Greetings From Hawaii

Hello again everyone and this time I send greetings from Hawaii.  I arrived here with a full blown case of bronchitis so that knocked me out for a week.  I actually had to go to the Emergency Room and everyone there was terrific.  I greatly appreciate their professionalism.  Talking about professionalism leads me to …. Please check out this month’s digital version of DentalTown.  They have a lot of content dedicated to Women in Dentistry and I think it is a very good read.  Kudos to DentalTown for publishing such relevant material.

I will be in Hawaii for another week and then I am heading up to San Francisco for the American Association of Endodontists Meeting.   This is always a good meeting and I am particularly looking forward to connecting with past friends and associates.  I especially love the Alumni Receptions, for the various schools and Programs.  I also hope to see what is new in endodontic technology.  The AAE is an excellent meeting to “case out” new ideas.  I certainly will give you an update on the newest and latest.

BTW, do we have any tennis fans out there?  I have been watching the Miami Open this week and I cannot remember weather playing such a significant role in a recent tournament.  No, not rain.  Rather, high Miami humidity combined with heat.  It is amazing to see such well conditioned athletes (men and women both) struggle with the conditions.  So, I guess that is a word to the wise for all of us mortals.  Be active, live a healthy lifestyle, and try to keep in condition. It also helps you stay young, IMHO.   Until next time, Aloha from Hawaii!

Ladies, Do the Endo!!!

When should we do a root canal???  This question has become repeatedly more complicated as new technologies have emerged in dentistry.  However, as long term success rates of implants are now being seriously re-evaluated (ref: Dr. William V. Giannobile, Editor, Journal of Dental Research) my thoughts go back to preserving the natural dentition when possible.  Therefore, I thought it was an appropriate moment to go back and review some cases where we absolutely should do the root canal.  Having done extensive restorative dentistry and prosthodontics (including being Chief of Prosthodontics at multiple Air Force Bases) for fourteen years prior to Endo School, I believe that I can offer some tips in this area. 

The question of “When do I do the endo?” is usually asked in reference to the old direct pulp cap vs. root canal dilemma.  The overwhelming majority of endodontists believe that direct pulp caps are best utilized on young patients with minimal exposures.  The increased vascularity associated with young people, and young pulps, will decidedly help the patient.  Also, the new bioceramic materials by Brasseler USA and Tulsa Dentsply are very good materials to use in these cases.  (I particularly like the Root Repair Material Putty by Brasseler) However, I am not an especially strong proponent of direct pulp caps on adult teeth as their success rate is much lower.  However, the world of direct pulps is changing due to improved science and materials.  And, in third world countries (Hate that term!!) it is a big issue.  In fact, I consider it a public health issue.  The unnecessary extraction of teeth World Wide still remains a Big Issue - especially the treatment of women and young girls!  However, let’s get back to the discussion, at hand, and look at a few examples where we should do the endo.

Pink Teeth:  Have you ever done a crown prep on a tooth, only to see it turn pink in front of your eyes?  Like, … what is going on??? (This is quite common on peg laterals.)  Indeed, a pink tooth looks cute but unfortunately what’s going on is …it’s cooked!!  Ladies, Do the Endo!!!

Bunny Teeth:  Bunny teeth are adorable and in certain cultures they are almost revered for being fabulously cute (Japan for instance).  However, these teeth have really high pulp horns and you need to factor this into your crown preparation.  If you get an exposure and there is, in fact, a pink halo around the defect, what do you do?  Ladies, Do the Endo!!!  Also, if the tooth color turns a dark brown purplish color … that means thrombosis has actually occurred in the prepared tooth!  It’s done.  So, what do you do Ladies??  Together now … Ladies, Do the Endo!!!

However, any discussion of endo-prosth cannot be finished without addressing the question of prosthodontic expediency.  In other words, when do I devitalize a tooth purposely for the long terms success of the case?  This can be a real dilemma for dentists, especially young dentists.

Here is a likely scenario.  You are doing six anterior teeth (crowns or laminates) and this is a nice case.  Fairly easy to do and there is a good fee associated with such a procedure.  However, tooth # 10 seems close to having a pulp exposure.  In fact, you may even be able to see pink through the tooth.  But here’s the problem.  The patient complained so much about the price of the case, that you are hesitant to tell them that they need to spend another $700 for a root canal.  Big mistake.  If this situation arises what should you do??  Ladies, Do the Endo!!!   Here’s why.

The absolute worst case scenario is to do a beautiful crown only to have you, or an endodontist, subsequently go back in, open up the tooth, and perform endodontic therapy.  Patients do not appreciate having new holes drilled into their beautiful new crown.  Trust me on that one!! An even bigger nightmare, is if the tooth is part of an extensive bridge and you accidentally crack the porcelain while making your endodontic access.  Nightmare!!!  There goes your lab bill.

I spent 14 years in restorative / prosthodontics and then 25 years in Endodontics.  I have seen this (and many other things in my lifetime) from both sides.   Never, not once, did I ever have a patient who did not understand why we had to do a root canal now, to prevent further damage.  No one likes to hear this; no one wants to pay an addition $700.  This is predictable.  But the good news is … they understand (Thank goodness for that!)  However, what they will not understand, is if you have to go in fairly soon after final cementation of their “beautiful new crown” to access a root canal.  They will be upset.  So how can we avoid this nightmare??  In unison now … Ladies, Do the Endo!!!

Hopefully, this entry has made you think a bit more about the relationship between endodontics and prosthodontics.  I am totally committed to saving teeth (when we can) and to preserving the occlusion.  Saving the dentition leads to the retention of facial architecture which leads to a more youthful, vibrant look.  We will address this in future blogs.  Meanwhile, I would love to hear your thoughts about endo-prosth and your experiences.  


Today, I would like to talk about relationships and how important they are in achieving one’s happiness.  The picture below is one of my ex-residents Dr. Emanuel Alvaro, with his wife Judith, this past May at graduation.  Manny practices Endodontics in Montreal, Canada and his wife Judith is an attorney with the Bank of Montreal.  I have managed to stay in contact with them not only because Manny is a great endodontist, but, more importantly, because they are Great people.  They have two sons and their Family is a complete treasure.  As an individual without children, their Family is like a gift from Heaven to me.  All four of them are simply wonderful!!  They laugh at my jokes, cook with butter, and they pour me exceptional French wine.  It doesn’t get much better than that!!!  It is beyond gratifying for me to maintain such a relationship.   As a former Director and teacher, it is so incredibly rewarding to see your students create such a meaningful, wonderful life.  Not only to provide exceptional dental service but to be a fantastic human being.  Sometimes, that is not as simple as it may seem.

This takes me to another area of relationships and that is, how we treat each other as professionals.  Oh my gosh, I simply cannot begin to count how many times I see young well intentioned dentists get taken advantage of by older, more experienced practitioners.  It is so predictable and it is so wrong.  Can’t we have some pride in ourselves as professionals?  Do we have to treat each other like this???  Yes, this can happen to both genders, young and old, but far far far too often I witness young women not getting their fair share of the pie.  The only way this is going to change, Ladies, is when women feel empowered to institute change by themselves.  I cannot believe that I see behavior patterns in 2106 that mimic 1977.  Come on!  We both (men and women) can do so much better.  We both (men and women) deserve more respect from each other.  It’s pretty simple.  Don’t you think?

These are my thoughts.  I would love to hear yours???

Relax, Recharge, and Repast

As I’ve mentioned in an earlier blog post - and will post continually - I don’t think I can stress enough as a human being - let alone as a dental practitioner - the importance of spending time relaxing and interacting with our family and friends outside of our dental practices and professional endeavors. "Downtime” cannot be stressed enough as an essential element to recharge our batteries and allow us to actually invigorate our professional lives.  A September 2014 article in Entrepreneur magazine (by Joe Robinson) titled “The Secret to Increased Productivity: Taking Time Off” is applicable to folks in any profession - not just dentistry - and is a good read. 

“Entrepreneurs are often celebrated for wearing multiple hats and logging numerous hours. But working without letup is a bad habit that can jeopardize business, health and the life you're supposedly working toward...”   ~ Entrepreneur Magazine, September 2014

Recently I was in Baltimore, working with my graphics guru Ben Ehrman, on multiple projects (including creating this blog site), and after working hard all day we went to Aldo’s Ristorante Italiano in Baltimore's Little Italy neighborhood.  Ben is good friends with the owners of this family run restaurant and we had the greatest time.      

Here I am with one of Aldo's owners Allessandro Vitale (center) and graphics guru Ben Ehrman (right).

Here I am with one of Aldo's owners Allessandro Vitale (center) and graphics guru Ben Ehrman (right).

The food is absolutely first rate.  In fact, Aldo’s is perennially listed as one of the 10 Best Restaurants by Baltimore Magazine.  It’s an honor well deserved.  The food is fantastic! The service is excellent and the hospitality is above and beyond.  Below you can see some of their fabulous menu items - Panko Crusted Cod with Lemon/Caper Sauce over Four Cheese Risotto and Asparagus, fresh Zabaglione with Strawberries and Aldo's famous house-made Limoncello for dessert. If you find yourself in Baltimore, Aldo’s Ristorante Italiano is a great place to relax, recharge, and repast!

Cold on Cape Cod but…A Warmer Future

Indeed, this morning was cold on Cape Cod.  Thank goodness it was cold and sunny.  Actually the sun made it somewhat enjoyable.  However, this weekend the forecast is for frigid weather here with wind chills up to 35 below zero. Yikes!!!  That’s like Chicago weather.  Chicago is a fabulous city but it can get really cold in the winter.  

So, as I sit in front of my fireplace, I thought that I would share a summer picture.The picture below is of Dr. Jun Ogawa (and myself )this past summer on Cape Cod.  Jun is a dentist who made the decision a few years ago to sell her practice and to go into the music business.   She is a very talented musician, song writer, and singer.  Since her career change, she has written and recorded numerous CD’s and when she finishes her new website we will link you guys over to it.  But as we ponder her decision, there is something even more important here.

Jun had the courage to do what she really wanted to do.   This is often not an easy decision.  In fact, I think Dr. Ogawa is inspirational.   Don’t give up your dream of being a periodontist, or of owning your own practice, or opening up a business totally unrelated to dentistry.  Have confidence in yourself, ladies.  Too often men “conveniently” make us feel as if we cannot accomplish something.  I am here to tell you that you can accomplish your dream.  Don’t give up!!

I’d love to hear your thoughts!!!

Top Ten Time-Savers in Endodontics

Today we have a really nice (and helpful) guest commentary from Dr. Patrick Wahl DMD, MBA.  I have known Pat for many years and he is an Endodontist in Wilmington, Delaware.  Pat offers some great tips!  ~ Annie

Top Ten Time-Savers in Endodontics
By Patrick Wahl, DMD, MBA

“You will never find time for anything. If you want time, you must make it.” – Charles Bixton

You may think that saving a few minutes here and there doesn’t amount to much. But if you look at the endodontic aspect of your practice like an efficiency expert, you’ll see that trimming a few minutes can easily reduce a tiresome multi-hour procedure to a comfortable visit. You’ll notice greater profitability and you’ll like having a few extra minutes to catch your breath or chat with a patient between procedures. Consider these time-saving ideas:

1. Select cases carefully. There is a saying among pilots. “Every takeoff is optional. Every landing is mandatory.” Don’t start what you can’t finish. Prevent headaches by doing the cases you can do efficiently and do well and send out the rest.

2. Prepare trays ahead of time. Trays preassembled with the needed materials will save time in setting up for endodontic patients. Use whatever container you feel comfortable with. I recommend instrument cassettes that can be placed in an ultrasonic for cleaning and the autoclave for sterilization.

3. Duplicate the patient’s chief complaint with Endo-Ice. Spray Endo-Ice on a cotton pellet and the pellet will become so cold that you can instantly duplicate the patients chief complaint, or confirm a suspicion of necrosis. Endo-Ice gets so cold that your test will work even through a crown. It works, and it works instantly!

4. Do the endodontics. Or as Dr. Annie Koch likes to say, “Do the endo, dude!” Your patients look to you for your best judgement. Give it to them. They see you because they trust you. Definitive treatment that prevents unnecessary emergency visits is often the best treatment. Don’t be afraid to recommend endodontics if that’s the best option for the patient.

5. Simplify rubber dam placement. You don’t need a warehouse of clamps that don’t fit, you need just a few that do. The Aseptico Handidam is a one-piece, disposable dam and frame that bends out of the way for radiographs. Pre-punching the dam saves additional seconds.

6. Achieve good anesthesia right off the bat. Learn to give a simple Gow-Gates injection in addition to a traditional mandibular block, and your success rate in anesthetizing lower molars will skyrocket. A comfortably numb patient will allow you to complete your work quickly and efficiently.

7. Choose one bur to open most all of your accesses. This bur can be set up beforehand. Make sure your chairside assistant knows to include it in your set-up and to test it before the procedure.

8. Use one landmark for measuring canals. Most dentists use a different landmark for each canal in the same tooth when determining working length. When you use more than one landmark, you lose any association between the measurements, and cannot compare them in any way. I usually use the mesial-buccal cusp as my landmark for molars, the buccal cusp for premolars and the incisal edge for anteriors. That way, I don’t have to take the time to write down my landmark unless it’s different. The landmark is standardized.

9. Obtain unimpeded access. Remove crowns and bridges before attempting your access whenever possible, as any attempt to save a crown will fail unless the root canal succeeds! If you have created proper access, you should be able to visualize all the orifices.

10. Determine working length after coronal instrumentation. A working length measurement taken before you instrument the coronal portion of the canal will be inaccurate. Fighting a small file down the canal prior to instrumentation provides no useful information because the canal length will change significantly during preparation.

Do you know how long the average endodontic procedure takes to complete? The answer is, “Just 15 more minutes.” When you save a few minutes here and there, you will get more of your cases done without additional unnecessary visits, and your patients will thank you. You’ll even notice you do better work when you complete it uninterrupted, and your mind is “inside the canal.” How many of us even remember what tooth it was we were treating at a previous visit weeks ago, let alone the curvatures and nuances of canal anatomy? You and your patient both win when your goal is getting the job done right.

Fat Free Endo


Holiday weight gain is an annual event, just like the “Super Bowl.”  People often result to exercise and diet to shed this excess baggage. Many diets are totally fat free and produce lean efficient results.  Endodontics is no different!  Reduce the fat and excess baggage through knowledge and make Endodontics a profit center in your practice.  On a routine basis we will offer WDSC Tips that are “fat free” ways to establishing Endodontics as a profit center in your practice.  Tip one is something I, and most endodontists, feel very strongly about.  This is case selection.  

In fact, the key to avoiding an “Endodontic Nightmare” begins with proper case selection.  You must be honest with yourself and decide whether or not you can properly treat the case. It’s no embarrassment (actually, it can be smart dentistry) to decide that the case is beyond your experience and to refer it to a specialist.  This is not just about complex dental anatomy but it’s also about medical history and patient management.  If the patient is only anxious (like who isn’t) make certain that you fully explain things to the patient before you start the procedure.    If you let the patient know what you are jointly trying to accomplish, you will find the patient more tolerant of the procedure.  Also, let the patient know that they do have some control over the situation.  For instance, if something is painful and they raise their hand, you will stop.  Many anxious patients will actually test you on this accord.  Work with the patient, not against them and you will find your treatment progressing more smoothly.

The American Association of Endodontists has also addressed the problem of case selection through the publication of a Difficulty Assessment Form.  Through a numbering system, based on difficulty, the dentist is given a “heads-up” as to the difficulty of the case they are about to treat. At first, it seemed to me to be a “1-800 ENDO” concept but upon further reflection, it became apparent that this can be a great aid in identifying those very difficult cases.  I recommend that every dentist, who is performing endodontic treatment in her office get a copy and understand its concept.  You can obtain this document by contacting the AAE at 800 – 872-3636 or at their website,



Eating Away From Your Desk

One of the main purposes of this blog is to discuss "how to have a life outside of your dental practice."  Part of living is enjoying food and the occasional drink with family and friends.  I especially hope that our younger colleagues understand the importance of "downtime" and the need to enjoy one's life. This can have many dimensions.  Consequently, last night our fabulous media guru (Ben) and I went to a Japanese restaurant - Matsuri in Baltimore, MD.  I lived in Japan for eight years and do know my way around a Japanese restaurant.

We sampled gyoza (fried not steamed), various sushi items including anago and then experienced all the various tastes of a hot soba dish.  I went with Tempura Udon.  Yum!! Or should I say, “Oishii!!!”  It was a fun evening.

Let’s compare our thoughts about different cuisines such as Indian, Japanese, Korean Vietnamese, and Thai etc.  In fact, I would love to dine with you and post our experience.  The heterogeneity of women in dentistry is a Huge Plus!!!  Also, there are three cities in which I spend a significant amount of time - Boston, Philadelphia, and New York.  If you live in any of these locales, contact me and we’ll try to get together and sample some “eats.”