale?
Bradley Gettlem: Correct.
Howard Farran: Amazing. And what would she say to a general dentist who said, "I want to sign up at the Holiday Inn course and learn how to do it."
Bradley Gettlem: What she would say to me, first of all, is that I married up, is what she would say to me. She would have issues with that.
Howard Farran: Well ask her this. Maybe if she knows anybody who'd write an article, maybe she'd want to write an article on it. But you know what?
Bradley Gettlem: She's written chapters in textbooks on pediatric anesthesia issues.
Howard Farran: I don't, you know, a lot of dentists complain to me when I say anything. On Dentaltown, or someone will post about the dentist who, in Toronto, who was filming his staff go to bathroom and got caught. And then people say, you know, "Why did you post that on Dentaltown or social media? You're destroying the image." I said, "Because if there's two million dentists on Earth and one idiot was doing that-
Bradley Gettlem: Somebody else was probably doing that.
Howard Farran: The other idiot needs to know that if you get caught, look what happens." Just like, I was on my way to Africa to shoot Cecil the lion's mom.
Bradley Gettlem: Oh really?
Howard Farran: But the story broke out, and I had the airplane turn around and come back. I mean, I realized that that probably was not a good idea. No, I'm just kidding.
Bradley Gettlem: Wasn't that the dentist in Minneapolis that shot Cecil?
Howard Farran: Walter Palmer. Yeah, Walter Palmer.
Bradley Gettlem: And it wasn't even a hunt. It was like shooting fish in a barrel, the way he went about that.
Howard Farran: Hell, it had a collar on it. I mean, it's sick.
Bradley Gettlem: That was ridiculous.
Howard Farran: Yeah. The point is, I still am asking people like your wife, how come we do every day in dentistry what's illegal in every hospital in America? And that is to administer the anesthesia while you do the surgery. You're either or the anesthesiologist until you leave the hospital, and then you go to the oral surgeon's hospital and he's both. A lot of countries are asking that question. The UK's obsessed with that question.
Bradley Gettlem: Oh really?
Howard Farran: Yeah. Because they're looking at the mortality rates. And even though a board certified anesthesiologist like your wife might only maybe lose one out of a million, the oral surgeons are losing like, three out of a million. And even though it's a rare, rare, rare event, they're still, people are just asking, "Why is this?"
And I'm gonna throw my homies under another bus, 'cause I believe this. I believe a profession has to police itself, and once you start running it like a country club and everyone looks the other way, then you invite in the government. So my deal is, do you want the people to run to Washington D.C. and say, "The dentists have run amuck," and them step up regulation? Or do you want to police yourself? There has to be checks and balances, and I think, looking at Dentaltown since 1994, I mean, dentists are well capable of policing themselves. One of the things that bothers me, 'cause I know my dentists, I know my homies. They give every ... I'll ask you. What percent of dentists after every molar root canal give them a Pen VK and 18 tabs of Vicodin?
Bradley Gettlem: Way too many.
Howard Farran: But what would you guess though? What percent would you guess, what's your gut feeling?
Bradley Gettlem: I would probably say 50 or more.
Howard Farran: Yeah, yeah, half. Every one.
Bradley Gettlem: I would say, let's take it another step further. I get patient coming all the time with thermal sensitivity. It's vital, agreed? That are on antibiotics. What is that gonna do for a vital case?
Howard Farran: Well here's what some of them say. Here's what-
Bradley Gettlem: Now we have, now we have superbugs. Why? Because of all the abuse and overuse of antibiotics and the bugs have mutated. Now we're getting. Soon, penicillin's gonna be like taking an M&M. The overuse and abuse of antibiotics. Now granted, if you do to research looking at that, a large part of that's the veterinary industry, cattle, all that kind of stuff.
Howard Farran: Is it really?
Bradley Gettlem: Yeah, it's a big big part of it. Bigger than I though 'til I read into it. 'Cause I have a real issue with that. The overuse and abuse of antibiotics is causing bugs that are gonna kill us, and I almost, I dunno. I was in the hospital for four days in September with a staff infection. I nicked my elbow at the gym. Remember Dan Levin?
Howard Farran: Absolutely. He's an endodontist in Missouri.
Bradley Gettlem: Yeah. One of my very best friends.
Howard Farran: Columbia?
Bradley Gettlem: Columbia, correct. He and his wife Cathy-
Howard Farran: Did I get it right, did I get it? Endodontist, Columbia?
Bradley Gettlem: Yeah, you're right on the mark. He and his wife Cathy, and myself and my wife Jodi were up in wine county in Napa for a little, nice little vacation. I woke up the second morning, there was a swollen elbow that hurt, and it continued to increase about, oh maybe a quarter inch every couple hours. I ended up coming home and being in the hospital on IV vancomycin, IV zosyn for three days, not getting out of bed. It took, the OR put a drain in and drained it for two weeks. I'm not saying I was close to dying, I'm not saying I was close to losing my arm-
Howard Farran: Could have been.
Bradley Gettlem: But you know, the antibiotics weren't working quite like they used to on these, that [mercin 00:55:34]. Why? 'Cause of overuse and abuse and bugs mutate. They're saying it. And now we have stronger antibiotics, but the side effects. And I was septic. You talk about being sick.
Howard Farran: Nine months ago?
Bradley Gettlem: So now, that being said, you cannot treat endodontic, be an endodontist or do endodontic therapy without the use of antibiotics, but I think they're overused, no question.
Howard Farran: But go over, okay. If you did a hundred first molars. What percent of the time would you send them home with Pen VK 500 milligram, 28 tabs?
Bradley Gettlem: When they're swollen, they have signs of infection, they're not feeling well. You know, they've got the malaise or feeling poorly. When they have signs of infection, not just 'cause I'm doing a root canal. When there's signs of infection. Remember?
Howard Farran: Yeah.
Bradley Gettlem: The information. Infection, rubor, dolor.
Howard Farran: What do the Greeks show? Swelling, red, rubor-
Bradley Gettlem: Rubor. Tumors, swelling.
Howard Farran: Tumors, swelling.
Bradley Gettlem: Calor, heat. Dolor, pain.
Howard Farran: Dolor, pain.
Bradley Gettlem: The signs of inflammation. Now inflammation doesn't always mean infection, let's get that. But that's kind of a place to start. If they're infected, there's signs of infection, they're going on an antibiotic. If there're not signs of infection, and periapical lesions, chronic apo periodontitis. Even if it's symptomatic, that's not signs of infection. With infectious flare ups second rendition in root canal therapy, maybe like a 5-8% chance of infectious flare up. So on those asymptomatic lesions, when you open them, oxygen gets in, the fact that they have their own bacteria. They come back the next day and say, "What the hell did you do to me?" Well that, I always tell patients before I start those. There's 100% chance you're gonna be infected and swollen at some point. Now you may outlive that day. Once we start, I've reduced that down to about 5-8% percent, but it's probably gonna happen in the next day or two. So I'm not gonna, for 5-8%, that means 92-95% chance they're gonna be a little sore, maybe need some anti-inflammatories or something. I'm not gonna put antibiotics on for 5-8%. If they need, I will get them back in, open drain. You get drainage, that's always the best thing.
Anti-inflammatories? Different story. I use those regularly. I use a lot of anti-inflammatories.
Howard Farran: Which one?
Bradley Gettlem: Motrin 800 is kinda my go-to.
Howard Farran: Four times a day?
Bradley Gettlem: Three to four times a day, depending.
Howard Farran: Three to four times a day. Here's another one dentists argue about. Some say you can only one-step a carioendo, but once you have a periapical radiolucency, the infection is out the bottom of the tooth and you cannot one-step it.
Bradley Gettlem: No, that's false.
Howard Farran: Then there's other people who said, "I one-stepped every single root canal I've ever done for my whole life." So when do you one-step, when do you two-step?
Bradley Gettlem: A lot of variables. Vital cases, there's no reason to not do them in one appointment. Cases with sinus fractures, no reason not to do them in one appointment, based on if I have time to do a good job. If I don't have time to do a good job, I'm not gonna do it in one appointment. So there's cases that I could do in one that I don't because of lack of time to do the quality job that I want to do. If there's signs of infection, I do not. You know, pus, swelling, draining. I won't do those in one appointment. Necrotic cases with a asymptomatic lesion, that's not necessarily infected. I'll do a lot of those in one. Some cases, I'll dress with calcium hydroxide, that's one. The one intracanal medicament that I use is calcium hydroxide, and I think you'll find most endodontists will say that.
Howard Farran: Made by who?
Bradley Gettlem: A lot of [crosstalk 00:59:07]
Howard Farran: Where do you, I mean, where do you buy yours from? Is that just Tulsa Dental, their calcium [crosstalk 00:59:12]? Is there a special kind?
Bradley Gettlem: [crosstalk 00:59:12] You can get all kinds of those needle tips.
Howard Farran: H26, was it?
Bradley Gettlem: That's an epoxy resin sealer, the H26 is. Calcium hydroxide is, you know, you have a pH of 11, 11.2, it's a great antibacterial material. So I'll leave it sealed in seven to ten days. I'll leave it in for a couple weeks, have the case back to finish it. That's the only intracanal medicament. When we're in dental school, we're using a form of creosol, we're using cresident.
Howard Farran: Cresident.
Bradley Gettlem: Creosol, beach wood, all kinds of different stuff that ... The only intracanal medicament I use is calcium hydroxide, and that's when they're infected.
Howard Farran: You said a quote by our instructor.
Bradley Gettlem: Dale Anderson.
Howard Farran: Dale Anderson. Do you, the funniest I remember him ever say one time, I don't know if you ever heard him say it. [inaudible 00:59:57], he said, "If you find all the canals, you get it all cleaned out and you get all the organisms out, you could fill it with sterile bird shit." You ever hear him say that?
Bradley Gettlem: Yeah, he said that. And I think that goes back to Dr. W.B. Hunter in Canada that was doing pulp caps with sparrow droppings. I think there's some literature on that. I think that's where that comes from. I mean, when you write a chapter in a textbook, you read a lot of articles. And there's a lot to throw, but you find some that are interesting. I think it was Dr. Hunter up in Canada at, I don't know if he taught at Dalhousie in Nova Scotia. I'm not 100% sure on that. But it was actually, the history of that was sparrow droppings for pulp cap back them, not op treating. For problems, that's full of bacteria.
Howard Farran: But the bottom line is-
Bradley Gettlem: Bottom line is, what he's saying is clean and shape the canal. Who cares what you fill it with? I agree. I'm not gonna, don't, got a perch of some sort. Not sparrow droppings or bird crap.
Howard Farran: Another thing that confuses the dentists. Number one, the media is bombarding everyone that ... When we were, for most of our career, there were three 30,000s. 30,000 die in car wrecks, 30,000 accidents, 30,000 suicides. Now out of nowhere, we got a new 30,000, and it went all the way to 47,000 opiod overdose.
Bradley Gettlem: This is an annual issue?
Howard Farran: Yeah, an annual issue. So America, during our 30 years of practicing dentistry, usually every year, about 30,000 people die in a car, 30,000 people die in an accident like falling off a roof, 30,000 die in suicide. Now we got a new one that passed it, went all the way to 47,000. Opiod addiction, Oxycontin, Vicodin, heroin, all this stuff. When we were little and got out of school-
Bradley Gettlem: What happened to Tiger Woods last week? Didn't he get pulled over? His blood alcohol was zero, but he was on Vicodin and a couple other mixture of narcotics, I believe.
Howard Farran: A lion can't drink and drive, but a Tiger Wood. But so the question in, when we were little and got out of school, the main press was saying, "Look how many doctors there are! She's got chemotherapy, she's got cancer, she's dying, she's in pain. These mean doctors won't give her a pain med." So doctors are like, "Okay, we should start giving them more pain med." And now the pendulum's clear over here and they've got this addiction issue. Do you think-
Bradley Gettlem: And you're creating it. You're getting liable for creating, you can get sued, becoming liable for creating the addiction as well. That's something you have to be careful of too. That's something new to lawsuits. Those'll go-
Howard Farran: And I've seen some doctors paid to put their dental assistant through the Betty Ford center because she was stealing prescriptions from his office, or calling in and ordering bottles of hydrocodone, and when she finally was full blown addicted, she says, "Well I've been stealing from your dental office, ordering them on your deal, and then you have to pay for my rehab."
Bradley Gettlem: That's wrong.
Howard Farran: But anyway, but my question is again. A hundred molars, how many of those hundred molars are you giving 16 tabs of Vicodin?
Bradley Gettlem: A couple.
Howard Farran: Couple. Single digit. And what percentage-
Bradley Gettlem: I give out very little narcotics. I use a lot of anti-inflammatories. I use very little antibiotics.
Howard Farran: And what's weird is when I look at the research, the researchers declare that when you rotate a Motrin and a Tylenol, that's the highest on the chart-
Bradley Gettlem: Yeah, 'cause you're-
Howard Farran: Opioids are way down the list.
Bradley Gettlem: It's, that seems to work the best. But what I'll do post-surgery, severe pain, some of those cases that are really bad, I'll still alternate Motrin with, and I use Vicodin, with Vicodin for break through pain. 'Cause the Motrin's gonna cut down the information there, the Vicodin's gonna kind of tell the brain you're not in pain. And I always warn them not to drive uncalculated when they take the Vicodin, but I'll do that for some lower second moral surgeries, some tougher surgeries where I'm going through a bigger deal. But I don't, and some of the Vicodin, it's just 'cause you get sick of arguing with 'em. You go through, you have these rose colored glasses where nobody's getting narcotics or something. But I get sick or arguing. "I can't take Motrin, I have stomach issues. Nah, I can't this, I can't take that. I can only take Vicodin." At this point, "Here's the Vicodin." I mean.
Howard Farran: So you get mean.
Bradley Gettlem: Yeah, I don't give them more than a couple days' worth and I try to talk to them, but after 20 years, you get fatigued. You're just like, "You know what, I'll give you eight. You'll have to work real hard for more than that." The fact that we can't call it in anymore, I think, has helped with that abuse too. In fact, the strongest stuff you can call in is Tylenol three.
Howard Farran: I want to ask you one more insurance data. When you look at the, like a hundred million insurance claims over the last 20 years, why did the ... What is it? Why do the apicoectomy and retrofill? I mean it's going the way of the dinosaurs.
Bradley Gettlem: Implants.
Howard Farran: Implants?
Bradley Gettlem: Implants. Clearly.
Howard Farran: And is that a good thing, bad thing? Do you do less than you did 30 years ago?
Bradley Gettlem: I do less retreatments and less surgery that 28 years ago. I'm not as old as you. Simply because implants are getting, and I think implants are wonderful. Don't get me wrong, I'm not saying anything negative about implants. But the best implant is what? Is your tooth. From a proprioception, they have a ligament; from an emergence profile, from a contour, contact, occlusion. Tooth is better. Now, if it's non-restorable, that's a different story. I think an apicoectomy and retreatment are very underused procedure. Sometimes it's not worth doing based on a proper diagnosis. Now with cone beam, we're better off diagnosed. We can do a better diagnosis. We can, you know, if it's an "Oh my god" fracture, it's a pretty good diagnosis, you don't need a cone beam. But if you have a small fracture with that little [tubladee 01:05:42] effect showing the bone loss, it might more hint that it's probably a fracture not worth doing the apical retreatment on. But if it's not fractured.
Fractured teeth have a terr, the prognosis is terrible, and some I'd rather get rid of them sooner rather than later, when there's a good amount of bone making that more predictable, than trying to be heroic, do the endo, do the retreatement, do the surgery. Which I've done cases on those that were fractured, and I probably shouldn't have before the use of the cone beam diagnostic ability. And then a year, year and a half later, there's less bone, making an implant less predictable. If it has a prognosis terrible, let's get rid of it now. Have the surgery, do the implant when there's a larger quantity of bone, making the implant more predictable. But if I feel the prognosis is good with retreatment and [inaudible 01:06:24], I still do plenty of them, and I will continue to. I think it's a great procedure and very predictable, properly diagnosed under the right hands.
Howard Farran: Here's another-
Bradley Gettlem: Makes sense?
Howard Farran: Yeah. Here's another confusing thing. People write articles that this tooth died because it had a leaking crown, but a lot of times you send that patient to the endodontist and they drill a hole through the crown. Well if the crown is leaking. Remember, I don't make these questions up. There's five million posts. The endo section is, by the way, the second most active section [crosstalk 01:07:06]
Bradley Gettlem: No, this is a great point, 'cause we're gonna get into coronal microleakage and I'll talk about access holes and whatever. This is important. This is important stuff.
Howard Farran: She's thinking, "Well Brad, if the tooth died because it leaked under the crown- "
Bradley Gettlem: I'm taking the crown off and removing all the [carris 01:07:20]. I'm not-
Howard Farran: You are?
Bradley Gettlem: Absolutely.
Howard Farran: So talk about that.
Bradley Gettlem: If it failed because of some kind of recurrent decay around the existing restoration, I'm gonna go through that. I'll take that restoration off and do it. I'm gonna go off on my tangent here a little bit, 'cause you went off on yours, so it's my turn.
Howard Farran: Oh, did I cut you off?
Bradley Gettlem: No, no no. No, but I'm gonna cut you off now.
Howard Farran: Okay, great. We'll call it even.
Bradley Gettlem: I'm one up. You owe me a cut off.
Going through a crown, which I do regularly, and trying to bond and seal the core, the access fill. We're not bonding the porcelain all that well. We're not bonding the dentin like we think we are. We can bond in there, we're not bonding the dentin like we think we are. We're going through a crown, there's no enamel. You're bonding to dentin and some kind of metal or ceramic. Agreed?
Howard Farran: Right.
Bradley Gettlem: How good are we at bonding to that stuff?
Howard Farran: Well I'm good, because I would use amalgam, 'cause it would corrode a seal.
Bradley Gettlem: You know, such an underused material. I would too. But it's like you're the anti-Christ if you use amalgam. True?
Howard Farran: I know.
Bradley Gettlem: But amalgam's probably the best restoration in that place, but you're the anti-Christ if you use it.
Howard Farran: Isn't that funny, how the guy who wrote a chapter in the most popular book in the world said amalgam would have been the best restorative material, and you just can't get that [crosstalk 01:08:32]?
Bradley Gettlem: But you're the anti-Christ if you use it!
Howard Farran: I know. I know, it's terrible.
Bradley Gettlem: But number one, the fact, and I'm not a restorative dentist. I'd rather do a root canal than the restoration. But the fact that if I do it, if I'm accessing to the crown and that tooth is never not under a rubber dam, that's the best time to seal your gutta percha, without question. You don't worry about the temporary falling out, then missing appointment. Best time is right then when the tooth is never not under a rubber dam. If I could convince every patient I treat through a crown to get a new crown, I'd have a higher success rate. 'Cause we're not, coronal microleakage causes more failure that apical leakage. When we're in dental school, we learn it the other way: apical leakage, apical leakage. Coronal microleakage is much better problem, endodontic failure than apically. There's no question about it.
Howard Farran: If you're nerd like me and you want all the literature, I'll give you the references too.
Bradley Gettlem: [crosstalk 01:09:18]
Howard Farran: What's the chance that bacteria would come out of the blood stream and go into the apex, versus the saliva, which has a billion microorganisms, bacteria, and fungi. Seriously?
Bradley Gettlem: My point, my point exactly. You do a good job of pin shaping the nail, the apico, that's not the problem. It's the crud, the mouth is the dirtiest place-
Howard Farran: On Earth. Well no, the microbiologists tell me that the human mouth-
Bradley Gettlem: It's disgusting.
Howard Farran: Well it has so much, and I'm not making this up. PhDs, they say you can't find a water in the Amazon rainforest, you couldn't find it in the dung of the rhinoceros and elephant, because nothing has more nourishment than a human mouth. I mean, you're bathing it in carbohydrates and proteins and sugars. They find more life per cc in a human mouth than in any other place on Earth.
Bradley Gettlem: Absolutely, it's filthy. So this is gonna bring us to the next logical question that Town is gonna answer. I'm sure you get this. Do you leave teeth open? That has to be a question. Do you ever leave teeth open?
Howard Farran: Yeah, absolutely.
Bradley Gettlem: How many ... I hate leaving teeth open. I'll leave them open for a couple hours under rubber dam and continue to drain, sometimes to drain. You know, people say they don't really need more than ten minutes. I disagree, I've had many teeth drain more than that. I'll complete the instrumentation, I'll leave them open. But they're in a rubber dam in my chair as long as I can leave them to sit. I don't want to leave a tooth open overnight. Why, you left an open area into what? The dirtiest place on Earth. Let's leave an open wound, we're gonna put it in the dirtiest place on Earth. That's a good service. I don't like doing it.
Howard Farran: Yeah. Okay-
Bradley Gettlem: Now there's some cases that I don't even know what the point was. You know what, I'm just gonna flap it. I'm gonna op treat this and do the surgery at the same time. Get the drainage, get it cleared out. It's like when they finally treated my elbow. It got so much better.
Howard Farran: We're into overtime. Can I keep you for, can we keep going or do you need [crosstalk 01:11:09]?
Bradley Gettlem: No, we can go a little bit longer.
Howard Farran: Here's another big debate. Some people, we're talking molars. Some people say, "Well you have to have a post to hold on the restorative build up," and then other people say that the only function of a post is to fracture a root; it has no other purpose than fracturing a root.
Bradley Gettlem: So let's be realistic. You have the ... That's not the only reason. The reason for a post is support, is to support the superstructure, okay? All the research shows you need an adequate ferrule. One and a half to two is the debate; I like two. You need an adequate ferrule.
Howard Farran: And say what a ferrule is, in case someone missed it.
Bradley Gettlem: Quantity of two structure, regardless of the core build up, post whatever. Quantity two structure, you need a couple millimeters. Some people say a millimeter and a half; I like two. Buckle and lingual. And approximately if there's a tooth on either side, it means this one's not as big a deal. And we need retention form of at least five millimeters. That's kind of the gist. If you're gonna do [crosstalk 01:12:06]
Howard Farran: But the ferrule should be five millimeters?
Bradley Gettlem: No. Retention formed it with a core. So I'm not talking about posts, I'm talking about from where the margin of the crown's gonna be up, you want a core of about five millimeters-
Howard Farran: Oh okay, the core. Like, two of that has to be two structure.
Bradley Gettlem: It has to be two structure. If that's the case, you probably don't need a post. Posts are overused and abused. Some cases to support the superstructure, you may need to put a post in. If you're really pushing the limits of ferrule, I'd probably put a post in. But a parallel sided, vented, ParaPost-like system, something where not an active system, a screw post. I don't like many things.
Howard Farran: No screws.
Bradley Gettlem: No screws, and I don't like real tapered posts either. But a passively cemented post. And if it-
Howard Farran: You name brands.
Bradley Gettlem: You have the Pro-Post by Tulsa, you have ParaPost-like system with [crosstalk 01:13:00].
Howard Farran: Pro-Post by Tulsa.
Bradley Gettlem: ParaPost type of system. ParaPost makes a good one, they have ParaPost and they have ParaPost wide.
Howard Farran: Can you do your entire practice pretty much from Tulsa Dental Supply? Pretty much?
Bradley Gettlem: Probably, yeah.
Howard Farran: Yeah. Okay, so here is-
Bradley Gettlem: But let's get back to that. So two milli, this is important. 'Cause I've talked to dentists about a ferrule and they go, "What?" Two millimeters, some people say one and a half, two millimeters of ferrule, buccal and lengual, and long as the tooth, mesial and distal, and a five millimeter retention form. Posts are overused. Sometimes you need them to support that superstructure, but they do. How many fractured teeth you see that don't have posts in them?
Howard Farran: How many?
Bradley Gettlem: I think most posts are pretty, cause a lot of the iatrogenic fractures. Now they come and they're fractured down the mesial marginal ridge. You can't get a crown down to 80% of it, that's gonna continue to propentiate as they continue to use to teeth and load it. You're gonna lose that from fracture. That's not from a post. Different story.
Howard Farran: But do you think a lot of the fractures you see are from posts?
Bradley Gettlem: Yeah, because the longer, bigger, they used to be real popular. And we know that beyond six millimeters, the retention is zero percent; it doesn't help you out at all as far as-
Howard Farran: Once the post is longer than six millimeters in the root.
Bradley Gettlem: It's not, you're not gaining anything. You're getting into the danger zone.
Howard Farran: But you agree that posts cause a lot of fractures. Are you able to say-
Bradley Gettlem: They do. Too long a post, to big a post, too wide a post.
Howard Farran: Too long.
Bradley Gettlem: But posts are, I'll say this. Posts are way overused and abused.
Howard Farran: Okay, but let's talk about-
Bradley Gettlem: But then some cases, they're necessary.
Howard Farran: But I have to, I mean, I know what's going out on the street because, you know, they don't say it in the lecture. They probably won't say it if you go to dinner with four couples. But you sit at the bar with them and drink 'til three in the morning, they're all gonna say the same thing. They're gonna say, "Brad, I'm in Tokyo. Tokyo, Paris, and London, the government dental insurance only gives you $100 US for a molar." So $100. In the United States, I used to get $1000 for a molar root canal, when we got out of school from Delta of Arizona. Now 95% of the dentists are on a Delta PPO, 95%. 82% are on two PPOs or more. I think, and then two thirds of dentists are between, on 4 or 12 plans. So when we got out of school, the number one overhead cost was labor at 28%. Now labor is still 28% on average at dentists, but the number one cost that shows up on a statement income, its adjusted production, I bill $1000 for a root canal but Delta kicks it back to $600. So the average general dentist has a 42%. The number one overhead is 42% adjust production write off.
So the post is a separate billed procedure. When you're eating dinner with dentists in Tokyo, Paris, and London, they say, "Brad, they're only giving me $100. I have to put a post in every freaking canal."
Bradley Gettlem: Well you're doing something just for the money. That's not, you don't do things for money. Do things for them.
Howard Farran: Well could you do, could you do this root canal in Tokyo for $100 US. I mean dude, we got the overhead of Phoenix. They're in Tokyo where land is a million dollars a square meter, and they're gonna give you one Benjamin for a molar root canal? I mean, your overhead-
Bradley Gettlem: It's a broken system.
Howard Farran: Yeah, it's a broken system. 'Cause for you to do that, if your overhead was 10%, you'd do it at cost.
Bradley Gettlem: Yeah.
Howard Farran: So my question is this, and I know it's ugly.
Bradley Gettlem: But that's the system when you start getting into socialized medicine and stuff. What are you gonna do?
Howard Farran: So here's my brutal question.
Bradley Gettlem: The people that suffer from that are the consumers.
Howard Farran: Yeah. Who-
Bradley Gettlem: Practitioners aren't.
Howard Farran: Who paid $800 of their own money for the new iPhone, and bought a $30,000 Honda Accord in Tokyo. I mean, you walk out in Tokyo. Every restaurant is plush and bank and expensive. The cars all look brand new. And then when they go to a dentist's office, "Well I'm not giving you a penny. I mean, the government pays for dentistry." And the government's broke. The United States has one GDP [adess 01:17:18] and we have $19 trillion, and we're $19 trillion in debt. Japan has a $4 trillion economy and they're $8 trillion. So they have 200% GDP debt, so the government's not gonna give them any more money. So my question is this.
Bradley Gettlem: But that problem's not fixable.
Howard Farran: But here's the ugly brutal, I want to ask you the ugliest, brutalest question ever. If you had to place a post in every canal because your government insurance scheme doesn't even give you one third of the money necessary just to do the damn root canal, what post would you, what unnecessary post would you put in every canal?
Bradley Gettlem: The smallest one I could.
Howard Farran: The smallest one you could.
Bradley Gettlem: The smallest one I could.
Howard Farran: Because some of the technical questions, they say there's fiber posts, there's metal posts. If you had to-
Bradley Gettlem: You know, a fiber one. Dentin has some inherent flexibility, and some of the fiber core posts flex like dentin. So instead of, when you get the real stiff posts, they're gonna fracture the tooth, or maybe the post will fracture depending if it's titanium. There's all those variables of the inherent elasticity of tooth structure versus the post. So the one that most, somebody's here, that most matches that of the tooth is probably the smartest one.
Howard Farran: Because when we're looking at. So we're looking at a maxillary molar. The big palatal root is very different than the little mesial buccal root.
Bradley Gettlem: Correct.
Howard Farran: So what post would you put in the little mesial buccal?
Bradley Gettlem: Oh, you'd be an idiot to put a post in there. Odds of doing that safely are minimal. You go down a millimeter or two, but what are you getting? What advantage is that, besides your billing.
Howard Farran: A billing, a billing code. In Tokyo, Paris, and London-
Bradley Gettlem: Well that's stupid.
Howard Farran: Well tell the NHS that. They agreed to get a new president or something or ...
Bradley Gettlem: I mean, I would never put a post in a mesial buccal or distal.
Howard Farran: But it ...
Bradley Gettlem: And you're gaining nothing, besides you're billing somebody, which is as far as I'm concerned.
Howard Farran: But what is the-
Bradley Gettlem: Why not just rob them? It's easier, quicker to put a gun at their back and go after their wallet. It's more efficient. You're doing the same thing.
Howard Farran: Yeah. Yeah, it's a weird world over there.
Bradley Gettlem: It's no different. It's highway robbery and it's more efficient.
Howard Farran: But if you needed the post, what post system would you recommend? You said the uh
Bradley Gettlem: The ParaPost, I like them.
Howard Farran: The ParaPost out of Tulsa.
Bradley Gettlem: Yeah, they're all real simple. That's Pro-Post from Tulsa. Any parallel sided post with a vent is probably just fine.
Howard Farran: So why do you not like tapered?
Bradley Gettlem: 'Cause I think a lot of them create some kind of, the potential for abuse and create an internal wedge, inducing fracture has a better chance.
Howard Farran: Here, now I'm gonna ask you-
Bradley Gettlem: Make sense?
Howard Farran: Yeah.
Bradley Gettlem: I mean, the less [crosstalk 01:19:55]
Howard Farran: But why not tapered? Why not tapered? Why do you keep saying parallel?
Bradley Gettlem: I think there's less chance for abuse and internal wedging. It's not gonna grate the ... A small taper's not a big deal, but the larger the taper, the more chance of wedging, thus inducing fracture with the occlusal load. You know that, that's [crosstalk 01:20:14]
Howard Farran: Now here, I know it's hard to ask these questions when you're not seeing a patient, but I have two more questions, two more questions. Number one, you have the insurance data that says the average MOD amalgam lasts 38 years. Now an MOD amalgam-
Bradley Gettlem: I have some in my mouth that are probably close to that old.
Howard Farran: Yeah. It's half mercury, half silver, zinc, copper, and tin. It corrodes to a seal that's unbelievable. Then you have the insurance saying that the average posterior composite lasts six and a half years, 'cause composites shrink when you cure them and they leak.
Bradley Gettlem: They leak like crazy.
Howard Farran: But on Dentaltown, there's this urban legend myth that endodontists love amalgams 'cause they crack all the teeth and they need root canals. So it's like, does an amalgam last 38 years and then cracks the teeth that need a root canal? And is it true that endodontists love amalgams because it cracks so many teeth? Because the insurance today is very clear that a posterior composite, six and a half years.
Bradley Gettlem: It's gonna leak. Better chance that that's gonna create an endodontic issue than the amalgam. The proof is right there, number one.
Howard Farran: So you-
Bradley Gettlem: I'm not an endodontist that wants every tooth with gutta percha. I'd like every tooth to have a nice, vital pulp in it. I'm not looking for dental deterioration. I think amalgams are underused restorations. I think composites are overused. Composites are much more tech extensive. Especially if you did a nice amalgam and you polish it like we did in dental school, they're probably well sealed and do a wonderful job. I'm not, I'm gonna figure what's best for that tooth.
Howard Farran: And I would love to take a picture of you talking, because I understand the whiter, brighter, sexier teeth for half the population, that's the women who gives a shit. When you're talking about some man on the [crosstalk 01:22:03]
Bradley Gettlem: Well plus, if you want, if you talk to somebody about putting an amalgam in, you're arguing with society, which is stupid. But it's the re, and you know what? It ain't changing.
Howard Farran: Yeah.
Bradley Gettlem: I don't care how many people you get on Dentaltown, how many people get podcast.
Howard Farran: It's crazy, but.
Bradley Gettlem: That's, the public wants what the public wants.
Howard Farran: But even dentists are irrational. I have dentist friends who have, like the whole time I've been talking to you this whole time, I have not seen anything behind your canines. I have not even seen any sign that you have any bicuspids or morals in your mouth.
Bradley Gettlem: I do, I do.
Howard Farran: Yeah. But I have no evidence of that. So you're a boy, they're afraid of dentistry, they don't want to get shot. It's your own son, he's six, he has an occlusal cavity in that six year moral. Most likely would be a root canal, pulled, bridged, implant, everything. And they put plastic occlusal that shrinks on their own son. It's like, this isn't about the consumer. You're a doctor, and that's your baby.
Bradley Gettlem: The bonds to that little bit of amalgam that's there. It's not bonded, not like we used to think.
Howard Farran: But you're a doctor, you went to eight years of college. It's your own baby, it's a boy, it's a maxillary moral. And you just chose a shrinking plastic filling in your own son. At this point, what would that person have to do to disprove you that, "Screw science, screw logic. I'm just a talking monkey with clothes on."
Bradley Gettlem: I'm a evidence based guy, I want to see the slides.
Howard Farran: Yeah, I know it. So you agree that composites cause more endodontic therapy than amalgams.
Bradley Gettlem: No question, they leak like crazy.
Howard Farran: Yeah, no question. But you know how many dentists, and this is how the human mind works. You show the data of 100 million claims. You go, "Yeah, but none of those guys did it right. I do it better. I'm all that and a bag of chips." And you're like, "No dude, you're not all that and a bag of chips." I mean, so they're always, their brain's gonna reset. "Well I do it the right way. All my colleagues who have eight years of college," you know?
So here's the last question, which is so tough for you to answer if you couldn't see the patient, but they do it all the time on Dentaltown. They take out this amalgam-
Bradley Gettlem: Put in the deposit.
Howard Farran: And there's a black line. And it always, they always take a picture and they stop and they go, "So is this fractured? Do I now go to extraction implant?" What do you do when you take out an MOD amalgam and there's a black line? How do you wrap your mind around cracks?
Bradley Gettlem: If it probes, I'd be a lot more concerned than if it doesn't probe.
Howard Farran: Explain that, probe what?
Bradley Gettlem: If there's a, if you're going around the tooth and you're probing, and not a six point probing. Endo, I do like a 20 point probing. I go in, three three three three eight, three three. I'd take the tooth out. If you're probing along and you're going, three three, two two, three three, two two, right in line with there. Nope, I wouldn't be that concerned about it. You know, if it's just a black, is it a crack, is it just a black line? Obviously you're thinking crack, is where you're going with this.
I may take a CBCT to see if there's any bone loss associated with that that I couldn't probe. Sometimes you can't get an approximate of what you want to. I'd be a little more concerned about that. If I'm doing, obviously for me, I'm probably going to the pulp. If I'm accessing the pulp and that crack, the black line goes down all across the floor, take the tooth out. If it doesn't, if it's just a superficial crack.
Howard Farran: You're talking about a crack-
Bradley Gettlem: That goes into the chamber and down the floor.
Howard Farran: In then, on the floor of the chamber. I was talking about a crack when you take out the amalgam above the chamber, a black line.
Bradley Gettlem: Yeah. If there's a pocket associated with that, I'd be more concerned.
Howard Farran: So if there's a black line above the chamber-
Bradley Gettlem: You're asking me to put myself in a scenario that I don't do. I'm not just taking out amalgams and putting in composites. If I'm taking out an amalgam, there's a reason I'm taking out the amalgam. There's some sort of pulpal issue or something like that.
Howard Farran: Yeah.
Bradley Gettlem: If it's just a cracked tooth, a leaky filling, a reversible pulpitis, I'm sending it back to you and you're doing it. But if I'm dealing with a situation where there's a crack and I'm taking out the amalgam to evaluate the extent, I'm gonna evaluate the extent of the crack. I wouldn't mind getting rid of it, going down 'til there's no crack evident. Could ramp out the crack, so to speak. 'Cause it's gonna propentiate. You continue to use that tooth, which you're going to, it will continue to propentiate and work its way down; you'll probably lose the tooth. I mean, just to show them. If you have a crack and you get the crown margin below it, you're probably gonna be fine for a very long time. If you can't, you're not doing the patient much of a service. I'd probably get rid of that tine and go with the implant 'cause there's a good bone at that time. If you wait too long, get silly heroic, there won't be good bone for that in a month, two months, 18 months, whatever. It's just a matter of time. It's not if, it's when. I'd get rid of the crack if it definitely is a crack. If it's a little stained dentin. I mean, there's stained dentin, there's little black areas that aren't cracked too, that we've all seen and we get all concerned.
Howard Farran: Hey, last part.
Bradley Gettlem: You know, and fracture versus crack too. Is it extending, or just a little [crays 01:26:56] line? 'Cause big deal about those.
Howard Farran: I hope we can get, you think Ben will let us put that video on the end of this?
Bradley Gettlem: I think he would.
Howard Farran: And another thing, I want to say something that's, your thoughts on this. Right now, everybody's saying you know, "The millennials are different." Like they're a different species and all this, and they don't want to own their own office and they all want to work for corporate and they all want to have the rest of their life. Do you remember when we were little, when we, 30 years ago when we were in school. You remember how they told us the girls were only gonna practice five years, they're all gonna get married and have babies?
Bradley Gettlem: And have families, yeah.
Howard Farran: And all that stuff. Look back at the girls who were. Stephanie Carmada, Deedee Richards.
Bradley Gettlem: Lisa Gonzales.
Howard Farran: Lisa Gonzales. They're still practicing with some of the biggest, most successful-
Bradley Gettlem: Wheezy. How 'bout Wheezy, you talk to her?
Howard Farran: Wheezy?
Bradley Gettlem: Louise Gilmore.
Howard Farran: Oh, in Saint Louis.
Bradley Gettlem: My partner. I haven't talked to her.
Howard Farran: And Laurie Ingleman. I mean, so-
Bradley Gettlem: I talk to Becky Cecil regularly, she's teaching at Midwestern.
Howard Farran: Yeah, and I remember when they were saying that, I could see the girls' nostrils flaring like, "I wish that idiot man would shut up and get out of here." Wouldn't you say, wouldn't you almost say? I mean, we don't have data, but don't you think the girls in our class were just as long and had just as big, or bigger, most successful dental offices than the average male?
Bradley Gettlem: The ones that I can think of. Becky practiced for 26 years. Stephanie just sold her practice recently. She practiced for what, 20, 25?
Howard Farran: I think Stephanie had the largest practice of anybody I know. I mean, she was crushing it.
Bradley Gettlem: Lisa's still practicing. Laura Ingleman's still there as well. So what do you mean, we don't have the data? They're data right there. Everyone you can name that's still practicing that we can think of.
Howard Farran: I mean, I think our class-
Bradley Gettlem: That's data. That's accurate data.
Howard Farran: Yeah. I think the average girl in our class had a bigger practice and practiced longer than the average man in our class.
Bradley Gettlem: A lot of them still are. I mean, that's data, that's accurate data. It's there.
Howard Farran: Yeah.
Bradley Gettlem: Now it's class of '87 UMKC, but it's that data.
Howard Farran: Yeah. So do you believe that the millennials now, they're coming out of school, are a different species and they just want to be an employee and work at a corporate industry?
Bradley Gettlem: I hear that. I don't know why.
Howard Farran: But do you believe it though?
Bradley Gettlem: That's what they're promoting, that's all I hear. I'm not in an academic environment at this point. I probably will be eventually. But I hear that's what they're promoting in dental schools. I hear that's what a lot of kids want. That's, I hear it.
Howard Farran: So the reason I call bullshit is because we're a two million year old species that a hundred billion humans have lived. And for two million years, no human wants to live in your cave; they want their own cave. They don't want to live under your thumb, they want to do what they want. They don't like curfews, they don't like checks and balances, they don't like transparency. And now all of a sudden, what? The species, what? Is it no longer homosapien? It's like homosapien millennial, like they evolved?
Bradley Gettlem: It's different. You say you disagree, you're calling bullshit. But you're not calling bullshit that that's what they want, 'cause that's what they're all saying, they're all talking like that. They're wrong; I call from that aspect. I think they're mistaken. But you're not saying that that's not what they're wanting, 'cause that's what they're all saying. You agree?
Howard Farran: Yeah.
Bradley Gettlem: I mean, you're calling bullshit that they're not gonna be happy, not that that's what they're being taught or-
Howard Farran: I think they're being brainwashed, that they have too much that they ... Because all those big corporations are in them schools giving them the Kool-aid.
Bradley Gettlem: I mean, if you're graduating right now from dental school, you're $400 thousand in debt. Oh my lord. And that scares me for a lot of different reasons. Corporate dentistry, I think you're gonna find some people over treating a lot of people just to pay their debt. That scares the hell out of me, and I've seen some of that.
Howard Farran: I could solve the student loan crisis in one minute.
Bradley Gettlem: How's that?
Howard Farran: I've lectured in 50 countries. I would just graduate and move to Sydney.
Bradley Gettlem: Oh really?
Howard Farran: Fuck. For half a million dollars, would I leave America and go to Sydney, Australia? Hell yeah! I'd just leave the country, say, "Thanks for the half million!"
Bradley Gettlem: "See ya."
Howard Farran: Yeah. I mean hell, half a million dollars to move to Sydney? I'd move there for $50 thousand. But hey Brad, thanks for all you do. Thanks for all the retreats you've done of mine over the last three decades. You even did a root canal on the other endodontic legend, Joe Dovekin. I mean, you're an endodontist lecturer, and when you lecture-
Bradley Gettlem: May he rest in peace.
Howard Farran: You didn't even really lecture general wise.
Bradley Gettlem: I don't do much of it anymore.
Howard Farran: I know, but dude, you're a legend. You're the endodontist who-
Bradley Gettlem: I'm just a guy.
Howard Farran: And I want to tell you another thing.
Bradley Gettlem: I'm just a guy who does root canals. I'm just a guy [crosstalk 01:31:33]
Howard Farran: But that's bullshit.
Bradley Gettlem: No it's not.
Howard Farran: Because when I talk to my endodontist friends and I say, "Well, what if you can't do the root canal?" And I can name you two right now, I don't know if they want me to say their names, but I will if you want me to.
Bradley Gettlem: No don't do that, no.
Howard Farran: And they say, "I send them to Gettleman."
Bradley Gettlem: I'm just a guy in Glendale who does root canals.
Howard Farran: Dude. Do endodontists send you root canals in the valley?
Bradley Gettlem: No no, never.
Howard Farran: Oh god, I could name two right now. But I just want to say that I think you're amazing.
Bradley Gettlem: Well thank you.
Howard Farran: To be asked to write a chapter in the number one selling root canal book, the most translated book of all time, amazing. I just think you're all that and two bags of chips.
Bradley Gettlem: Well thank you for all you do. Thanks for all you do.
Howard Farran: Hey. But it would be-
Bradley Gettlem: Just like going back to Dr. Edwards having a beer after finals.
Howard Farran: It would be the most amazing thing if you ever built us an online course on Dentaltown. I'll tell you why, Brad. I know how to get you to do it. We only charge 18 bucks for that course in rich 'ole America and Canada and all that. But when you go to dental schools in Africa and Kathmandu and all that, they're all free. I've walked into dental schools where the dean, when she finds out that I'm the Dentaltown guy, they burst out balling because they can't afford these books. It's all on the internet. And so many of those dental schools, the instruction is a Samsung and it's YouTube videos. I'm not knocking that, the YouTube video is a hell of a lot better than a 20 year old ... I remember when I went into Kathmandu. All their textbooks were donated. Half of them were donated from China, there were 25 year old books written in Mandarin Chinese. The other half were donated from France. No one in the school could speak Mandarin or French.
Bradley Gettlem: So they're just paperweights.
Howard Farran: So they just looked at the pictures. And then Dentaltown comes out and now they've got 411 courses, and that lady in Kathmandu, I mean, she held me and she cried. And same thing in these schools.
Bradley Gettlem: Thank you for what you do, a world of benefit.
Howard Farran: So when you do an online C course on Dentaltown, you'll be educating girls how to do endo that can't afford your textbook on Amazon. So I'm trying to guilt you into this, I'm trying to.
Bradley Gettlem: You're doing a good job.
Howard Farran: I'm doing a good job. All right, right on. But again, last final question. If you had to go back to dental school and marry one of the girls in our class, which one would it have been? And we're not editing this out.
Bradley Gettlem: Not editing this out?
Howard Farran: Oh hell no.
Bradley Gettlem: Mary Kay Wilkinson.
Howard Farran: Mary Kay Wilson.
Bradley Gettlem: Or Sigrid.
Howard Farran: Sigrid Simonson?
Bradley Gettlem: Or Lisa.
Howard Farran: I would have become a Mormon and married all of them.
Bradley Gettlem: I was gonna say, I got Lisa Gonzales. You gotta love Deedee.
Howard Farran: Deedee Richards, Lisa Gonzales, Stephanie.
Bradley Gettlem: Stephanie, how can you pass up Stephanie?
Howard Farran: My god, that was a great class, just a great class.
Bradley Gettlem: I could just go down the list, there was a ton. And there was another African-American girl who was beautiful.
Howard Farran: From Saint Louis.
Bradley Gettlem: What was her name?
Howard Farran: Yeah.
Bradley Gettlem: You know who I'm talking about?
Howard Farran: Oh, absolutely.
Bradley Gettlem: She was stunning! Oh, we had some lookers. I'd marry 'em all.
Howard Farran: But I'm not kidding when I say this.
Bradley Gettlem: I'd marry 'em all.
Howard Farran: In every dental school I've ever been to, I always make a point to tell the guys, "Don't ever graduate from dental school without marrying one of the chicks in the class." And I kid you not, I mean, it's a different woman who got a four year undergraduate degree, got into dental school, became a doctor of dental surgery.
Bradley Gettlem: I'll stick with my, I like my wife.
Howard Farran: But your wife's an anesthesiologist. Same thing, same thing. I mean, it's different, because what do men most look for?
Bradley Gettlem: We had some lookers in our class, a lot of 'em.
Howard Farran: But what do the men usually do in dental school? The women always marry someone intelligent. The men always marry the best looking waitress at the Waffle House. And it's just a huge mistake.
Bradley Gettlem: Funny.
Howard Farran: Okay, thanks again, Brad, for all you do.
Bradley Gettlem: Thanks for all you do.