Dr. Uzbelger Feldman has been granted with several awards on his proprietary low-dose dynamic radiography pioneering NeoImaging breakthrough. In 2014, this concept received the Medical Device & Diagnostic Industry Dare-to-Design Reader's Choice Award at the Medtech Design Challenge. He is the 2013 William H. Rollins Award recipient established by the American Academy of Oral & Maxillofacial Radiology (AAOMR) to recognize an individual with an outstanding body of research in the field of dental radiology. By the first time in dental history, his other research area of expertise has showed evidence of the cervical plexus nerve implication in dental anesthesia failures and cardiac jaw pain which lead to the development of an improved intraoral cervical plexus anesthetic technique. These efforts have guided to the accessory innervation theory substantiation in dental anesthesia. Dr. Uzbelger Feldman has been a reviewer at three prestigious dental/medical journals (Clinical Anatomy, JADA & JDR). He received his Odontologist dental degree (DDS equivalent) from Central University of Venezuela in 1995 and his Post-Graduate Certificate in Endodontics from Carlos J. Bello Hospital in 1997. His private practice in Venezuela, where he worked from 1995 to 2003, was limited to Endodontics. During those years, he practiced at the Miss Venezuela Organization affiliated dental office among other prestigious practices in Caracas. He obtained the Honorific Mention award “Pedro Henriquez” for best research in the Venezuelan Society of Endodontics (SVE) 1995-1997. Dr. Uzbelger Feldman worked 2 years as a clinical instructor in the Undergraduate Program of the Department of Endodontics at Central University of Venezuela and 5 years as a professor of Endodontics in the Post-Graduate Program of the Venezuelan Red Cross. He was the Secretary of the Commission of the XI National Meeting and XII International Symposium of the SVE, 1999- 2001 and also assisted at the AAOMR Strategic Planning Committee from 2009-13/2015-16. Since 2003, Dr. Uzbelger Feldman has been teaching and researching in the Department of Endodontology at Temple University Kornberg School of Dentistry (TUKSoD) where he earned his DMD certificate in 2006. At TUKSoD, he is former Director of the Current Literature Review II Course, Post-Graduate Endodontology Program; former Co-Director of the Advanced Rotary Endo Course and former Co-Director of the Clinical Endodontology Course, Third Year Predoctoral Students. Currently, he is involved with research activities at TUKSoD in the low-dose dental imaging, accessory innervation in dental anesthesia and endodontic obturation materials fields. With 22 years of experience, he worked five years at the private practice in Philadelphia, PA and now he serves patients in the Cleveland, OH suburbs.
VIDEO - DUwHF #1037 - Daniel Feldman
AUDIO - DUwHF #1037 - Daniel Feldman
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Howard: It's just a huge, huge honor for me today to be podcast interviewing Daniel Uzbelger Feldman, DDS, DMD. He has been granted with several awards on his proprietary low dose dynamic radiography pioneering NeoImaging breakthrough. In 2014 this concept received the Medical Device and Diagnostic Industry Dare-to-Design Reader's Choice Award at the Medtech Design Challenge. He is a 2013 William H. Rollins award recipient, established by the American Academy of Oral and Maxillofacial Radiology to recognize an individual with an outstanding body of research in the field of dental radiology. By the first time in dental history, his other research area of expertise has showed evidence of the cervical plexus nerve implication in dental anesthesia failures and cardiac jaw pain, which leads to the development of an improved inter-oral cervical plexus anesthetic technique. These efforts have guided to the accessory innovation theories substantiation in dental anesthesia. Dr Uzbelger Feldman has been a receiver of three prestigious dental medical journals, Clinical Anatomy, JADA, and JDR.
Howard: He received his Odontologist dental degree, DDS equivalent from Central University of Venezuela in ‘95 and his Postgraduate Certificate in Endodontics from Carlos J. Bello Hospital in ‘97. His private practice in Venezuela where he worked from ‘95 to 2003 was limited to Endodontics. During those years he practiced at the Miss Venezuela Organization affiliated dental office among other prestigious practices in Caracas. He obtained the Honorific Mention award, "Pedro Henriquez" for best research in the Venezuelan Society Endodontics ‘95 and ‘97. Dr Uzbelger worked two years as Clinical Instructor in the undergraduate program of the Department of Endodontics at Central University of Venezuela and five years as a Professor of Endodontics in the postgraduate program of the Venezuelan Red Cross. He was the Secretary of the commission of the national meeting and international symposium in 2001 and also assisted as the AAOMR Strategic Planning committee, 2009 to 2016.
Howard: Since 2003 he has been teaching and researching in the Department of Endodontology at Temple University Kornberg School of Dentistry in Boston, right?
Daniel: In Philly.
Howard: In Philadelphia. I'm sorry about that. Where he earned his DMD certificate in 2006 at TUKS. He is former director of the current literature review course, Postgraduate Endodontology Program, former co-director of the Advanced Rotary Endo course and former co-director of the Clinical Endontology course, third year, pre-doctoral students. Currently, he is involved with research activities in the low dose dental imaging, accessory innovation and dental anesthesia and endodontic obturation materials field. With twenty two years of experience, he worked five years at the private practice in Philadelphia and now he serves patients in Cleveland, Ohio, suburbs. My God! I think you might be the smartest person that ever came on the show.
Howard: I can always tell because your brain gets so big, all the hair follicles are squeezed out and you just end up with a beautiful bald head.
Howard: If you're on iTunes, his bald head is actually better looking than mine.
Howard: Thank you so much for coming on the show. It's just that the only reason this show is a success because I'm able to get people like you to give my homies an hour of your time. I don't even know where to start with you. My gosh! First of all, I want to start with the "is radiation exposure the new tobacco" because when you go, right now at the Washington DC, this is the last day of the AAO meeting. The American Association of Orthodontics meeting has been going Friday, Saturday, Sunday, and today's the last day, Monday and people selling CBCT's are saying every child should have a CBCT. And then you got Radiologists, they're just like cringing, like really? And then, now there's people saying that when you do a molar endo, that standard of care would be taking a CBCT of this molar to see if it, make sure you got all the canals and all this.
Howard: And then it's... the public is even more confused, the patients are confused. Because look at the patients, they're reading equal amounts of research that say you should go out and get ten minutes of sun a day so that you get thirty to forty thousand units of Vitamin D3, and then the dermatologists say, no, no, no you put sunscreen all over yourself and you never let yourself see the sun. So what is it? Should we get ten minutes of sun or should we put on sunscreen every morning and should we, is a PA good enough for a molar root canal or do we need to CBCT every molar before we start working on it?
Daniel: Well, regarding to the sun, I don't have expertise in that area, but regarding to the radiation, I can tell you the following. Let's say that you are six years old right now and you're playing soccer and you bump your head with another kid. The first thing that your mom will do is to take you to the clinic and then they will take your first CT scan. Then you are nine years old and then you have like a low abdomen pain. Your mom takes you to the clinic and then they do your second CT scan. Then you bump your tooth, you are nine years old, bump your tooth playing soccer. Take you to the endodontist, your third CBCT scan. Then you're twelve and you need braces. Your mom takes you to the orthodontist, what's the first thing they will do there? Your fourth CBCT scan and finally you are around sixteen and you need wisdom teeth extraction.
Daniel: Your mom takes you to the oral surgeon, there you get your fifth CBCT scan. Did you know that if you get five CT scans when you are during your childhood, your cancer risk increases considerably? So practically you will have thirty, forty years old, you will never smoke, you ate organic all your life, you were a vegetarian, you don't have any person in your family with a previous history of cancer, but then you will develop thyroid, brain or salivary gland cancer. Where is this coming from? It is coming from all these CBCT scans that you got during your childhood. So this is why I am saying that radiation exposure is the new tobacco. I will tell you something, at least if you smoke, you enjoy it. If you get this scan, you don't enjoy anything. So this is why I urge through the development of a solution for this problem.
Daniel: I believe that the CT scan as an invention is great. I believe that when we need it, we should use it. But I also believe that we should reduce the radiation dosage through which we are being exposed and the good news is that there is a promising technology that will do that. We call it NeoImaging and NeoImaging is the largest radiation dose reduction since the x-ray's discovery in 1895. What we did is we use, I am sure that you are familiar with the cell phones and the new cameras, this new iPhone's and Samsung's they can practically see in the dark and they can take very good low light pictures and videos. We're practically converting the sensor from this kind of a cameras and cell phones into an x-rays detector and then if we do this, we can considerably reduce the radiation power at the x-ray source and we can capture the images.
Daniel: So we did this proof of concept in 2013 and 2015 and we were able to not only reduce the radiation dosage but also to minimize the pixel size for an improved image resolution. So I am talking about getting x-rays into the eight K, like the new TV's, the new flat panel TV's. That will be a resolution of the x-ray that we will take on you in the future. So we call this concept NeoImaging because this will be the new way to take x-rays. And currently, we are translating this, a concept from the dental arena, because it started there to the medical setting. We are planning to develop flat panel detectors for all medical and dental imaging modalities including CT scan.
Howard: Wow! That is amazing. It's funny how history repeats itself because when William Conrad Roentgen invented the x-rays, as you said, in 1895. Do you remember how he died?
Daniel: Yes, he died, all of them they died due to...
Howard: He committed suicide.
Daniel: Overdose. Oh really?
Howard: He was in so much pain; he blew his head off...
Daniel: Right, but all of them, they died because they got cancer because of all the radiation they got.
Howard: Yeah, he kept taking x-rays of his hand and he actually got hand cancer.
Howard: And then it was, I think it was like fourteen months after he was taking x-rays of his hand, this other guy started taking x-rays of his teeth and he was holding the plate in his mouth and that guy, so many people died. And now I was reading some of the facts that you sent me, I want to just read this. Worldwide estimates indicate that three point one billion diagnostic radiographic, half billion dentals and thirty seven million nuclear medicine examinations are performed annually. Globally, the average annual per capita effective dose from radiographs has approximately doubled in the past ten to fifteen years. CT scanning counts for almost half of the collective effective dose for medical procedures in the United States, where only about 17% of the total number of procedures performed. Publications in medical imaging have suggested that as many as twenty to 50% of high tech imaging procedures failed to provide information that improves patient welfare.
Howard: Current dental digital x-ray image technologies allow detecting decay after 40% of the enamel has been affected due to their less than nineteen µm pixel size. A smaller pixel size would have a positive impact in early stage fractures identification, incipient lesions, and caries detection. I was so upset. My boy had a little bump, my youngest, (unclear 0:11:05), he was, this is a couple of years ago, I think he was twenty and he had a bump and I could tell it was really concerning him and I thought, well, let's just run down to the emergency room and we'll just go through triage because I know this is really scaring you. So they took him back there, the lady was a nurse. First thing she did is took a CT. When the doctor got there, he looked at her, he chewed her out in front of me. He goes, "What the hell did you do that for? You can't take this without me." And so that was his whole scrotum testicle area because it was halfway between his belly button and his scrotum. He goes, "That's just a little fat bump, that is nothing." And I thought you just irradiated his testicles and you're not even a doctor. And you know why they did it because when I got the final bill, you know how much that little picture cost?
Daniel: Wow! No insurance?
Howard: Well, yeah, well, that's what the insurance had to pay.
Daniel: That's not... oh wow!
Howard: Yeah, yeah. So (unclear 0:12:02) the insurance but it's like you know that's the only reason they took it because they could bill eight grand.
Daniel: Well also because of a defensive medicine. What if they don't take it and then this bump starts growing and it's, hopefully not but it's a malignant lesion and then they get a legal problem because of that. So I will not blame the doctors, the medical physicists, the radiologist. It's very hard to blame someone because of this situation and also the dentist, the dentist taking these CT scans. What if you don't take it? That's a problem. But thank God we are working on solutions for the problem and hopefully in the next future, this problem will be solved.
Howard: Well, where could my homies read about what you were talking about with the smartphone, where could they read or learn about that?
Daniel: We have a website, it is www.neoimagingtech.com.
Howard: And what are, what is everyone going to find when they go to that website?
Daniel: The (unclear 0:13:18) since we don't have any project and we're not selling anything. They will just find our ideas, our concepts on something that they, if they like new things and things for the future they will enjoy it but there is nothing else. It's just the concept. Because currently, we are working on raising funding in order to move forward towards the market.
Howard: So it says on the website, neoimagingtech.com. You write, the light bulb went off for co-founder Daniel Uzbelger Feldman when he was performing a challenging dental procedure to retrieve bypass a separated instrument fragment left on a patient's molar tooth during a root canal. Still remembers his frustration, more importantly, the patients suffering. After three unsuccessful attempts of more than one hour each to retrieve the fragment, since necessity is the mother of invention, he tried to find an alternative way to visualize these procedures during procedures instead of before and after due to the limitations of existing x-ray imaging technologies. Man, that's going to be so cool. So, how far along is this project? (Unclear 0:14:27).
Daniel: We have the proof of concept done. We have all the proposals for developing it from the engineers. We just need to get the money and get it done.
Howard: So how can my homies help you find the money? What do you need? Do you need connections to venture capitalists? Do you need?
Daniel: Yes, all of you can, if you have these connections, we appreciate your help.
Howard: Well send me the proposals because I know everybody in dentistry who's a billionaire and a hundred millionaire and send, you and your buddy CEO, Michael Sinsheimer, MHA, MBA. Yeah, send me the whole proposal then I'll forward it to the big boys like Rick Workman who owns Heartland, Steve Thorne who owns Pacific Dental, there's a lot of people that just are so passionate about dentistry.
Daniel: Will do.
Howard: So, what else has got you passionate?
Daniel: Well, in addition to the radiation situation, there is another problem that I seen in dentistry, which is the fact of that we have been working blindly during all these years because we can only take x-rays prior or after the procedure, but during the procedure we don't see what we are doing. We have been doing guesswork during all this time. So what if we could have like a video x-ray that allow you to see where or when the file is going up to the (unclear 0:16:07) or the gutta percha or your rotary system or what if you can see the implant placement while placing it in real time. But I'm not talking about seating the patient, taking a mold, preparing like a tray, then sending the patient out or taking a CBCT scan in your office and then sending all this information through a navigation company.
Daniel: Then waiting a couple of weeks to get the navigation path and then using a visual navigation path for placing it. I am talking about you seat the patients, you show a video from the last patient you work at, showing how you put the implant, open your mouth, you put the implant, you see everything and that's it, five minutes and the radiation that the patient will get in that implant placement is much lower than the CBCT scan. So this is what I am talking about. This is the other area which I am passionate about, which is dynamic imaging and this can be done thanks to NeoImaging because radiation is so low that we just need to add thirty frames per second and you get video. In addition to this dynamic radiography, there is another problem with the current devices because we currently have 10% of retakes, which means that when we're taking an x-ray, we can have a concord overlapping shortening or elongation. This happens because we can 't aim before we take the x-ray. But what if you could aim like a cell phone or a digital camera, then you say cheese and as soon as you like it you take it. So this technology will allow doing that. So we will take the x-ray just once, not repeating x-rays anymore.
Howard: And how far along is that project?
Daniel: It is the same situation. We have three projects within our proposal development and this is one of them.
Howard: And where does all this come from? Talk about your journey. First of all, do you mind me asking how old you are?
Daniel: Forty eight.
Howard: Forty eight. So when did you first start it? When did you first decide you wanted to be the next William Roentgen?
Daniel: When I was twenty nine. The day, when that happens, I was doing this root canal in Venezuela and then I was struggling because we can't see what we're doing trying to bypass or retrieve the separated instrument. Back then I used to work in a very large office with physicians and that morning the ophthalmologist, her patient didn't show up so she came to my to my chair to say hi and to see what I was doing. I was explaining her my frustration and then she say, "But how come that you are struggling like this? If you could have fluoroscopy, you could see everything and you won't have any problems for doing the root canals." Then I asked, "What is this fluoroscopy?" Then I started searching what fluoroscopy was and then this is how as soon as I figure out, I start working on this and I've been working on this for since 1999 practically.
Howard: Ninety nine. Did Prince's song have anything to do with this? Party like it's 1999?
Daniel:I think it would... yip, it did.
Howard: My gosh. They always say the best ideas are the mother of necessity and if all you're trying to do is solve your own problem and you really care about your customer, I mean if you work hard, you really care and you're trying to build a business to solve a problem that you have. I mean that's the three ingredients to just doing it.
Daniel: Yep (inaudible 00:20:03).
Howard: So, are you pretty optimistic that you'll get funding and pull this off?
Daniel: I think so. I don't see one reason for not getting it.
Howard: Yeah. So what else are you passionate about?
Daniel: Well, the third thing, which essentially what I am talking about in the present moment is dental anesthesia and it seems that finally, after over hundred years of failures to describing why we can't get numb the posterior mandibular teeth. Finally, it seems that we have found a very simple explanation for that. The name of the explanation is accessory intervention. So I always say if there is a fight in between NeoImaging, the dental dynamic a innovation that I describe here before and the accessory nerve innovation, who wins? I think the accessory nerve innervation a concept will beat the other two. Why? Because this one doesn't need any money, doesn't need any development, it is just ready to go. So I just published in your Dentaltown magazine in the April issue, our anesthetic... accessory innervation anesthetic protocol and we have received a very good feedback regarding to it. So currently I am working in the video presentation, which is very cool because there I show how we discovered the nerve and we're talking about the discovery of a nerve coming from the neck and entering the mandible by first time in dental history.
Howard: It was an amazing article. It's called Accessory Innervation Anesthetic Protocol: From Research Theory to Clinical Reality by Daniel Uzbelger Feldman. I'm sorry; I am so bad with other languages. The only D... I'm embarrassed to tell you this, the only D I ever got in my life was in high school Spanish and Dr (inaudible 00:22:18) Martine told my mother that I was linguistically retarded. Then at the same time, my piano teacher after an hour, she's making money off these lessons for me and my five sisters and I'm the only one she fired. She told my mom, "Howard couldn't carry a tune in a lunch pail." So I'm sorry if every time I say your name, it sounds different than the time before. But this article was just amazing and I wanted to ask you, one of the guys that replied to your article was tuttle numb now with his local anesthetic. I just wondered were you familiar with his anesthetic technique? Do you think there's any merit to that?
Daniel: Not before I'm happy that he replied to the comments because they gave me the opportunity to see what he's doing and I believe it is great because what he's doing is improving the intraosseous technique and, as you know, the main advantage of the intraosseous technique is that it gets numb all these accessory nerve that I am talking about in one shot. So it is pretty remarkable.
Howard: Very, very nice. And that's what I like about Dentaltown magazine as I said, if you read a newspaper or you read a magazine and you have a question, I mean that one-way media. I used to do that. I had a magazine called The Farran Report from 94 to 98 where I just mailed it to you. It was from me to you. So it was The Farran Report and all the information was what I was learning when I was lecturing every weekend, you'd be having breakfast, lunch, and dinner with your homies and you would wrap that up in a magazine. But (inaudible 00:24:00) when I saw them talking on ESPN message boards about soccer and football, and by the way, you're from both hemispheres of America. You're from the north and south in the south football is soccer and in the north, football is the other kind. Which football do you prefer the most?
Daniel: Well, since I came originally to Philadelphia, I'm a super fan of sports and competition and you know. So I fall in love with the American football, but as you know, in my south hemisphere we love soccer. So I liked both, football is the number one sport in this country. Soccer is the number one sport worldwide. I am looking forward for the World Cup right now on and I am looking forward for the Cleveland Browns, improv.
Howard: Soccer will be the number one sport for the next century because it's the lowest cost sport. And you're not going to have ice hockey in Africa and Asia.
Daniel: Or baseball.
Howard: Yeah, I mean so it's cost. I mean every business has got to be faster, easier, higher quality, lower costs. And then it ends up being miniaturized, which is number five. I mean, the iPhone I'm holding in my hand has the power of a IBM mainframe computer when I was in high school. And so everything gets faster, easier, higher quality, lower cost, and more miniature. People oftentimes forget that number five, like when I bought my first intraoral camera; it was the size of a refrigerator. It was called Fuji camera and it was $38,000 and I could not pick it up myself. I mean they put it on wheels and now you have these little things and the new oral scanners from Copenhagen, Denmark.
Howard: What is it? TRIOS? TRIOS. Yeah. And yeah, so the miniaturization is wonderful. But yeah, soccer is amazing. And what's amazing is football is getting all the attention and movies made about their concussions. But soccer, it's actually could be just as bad or worse because what the pros have figured out is that if you have a Sunday game, you get your brain banged up, that if you don't do anything for the next forty eight hours, it heals up pretty rapidly. The problem with soccer is these boys and girls are playing it every single day at recess, lunch, after school. Every day they're banging this head and having two older sisters that are Catholic nuns, I know there's no way I could convince them to be Muslims or Hindus or Buddhists and if you tried to go back to central and South America, Africa and Asia and say, "Hey, let's quit using our head and use her hands." What do you think the chance of that going through would be?
Daniel: I don't think so.
Howard: I mean it's impossible. So then again the next step is you got to tell the kids that when you're playing soccer, you can only use your head two days a week because that would significantly reduce the damage. I mean there's been, and you know I've read so many papers on it. So my question to you is, are you going to let your kids play soccer?
Daniel: They do you remember when I started talking about this radiation problem, I didn't mention bumping your head playing football, I mentioned soccer it's because that's a big concern. Nevertheless, one of my kids, he likes soccer and he's seven years old now and you know, we are trying to, I am there watching. So I guess if there is any issue I will be there. So the coach is there and everybody's there.
Howard: Well, the most pro-reason for a union I've seen is that the professional football players in America, they actually threatened to go on strike if they didn't have helmetless, pad less workouts two or three days during the week. They only wanted full contact on game day and one practice day. But the college football, because they had the research, so they had all the neurologists in there saying they need forty eight hours of healing and that significantly reduces it. But the colleges in America, they don't have a union and usually the college football coach I think is the highest paid state employee in like thirty six of the fifty states. So all they want to do is win. So those poor kids are in full helmet and contact banging each other’s head all day, every day for the whole season. And it's like, okay, well there's a perfectly good reason of checks and balances of why workers should have unions. So you also talk about dental anxiety.
Daniel: Yes, because that's part of a problem here with the dental anesthetic failure because patients, they are terrified to go to a dentist because they believe that they are not going to be totally numb and patients, they don't like to start jumping on the chair and holding hands. So if I were a patient and I go to the dentist for a filling on my back molar and the dentist can't get me numb, I am not going back. It's that simple. And that happens on a daily basis. I'm not even saying for root canals or extraction, for fillings. So patients when they come to me for a root canals, they are terrified from previous experiences and we're in 2018, (inaudible 00:29:35) Philadelphia, these are major cities with dental schools in the cities. So there is no reason in my mind for this to happen over and over again.
Daniel: This is why it is so important for dentists and dental schools to start promoting this accessory innervation ask the reason for failures and make sure that the new dentists and the young generations will start getting numb all the nerves prior starting doing a filling on the tooth. How they are getting numb all the nerves, that's their decision. They can do the protocol that I proposed, which is free; you don't have to buy anything. You don't have to pay for anything. You just use your syringe. You just use a blue needle, a yellow needle and then you get numb the lingual nerve, the femoral alveolar nerve that you know how to do it, you get numb the (inaudible 00:30:38) you know how to do that. You get numb the buccal, then you get numb the cervical plexus, that's a new nerve we've discovered. The Dentaltown magazine, you come and read how this technique is administer, which is practically a infiltration below the tooth you want to get numb and after that, believe it or not, you should do the mental nerve because if you don't do the mental nerve, the patient may feel your work. So after doing all of this together, the tooth should be numb, the patient should be numb and no more jumping in the dental chair, no more holding hands in the dental chair. No more anxiety, no more problems.
Howard: That was amazing, man. You've got enough work on your plate. if you're forty eight, you're going to have to live to be at least eighty eight and then by then, you'll have five more projects.
Daniel: (Inaudible 00:31:32) like a never-ending story.
Howard: So your dental school, which is now... I'm old school, it used to be University of Philly, but now it's the... oh gosh the...
Daniel: Temple University.
Howard: Temple, yeah, it used to be called Temple University. Now it's called Kornberg, Kornberg School of Dentistry. Do you know what the yearly tuition is now there?
Daniel: I am not familiar with that right now.
Howard: That's a private school. Is that a state school or a private school?
Daniel: It is half and half.
Howard: It's half and half?
Daniel: Half private, yes, half state.
Howard: Yeah, but I wanted to switch to molar endo because you're an endodontist. These kids come out of school; a lot of these schools are now seventy to $100,000 a year. So just as little as five years ago, it seemed like anybody I was talking to was about $300,000 in debt. In just a blink of an eye it's $400,000 in debt and it takes a lot of personality to sell bleaching, bonding, veneers, big cases and they don't even have the skills for these full mouth cases. They're still trying to learn how to do a filling, a crown, basic endo and root canals are something you don't have to sell. They're coming into you and they're in pain and the public health people keep screaming that 8.5% of all emergency room visits are odontogenic in origin.
Howard: And a lot of that's because the dentist's office is closed or they went to a dentist, they said, well, here's a referral to an endodontist and the endodontist can't get him in for five days and now it's two o'clock in the morning. So they need to learn how to do molar endo, but they always come out of school and they say, "Howard, I hate it." What advice would you tell 25% of our listeners are still in dental school, the rest are pretty much under thirty. Please send me an email, firstname.lastname@example.org and tell me how old you are, what country you're from, and what would you tell a kid? Because I'm telling him there's nine specialties and they always talk about your specially endo and perio and peto and orthodontics, but they never talk about public health.
Howard: And gosh darn it, when someone walks in your office and they're in pain, and the most, the people that make the most money are the oral surgeons because they know how to pull the tooth, the endodontists because they know how to do a root canal. They're coming in, they're looking for you, you're not having to send them a flyer in the mail. And all of your advertising doesn't work because it doesn't target them when they have a toothache. There's no targeting involved. It's like watching cable television, there's no targeting involved. You're sitting there next to your five year old granddaughter watching a CIALIS commercial. Just it's insane. What would you tell these kids in dental school who already have this mental block and they say, "Dan, I hate, I hate endo?"
Daniel: Well, believe it or not, one of the main reasons for hating endo is difficulty for getting numb the patients. It is frustrating as a dentist when you have a lower molar and you are ready to start. The patient is having pain, he is not numb, then you do six, seven, eight (inaudible 00:34:46) and then he doesn't get numb and then you have to put a temporary filling and send the patient out, give antibiotics or anything, you know, thinking that this is happening because of the inflammation or there is pus coming out. It is frustrating. So I do believe that if the new graduates or if the dental students focus on these accessory integration technique or that they understand the anatomy of the oral cavity, figure out how to get numb all these nerves, they will tackle one of the main problems of doing molar endo which is getting numb.
Daniel: So for years, we have heard that one of the main objectives in endodontics is cleaning and shaping of the root canal system. One of the main objectives in endodontics is the disinfection, irrigation, the alteration. But in my opinion, one of the main objectives in endodontics is to get numb the patient and if you're going to... Because this is the first time, this is your introduction card, this is how you're saying to the patient, "Hey, I'm Dr Uzbelger Feldman, nice meeting you," when you get them numb. You cannot imagine how happy and you know all the things, the beautiful things that the patient tells me on a daily basis each time that I work on them, just because I get them numb. It is incredible. So this is what I recommend to the new graduates to focus on getting numb the patients really well and then they will see how their life will change in the dental practice. They will have a super relaxing... they will want to go to the dental practice. Get numb the patients and say hello (inaudible 00:36:36), which is what I have been promoting during all these years.
Howard: When you come out with it, your advertisement should be the Scarface scene, you should say, "Say hello to my little friend." And you should be holding a syringe. That would be so (inaudible: 36.52).
Daniel: I am the presentation that I'm working right now for Dentaltown; this is the first slide is just that. So you have...
Howard: Is it Scarface?
Daniel: No Scarface, but what you just say... like a video of a very nice (inaudible 00:37:09 pulp?) that I remove like in slow motion, so it's really cool.
Howard: You should Photoshop your face over Al... What was his name? Who's that guy in Scarface?
Daniel: Al Pacino.
Howard: Al Pacino. I said, Al Capone, that's how dumb I am. And then take out the machine gun and put a syringe in his hand that would be so hilarious. They've always told us for a thousand years, it takes your whole life to build your reputation and you can ruin it in five minutes. They'll still only remember Bill Clinton for Monica Lewinsky or Kennedy for Marilyn Monroe. Septocaine got a really bad rap decades ago and it still just keeps lingering on. I'm still amazed that I feel ten years after this has been put to rest, you still have all these kids ask you, "Well, do you think I should just use Lidocaine because Septocaine might increase paresthesia?" Do you still hear that question and how would you answer it?
Daniel: Yes, when I talk about the anesthetic protocol for accessory innervation, I recommend to use Articaine, which is a Septocaine, only for the cervical plexus technique or for the cervical plexus infiltration. Why? Because the cervical plexus is a very thin nerve, it’s thinner than a hair of my head and I am bald. So you will never cause paresthesia of the cervical plexus in this level. For the rest of the injections I recommend using Lidocaine or Mepivacaine if the patient has cardiovascular issues or cannot get epinephrine. So for the upper maxilla, I do recommend to use Septocaine for all the injections. There are only very few reports of paresthesia in the upper maxilla as compared to the mandible. And as you know, the most common nerve getting paresthesia is the lingual nerve. So I do not recommend doing, using this kind of anesthetic for the lingual or the inferior alveolar.
Daniel: Nevertheless, there's a very famous doctor who is the doctor writing the books and I really admire him because all the work and trajectory that he has. He's Dr Malamed and he recommends to use Septocaine for any technique that you want. So just to let you know because you know, it's good for new graduates to listen to all the opinions, my humble opinion is to use it only for the plexus technique and for the upper maxilla but to use it with no concern, no hesitation. Following Dr Malamed, he recommends to use it for the (inaudible 00:40:03) nerve and for everything. So it is up to the young or young peers to put in the balance and do whatever they believe is the best. In my experience, I have never had one case of paresthesia and I do lots of shots because I do the whole protocol in my patients. So I believe that my protocol is really safe and very reliable. So if they are really concerned about paresthesia, use my protocol the same and you will get numb all the patients in a very high percentage of time, you can even do it with Mepivacaine and do a molar root canal in a patient with universal (inaudible 00:40:45) with no problem. Of course, anesthetic will wear off in forty five minutes, so you have to explain to a patient that may need extra anesthetic later on.
Howard: I'm a big fan of Stanley Malamed too. He was on episode nine seventy one and the thing I love... my biggest idols like Walt Disney, he actually lived above the fire station in Disneyland. Right now, the favorite guy in finance I love to listen to is Jamie Dimon, who I've had the honor to have dinner with three times. He lives on the top floor of that bank. I mean, when he was working at... he cut his teeth on Citibank and Citigroup. It was Citibank then it turned into Citigroup and he didn't even have a car then. He said, "I don't have time for a car." He said, "I just want to jump in a taxi and if I ever make it big, I'm going to get an office big enough for my bedroom can be there."
Howard: And Stanley Malamed, he was on his honeymoon, right? Not honeymoon, anniversary. He was on his anniversary in Las Vegas and he snuck back into the hotel room. I don't think he even wanted to let his wife know he was going to do a podcast with me for an hour. I mean, this is a guy that could probably...
Daniel: Yeah, he's incredible.
Howard: Well, he loves it so much he can talk about it in his sleep. But no, it was his birthday. It was definitely his birthday and my gosh as I was like, "Okay, it's your birthday and what do you want to?" You want to talk about dental anesthesiology. I just love passion.
Daniel: Yes, he's incredible, no question about that.
Howard: I also, speaking about it takes a lifetime of building your reputation and five minutes to ruin it; the next one would be broken file. I still see people paranoid about endo because of broken files because back in the day they would break. The first ten years that I practiced, everybody routinely had files break, but they stopped breaking a long time ago. I can't... what do you think about file separation night? That's the first thing on your website. You're talking about a separated file, but you've been doing root canals for almost twenty five years. Do you see file breaking and separation kind of almost gone?
Daniel: Yes, it is still, it is... not really, it is still a concern and we have to follow the protocols and guidelines recommended by the endodontists and the filing manufacturers of using the files just once. I have seen that the reciprocating systems, they separate less as compared to some of the rotaries. Some of the rotaries may separate less when you compare to the other because there are so many designs and kinds of a rotary systems. But, one of my dreams in the future is to try to find the ideal alloy for the dental file, one alloy that is flexible enough for negotiating the (inaudible 00:44:16) canals and strong enough to prevent a file separation. As you know, I am very busy right now, I don't have time to look into this anymore. But believe it or not, my very first area of expertise in 1995, we did the first-ever analysis of the endodontic file. I am talking about the stainless steel one. So believe it or not...
Howard: Was that the one by Barry Musikant?
Daniel: Well, actually, the analysis that we did, it was the first analysis ever. I did that in Venezuela and, believe it or not before that we didn't know what kind of stainless steel we were using. Can you believe it? And I guess if you don't know what you're using it's very hard to know the properties and understanding what kind of instruments you are using. But then nickel titanium came with a Dr Walia and Brantley a study, and endodontists became really an expert in alloys, mostly towards nickel titanium. So but yes, I believe that the separation is still there and we should do something about it.
Howard: Are you familiar with the endodontist Barry Musikant with Essential Dental Systems? I mean his entire company is built on the alternative to nickel titanium and going around and round and reciprocating stainless steel. Are you a fan or do you think that that involves merit? I mean if separation is still an issue?
Daniel: I think that we can do better than stainless steel and nickel titanium. We should try to find something better and better. What I don't know yet, I really, and will we still have the time to look into that but...
Howard: Yeah. So what else do you think... you talked about that these kids are afraid of molar endo because they can't get anesthetic and you talked about that. We talked about files. What percent, I'm reading that after you get done cleaning and shaping, you're probably only removing 50% mechanically. Is that about what you believe... do you think it's fifty fifty or do you think it's sixty forty? How much do you think we're removing mechanically?
Daniel: Well, it has to be a combination. It needs to be chemical and mechanical or bio mechanical removal. Sodium hypochlorite so far is the best that we have. Now we are using it in combination with descalent solutions. Yep. So many times we use Chlorhexidine. We try not to mix Chlorhexidine with the Sodium hypochlorite because it becomes like a precipitate. That is not good, but so far this is what we have. Maybe in the future something else will come. I don't know yet, but yes, mechanically mechanical by itself I believe that doesn't work. A chemical by itself doesn't... there is a recent system now for irrigation that it makes sure that there is not any bubble of air remaining there and all the Sodium hypochlorite goes everywhere. That seems to help a lot, but so far that's what we have and what we are advocating. I'm not sure if there is something else. Is there anything else out there?
Howard: Well, I think that it's... I don't know, maybe fifty fifty. I mean you can auger out, clean and shape half of all those little fins and canals and all the extra stuff that the irrigation is what's going to get the other half. And it seems like, I don't know if it's because the final x-ray is what you're sending to the x-ray or the final x-ray is the only thing that one million attorneys in the United States can see. But it seems like there are so obsessed with radiographic, artistic beauty, they want to get it to the end, that they want it to look beautiful on an x-ray and it can look beautiful on x-ray and just be filled with every microorganism, fungi, bacteria, and virus known to man.
Daniel: Yeah, and the biofilm.
Howard: And the biofilm. So, is there any... do you think the irrigation adjutants mechanical?
Daniel: Yeah, there's one with the ultrasonics. That's the one which seems to go everywhere.
Howard: So which one? What brand name you like?
Daniel: I don't like to... I prefer not to give brand for that but there are some with ultrasound that you can use some, they seem to be really effective.
Howard: What about lasers?
Daniel: What I can tell you is that the best irrigation protocol that I know is the Haapasalo protocol. He's the one who combines the sodium hypochlorite....
Howard: The which protocol? What's his name?
Daniel: Haapasalo. He's the one who proposes combining the sodium hypochlorite with (inaudible 00:49:57) and then you have a very good irrigation. Also he's involved with one of the these ultrasonic irrigation systems that I prefer not to say the names and that's the best one.
Howard: Would you mind posting his protocol in the comment after your article?
Daniel: Sure, sure.
Howard: I'd really appreciate that, thank you.
Daniel: Sure, yeah, no problem with that. Then in regarding to lasers, you know at Temple University, we have done lots of research regarding to lasers. It will be ideal to have a laser which can kill bacteria, but it's not melting the dentin and also is not causing damage to the PDL because of the heat that it causes. Not sure how the lasers are now. How near to that goal the lasers are because I haven't looked into lasers recently, but if you asked me what the ideal laser will be, it will be the laser that can kill bacteria, doesn't melt the dentin, doesn't damage the PDL because of the heat.
Howard: Well, the lasers, what's silly about them is they don't have to be perfect at all because boys just loved toys and my god, you only have to barely twist the dentist's pinkie and he'll buy a laser for peri-implantitis or a laser to cut teeth. I mean they just love lasers. I'm all for it, if that's what flips your flipper and puts a smile on your face and makes you want to go play dentistry. But if you're coming back to me and you're telling me that you have to have this for therapeutic protocol, or return on investment, then I tell you that you need to go get therapy starting with your CPA. But if they burn out, that costs them millions. I mean I cannot, I don't know whether... I almost want to cry when I hear a forty year old dentist telling me he hopes he can retire in five, before he's fifty and I'm like, dude, fifty? Fix why you want to quit. Don't sit there at forty and say I only got ten more years, that's not the answer. The answer is, why do you want to quit today? Go solve that. So sometimes it's just in their head, sometimes they need to see a therapist. Sometimes they need medication, sometimes they need a divorce, sometimes they... but just fix while you're miserable, and I remember 25% of the listeners are still in dental school. A very common problem they have is they obviously know it's coming from the lower right, but they're not a 100% sure if it's one molar or the other. Any low hanging fruit tips when they just can't decide if it's one tooth or the other?
Daniel: Yes, the best way to find out is to use a very consistent, a pulp vitality testing protocol. The first thing they should do is to ask the patient where they do believe the pain is coming from. Sometimes they just show you with the finger or with the tongue. Then the first test that they should do is percussion because that's a very useful test and sometimes it just tells you what is going on. So percussion first, then they should do a tooth slooth which asking to a patient to bite down on the bite, stick tooth by tooth until the patient feels something. And finally the most important test of all is the endo ice because that one will give you whether or not the tooth is necrotic or if there is any lingering pain. The best way to do the endo ice test is not with a Q-Tip, because I have seen a dentist doing this with a Q-Tip all the time.
Daniel: The problem with the Q-Tip is that the Q-Tip has like a wood stick and when you apply the cold, the wood will absorb all the cold and isolate it and then at the time you put it there, the cotton is not cold anymore. Yeah, you were asking me about how to identify which one the problem tooth is when the patient is pointing to the lower right. So I was saying I am not in what part the communication drop, but I was saying that the first thing that I like to do is ask the patient where he or she believes the pain is coming from. Sometimes they show you with the finger, sometime they show you with the tongue. So then the first test that I like to do is the percussion. That test is very helpful.
Daniel: Sometimes it tells you, gives you a lot of information. Then I like to do the tooth slooth because sometimes the pain could be coming from a crack on the tooth and that pain is another test is very useful for detecting the, what we call the cracked tooth syndrome. Then the third test that I recommend to do is the endo ice in that order percussion first, tooth slooth second, endo ice third because the endo ice will give you the pulp vitality status, you can tell whether or not it is necrotic or vital or lingering, which means symptomatic (inaudible 00:55:42). There is another test that sometimes we use when we are not sure which is the EPT, the electronic pulp tester that one helps also a lot. When doing the endo ice, I always recommend to students and to other dentists to do it with... not to do it with the Q-Tip because when you spray into the Q-Tip, the cold is absorbed by the wood and then was at the time you put it on the tooth.
Daniel: It is not cold enough, so what we do is we prepare a small cotton ball and then we take it with the cotton plier or the cotton forceps, we spray the cotton forceps and then that cotton pellet is cold enough for making or not the patient having a response to the cold. Of course, all these should be complemented with x-rays. Sometimes you can tell the x-rays complement all this information and also I like to do a perio probing because sometimes the problem is coming from cracks as I mentioned before, and palpation. Palpation is very helpful and we always say look for a possible fistulas or any other kind of lesions and intraoral extraoral swelling as well. So if you do all this together, you will form a very accurate diagnosis skills and then you will be very confident finding out what the problem tooth is.
Howard: You promised me an hour of your life and I already went over the hour mark, but can I just ask two more questions?
Howard: It's Dentistry Uncensored, so I don't like to talk about anything everyone agrees on, I've got two final questions. The first one will be pain medicine and the second will be antibiotics. To put a little historical perspective, when I got out of school thirty years ago, the doctors were the bad guys because all these people were in pain and the doctors wouldn't give them pain meds, especially with cancer patients or like, look, grandma's going to die anyway. Why don't you, I don't care if you have to give her heroin or opium or I don't care what it is. Now, thirty years later, now we're the bad guy because they say we over-prescribe way too much and Hydrocodone has been the number one prescribed pill at a pharmacy for over a decade. What percent... I'm going to hold your feet to the fire. What percent of your patients as an endodontist, are you giving opioids narcotics like Vicodin at the end of the appointment?
Daniel: Actually now, because of all these opioid crisis and all these problems and the new protocols, I am doing just one percent because they request or because you know... yes, because they say that they have allergies to the other medications, because they say that their stomach can't tolerate sometimes. They are addicts and they just are requesting who knows. But I try to; I minimize that a lot because I explain them that due to all these crises now we have a new protocol which is giving together the Ibuprofen six hundred or eight hundred milligrams together with Tylenol, like five hundred or six hundred and fifty milligrams. So I explained to them that if they take both at the same time, that works incredibly for pain and they believe me.
Howard: So Tylenol, so Ibuprofen, six hundred milligram and Tylenol, how much?
Daniel: The six hundred and fifty if you want to do it every eight hours, if you want to do it every six hours.
Howard: Okay. Ibuprofen six hundred combined with Tylenol six fifty every eight hours.
Daniel: Ibuprofen eight hundred, Tylenol six fifty every eight and if you do the... yes. If you maybe have a younger patient or the body weight is not, it's not enough for giving this high doses - dosages, then you can do six hundred Ibuprofen, five hundred Tylenol every six hours.
Howard: Okay, final question, antibodies, antibiotics. I mean you would not believe how many dentists after every single molar endo they do give them, you know, NVK and they say it's CYA - cover my ass and it helps. What percent of your molar endos that you do, do you give them antibiotics at the end of the procedure?
Daniel: Well, as we reveal previously these diagnostic tests, as you can imagine, I do it on every patient before starting or before prescribing, so if I found out that tooth diagnosis is in necrosis or necrotic pulp or (inaudible 01:00:52) necrosis or acute apical periodontitis, then I consider an antibiotics prescription also, of course, if there is a fistula or if the patient is swollen. If I diagnose a irreversible pulpitis, I am not prescribing antibiotics. So I just prescribe antibiotics on cases of necrotic pulp.
Howard: When I think they need antibiotics for those reasons and they say, "Well, I don't want to take antibiotics because they're not natural", you know what I say? I say, "Why don't ants ever get sick? Because they have antibodies." Is that the worst joke you've ever heard?
Daniel: Well, it's a good one. I will start saying it to my patients now.
Howard: But anyway. Hey, I just can't believe I got you to come on the show. It's just a huge honor. I'm sure my homies learned so much. I learned a lot. Thank you so much reading that article and let me tell you something about these articles, kids that one-way media just doesn't work for you. If you read an article and you have a question, that's why I love, that's why we love Dentaltown because you can read his article on Dentaltown and if you don't get it, just ask a question. And don't be afraid to ask a question. I know after lecturing a thousand times that you say before the break, does anybody have any questions? No questions? Okay, let's take a fifteen minute break and then twenty people rush up to you because they want to ask a private personal question that every single other person on the planet has.
Howard: I mean there's nothing unique about anybody. I don't care if your name is unique, you're not, so when you read these articles, have the courage to raise your hand and post and if you disagree, just because you're young, I don't care if you're in dental school. If you sat there and said, "I completely disagree," neither of us are going to go home and cry. You know what you know, you have to be... We love the passion. We love the challenge. Ask your questions. If this is on YouTube comment on the YouTube deal, and by the way, you should not be watching this show on listening to this on iTunes. You got two gorgeous bald men, so you should switch over to YouTube for this one, but hey, thank you so much for coming on the show. I hope you have a rocking hot day.
Daniel: Thank you. Thank you very much and pleasure meeting you guys (inaudible 01:03:17). Now you know how to do it. Thanks.