Wednesday, August 14, 2019

The Buzz About Endodontic Irrigation

There is lots of discussion about Endodontic irrigation.  The introduction of new technologies, such as Gentlewave, and the accompanying marketing associated with this product have increased the  attention to the importance of endodontic irrigation.  Many of you may remember the cliche you heard in dental school that if you properly clean the canal system, could could fill it with bird feces and it would be successful.  While we know that bird feces would reintroduce bacteria into the canals - the funny point of the saying was to stress how important the cleaning of the canals is to the success of endodontic treatment.

Just like endodontic shaping techniques, there are multiple endodontic irrigation solutions and delivery techniques.  Furthermore, there are myriads of combinations and concentrations of each of these irritants.  To make this further cloudy, a Cochrane Systemic Review of endodontic irrigants reports "Although root canal irrigants such as sodium hypochlorite and chlorhexidine appear to be effective at reducing bacterial cultures when compared to saline, most of the studies included in this review failed to adequately report these clinically important and potentially patient-relevant outcomes. There is currently insufficient reliable evidence showing the superiority of any one individual irrigant. The strength and reliability of the supporting evidence was variable".

For the purpose of the is article, we will consider NaOCl as the gold-standard, most used irrigant in the world and will avoid the discussion about concentration (although I prefer full strength).

Delivery of the NaOCl irrigation can be done several ways:

Passive Irrigation - syringe only with instrumentation files pushing the irrigation to the apex
Active Irrigation - sonic or ultrasonic energy used to stir or active the irrigation throughout the canal system
Lasers Activation - use of laser irradiation is typically recommended in addition to traditional NaOCl irrigation protocols
GentleWave - combination of acoustic and hydrodynamic energy to deliver irrigants through canal system

In our practice at Superstition Springs Endodontics, we have been using active irrigation for years, starting with ultrasonic and now currently using sonic activation on every case.  We have found that with adequate irrigation time, sonic activation and removal of the smear layer (using EDTA), we are finding and filling more and more lateral canals, accessory canals, apical deltas.  (The use of radiopaque sealers also increases the visibility) In my opinion, its difficult to say how much of this is attributed to the removal of the smear layer - but I expect that it is a combination of the active irrigation and removal of smear layer.

Here are a few of the cases demonstrating the benefits of active, sonic irrigation and smear layer removal.

So as you can see, the proper cleaning, shaping, active irrigation and removal of smear layer of the canals allows for us to open the lateral, accessory and apical deltas that we know exist in the complex canal anatomy.

Whether this changes the outcomes or success rate of the endodontic procedure is unknown, but it sure looks pretty!

Related Articles:
Passive ultrasonic irrigation in root canal: systematic review and meta-analysis.
Endodontic irrigants: Different methods to improve efficacy and related problems
Effectiveness of ultrasonically activated irrigation on root canal disinfection: a systematic review of in vitro studies.
The Use of Lasers in Disinfection and Cleanliness of Root Canals: a Review

Tuesday, February 26, 2019

"The Root Cause" Netflix Documentary & Psuedoscience: A Recipe for Confusion

A recent trending documentary on Netflix, titled "The Root Cause", has garnered the attention of patients and dentists alike.  The documentary tells the dramatic story of a man's search for the solution to his health problems only to discover that a root canal treated tooth was the cause.  Multiple "experts" from the fields of biological dentistry and alternative medicine opine on the dangers of root canals, titanium implants and cavitational lesions from improperly done tooth extractions.  In the end, people are encouraged to seek out biological dentists to prevent a whole host of health issues from heart disease, cancer, MS and a host of other chronic diseases.

Some of the outrageous claims made in this documentary include:
  • "The vast majority of chronic degenerative diseases begin with problems in the mouth, infections and toxins, and it is only until those are addressed that you are going to get any clear positive response with your disease.
  • "70-90% of all medical problems originate in the mouth"
  • "Data that we have just recently gotten shows now that the #1 cause of heart attack is a root canal treated tooth. Plain and simple. Not correlation, not link, cause and effect"
  • "Conventional dentistry believes that you should save a tooth at all costs and if the patient dies, well that is the price of saving the tooth.  They don't really come with the concept that you should take things that are dead out of the body."
  • "All root canals are infected without any exception."
  • Every tooth connects up energetically through a meridian system to certain organs or glands. Root canal treatment disrupts this normal flow of energy and causes problems with the other tissues of the body on those same meridian lines.
Dr. Weston Price 1870-1948
The documentary references the work of Dr. Weston Price in the 1920's and the resulting focal infection theory.  While Dr. Price's research was creative at the time, it was primitive and would never stand up to modern scientific standards for research.  His research, done in the dawn of what we would call modern microbiology, is still quoted by biological dentists, such as Joseph Mercola, George Meinig and the others in this documentary, as the evidence to support their claims.

In 2006, Dr. Micheal Barnett wrote, "By the 1930's the validity of the focal infection theory began to be questioned, and investigators found, when they considered the available real outcome data, that there was no clear basis for ascribing the occurrence of much systemic disease to the presence of oral foci of infection.  as a result, the focus of dental practice changed such that restorative dental procedures re-emerged as the mainstay of most dental treatment plans."

In 1951, the Journal of the American Dental Association devoted an entire issue to addressing the concept of focal infection and Dr. Price's theory.  It was determined that Dr. Price's research lacked many aspects of modern, scientific research, including absence of proper control groups and induction of excessive doses of bacteria.  These findings shifted the standard of practice back to endodontic treatment for treatment of teeth with non-vital pulp.

The American Association of Endodontist has published that "since that time, decades of research contradict the beliefs of the "focal infection" proponents; there is no valid, scientific evidence linking endodontically treated teeth and systemic disease."

In today's digital world, with the ability to create, publish and distribute digital media, misinformation and myths can live on forever.  For example, a 2012 paper by Joseph Mercola, and the recent Netflix documentary, cite the recycled claim attributed to Dr. Josef Issels, a German physician, who reported that in his 40 years of treating cancer patients, 97% of his cancer patients had root canals.  In today's day and age of fake news, we might also describe these types of claims as "fake science" or pseudoscience.  The anecdotal and epidemiological studies quoted in the Netflix documentary are misleading and designed to create fear.

The Problem With Epidemiological Studies

In a recent discussion with Dr. Hessam Nowzari DDS, PhD, an expert clinician, educator and scientist, he explained the problem with these types of studies.  He said, "If you are using epidemiological studies, you can find correlations between anything.  You can find that people with cancer that had root canal treatment.  But what people don't realize is that you can also find that those people were wearing shoes, but that does not mean that wearing shoes causes cancer! That's the problem with epidemiological studies. Epidemiological studies have no right to make any conclusions whatsoever, and they do it all the time.  Epidemiological studies are routinely used because we are lazy with our research.  We don't do long term studies, or prospective studies because we are lazy...there is no accountability and you can say whatever you want." He continued, "That is why we need Bayesian statistics.  We cannot have epidemiological studies and we cannot only use this nonsense of p-value.  When you start measuring p-value you are measuring so many different outcomes, sooner or later you can find a relationship and then you can justify it with p-value.  Take for example this argument...If you go to bed with your shoes, when you wake up you will wake up with a headache.  What's the problem here?  Is it the shoes? No - the problem is that people who go to bed with their shoes on are usually drunk!  The cause of the headache is the alcohol, not the shoes.  But if you didn't know about the alcohol, you might argue that the shoes caused the headaches.  We have so many of these nonsense types of statements."

The Tooth is Not Dead!

When discussing the Netflix documentary's claim that a root canal treated tooth is dead and dead tissues should be removed, Dr. Nowzari stated... "First, when you do a root canal, the tooth is not dead.  Even after a root canal, the tooth has bone, ligament, gingival fibers, transeptal fibers, periosteal fibers, innervation, circulation all of which is very much alive.  When you go inside the root and do a root canal, it does not affect the system or the rest of the dental organ.  The periodontium is still there, intact and very much alive."

The dental organ includes the tooth, periodontal ligament, bundle bone, periosteal fibers, gingival fibers etc. All of these tissues are alive and vital following root canal therapy.  These tissues are all considered part of the dental organ because they are derived from the same embryologic tissue. The periodontium belongs to the tooth and remains alive after root canal treatment.
Stop Hating Bacteria!

The Netflix documentary also makes the assumption that because we cannot completely sterilize the root canal system we should extract the tooth.  It argues that if you cannot remove all the bacteria, then you will have a chronic problem.   Endodontists agree that there is no way to "sterilize" a root canal.  More accurately, we are removing necrotic tissue, disinfecting the canal system and sealing the canal with antimicrobial filling materials.  Despite our inability to remove all bacteria from the canal system, we find complete resolution of symptoms, healing of the peridontium and a return to full function for the patient.  Dr. Nowzari proposes that we need to take a new approach to looking at the microbiology.

Dr. Nowzari explains:

Tolypothrix sp. of Cyanobacteria
You know for years, we have been trained to think that bacteria are our enemies. But they are not. They are our best friends.  Only a very, very  small percentage of microorganisms are dangerous. I would say that 99.9% of microorganisms are fantastic!.  Microorganisms are responsible for the earth as we know it.  They are responsible for the recycling of carbon and the recycling of all atoms.  They are in the oceans, like cyanobacterium, responsible for the production of oxygen.  Microorganisms are responsible for photosynthesis, production of vitamins, and coagulation. Fortunately, there are so many microorganisms in our eyes and ears and more than a thousand different species on our skin that are protecting us.  I’m always surprised that we don’t die a hundred times every day because we are exposed to so many bacteria and viruses.  The reason is that most viruses and bacteria are good for us. It’s a very small percentage of them that are harmful.

Microorganisms are the first life on Earth. They go back to 4 billion years ago and they are still with us. The same cyanobacteria that gave us this gift of oxygen is still with us.  They are still inside our mitochondria.  Mitochondria has its own DNA because it was a microorganism.  Our mitochondria is a result of symbiosis with bacteria.  It is fascinating what microorganisms are doing for us!

A fascinating thing to consider is that we have more microbial cells in our body than human cells. This is well known fact in microbiology.  Our bodies are made up of about 50 trillion human cells.  We have more bacterial cells than human cells.  The day that we successfully kill the bacteria is the day we have eliminated life on earth.

For example we have 100,000 vital elements in our DNA.  We call those antique viruses, or domestic viruses.  These are viruses that attacked us 2-4 million years ago and we domesticated them.  Today they are providing us flexibility.  So when we get attacked by these viruses we know them, they are who we are.  So first off, we have to recognize that bacteria are our best friends.  Microrganisms are the best chance we have. We have to stop hating bacteria and start loving them!"

Every time you eat, you send billions of microorganisms into your system. Everytime you floss you send billions of microorganisms into your gingiva and your system. You are not dying because they know who we are.  People need to realize that we are bacterial ourselves.  We are of one entity.  It is not humans vs. bacteria.  We are bacterial.  We share our DNA with them.  We are all tied together in this universe and bacteria are an important part of that.

We have to change our understanding and prejudice against microorganisms.  Our focus on “anti-bacterial” or “anti-microbial” treatments and products and overuse of antibiotics is killing our best friends.  Many of these products that we have developed and are overusing are cycling back into our environment.  These are the real environmental threats that we face today.  We have to change our educational system.  We need to teach our medical students that “anti-bacterial” or “anti-microbial” makes no sense whatsoever.  We have to stop it.

The problem with these charlatans (referring the "doctors" in the Netflix documentary) is they just don’t understand microbiology!  They think that microbes are our enemies.  Do you really believe that our immune system could protect our nasal cavity from what’s going on outside in our environment?  No, it’s all because of the microorganisms.  That’s our first line of defense.  But in medical school, they teach our first line of defense is macrophages, antibodies, neutrophils.  That is not true! Our first line of defense are microorganisms, so we better start loving them again!

When I was the director of periodontics, we did lots of periodontal surgery. We never gave antibiotics to patients after periodontal surgery and nobody ever died.  Why? You open the gum, reflected a flap, touched the bone, you put it back and sent them home and nobody ever died.  Why? Because of protective bacteria!  Now since we are using allografts, alloderms, we give antibiotics.  Not to protect the patients, but to protect the product!

Over the last 30 years, we have entered a period of endarkenment.  Who is responsible for this endarkenment? Psuedoscientists.  Now we are using epidemiological studies and everybody is a doctor.  Psuedoscience is pushing us back into endarkenment.  Forget about the enlightenment. People are shocked to hear these kind of things because we have been brainwashed in medical school.  Bacteria are bad.  Talk to any medical student.  Wash or don’t wash your hands five million times a day – nothing is going to happen. Go to the airport – and watch people wiping down the chairs. They don’t realize that contamination is all over the place and the reason nothing happens to us is that microbes are our friends. We need to stop being so sarcastic about microorganisms.  We have to get to know them again. We have to understand that Earth would not be what it is today without microorganisms.

Bacteria and Root Canals

Dr. Nowzari explains: Dentists are trained to think that bacteria are the problem with necrotic teeth.  But the problem is the necrotic tissue and the enzymes that are released with necrosis.  For example, what is more dangerous, living p. gingivalis or dead p. gingivalis which releases endotoxin?  So the problem is necrosis of tissue, and then when the microbes come later, we blame them for the necrosis.  We need to tell patients that their tissue is necrotic and a root canal will remove the necrotic tissue.  That’s why endodontics works. We can never eliminate microorganisms. A very small percentage of the time do microorganisms cause failure.  But what is our failure rate? By far, much less than implants.  And up to now, they are still not capable of generating papilla between two implants. If they are so wonderful, so successful, so bright, just give me 2 mm of papilla and I’ll give you the Nobel Prize!  A tooth with a root canal does not lose the papilla.

The root canal has passed the test of time. Gutta percha is still the best.  At the apical part of the root canal tooth we have an microbial ecosystem, a microbial community.  There is no question that that community is protecting us.  Yes, if you look at the inside of the root canal, there are microorganisms. So? So? Why do you think that because there are microorganisms that is a bad thing? That microbial ecosystem between the end of the root canal and the bone is a community and it is protecting us…Having said that, when you have an abscess, it is a planktonic type of problem. It is not an ecosystem or biofilm problem.  For whatever reason, the bacterial infection is powerful enough to cause the abscess.

Bacteria Hasn't Changed, We Have!

Dr. Nowzari continues:

We have to stop hating microorganisms.  We have to start knowing them again.  We have to start appreciating them.  We have to start to know them if we want to know ourselves.

If you look at the skulls from a million years ago. They did not have cavities, yet they had the same microorganisms as we have today. Our lifestyle has changed. With that change in lifestyle, we are encouraging the formation of cavities.  We change our lifestyle and then we accuse the bacteria of the change, the same bacteria that have been with us for millions of years. We are consuming sugar, 1.2 million people die every year because of sugar, but we don’t attack sugar.  We attack bacteria.  Why do we accuse the microorganisms of causing the problem when what changed was our lifestyle.  The microorganisms that have been with us and have not changed in millions of years. We have changed our lifestyle and then we look for something to blame and that is usually the bacteria.

We must understand that we are all in the same boat. And by all I mean us, dogs, rabbits, birds etc.  We are all truly a part of this universe because our DNA is the same. We are all cousins...We have to start to know the other members of our universe.  We have to study bacteria. There is an interconnectivity of the members of this universe and we should be really grateful for this.  This is really the beauty of life.  That is the miracle of life!


The Root Cause is a non-sensical, non-scientific advertisement for holistic dentistry.  The 100 year old research used to justify its claims do not stand up to modern, scientific scrutiny.  The misinterpreted epidemiological studies used to support their claims should be considered psuedoscience.  The whole premise of the documentary is based on a misunderstanding of microbiology and the role of bacteria in our teeth, bodies and lives.  We will never be able to eliminate bacteria from our teeth, mouth, bodies, communities or world. If we did, our lives and world would cease to exist as we know it.  Bacteria provide more benefits and protection for us than we give them credit for.  Root canal treated teeth are not dead and do not need to be removed.  Root canals allow for dead, pupal tissue to be removed providing a cost effective way for patients to retain their natural teeth and the beauty, form and function that only a tooth can provide.

Learn More!

The past few years have presented an exponential increase in our understanding and knowledge in a variety of scientific and technological endeavors.  Scientists and researchers from different backgrounds have been invited to present their unique research at the upcoming Nowzari Symposium on Friday, May 10th in Beverly Hills, CA.  Dr. Nowzari will present more information about "How our microbes make us who we are".


Barnett, Michael L. "The Oral-Systemic Disease Connection. An Update for the Practicing Dentist". 2006. JADA vol. 137, p 5S-6S.

Root Canal Safety: AAE Fact Sheet 2004

Personal interview with Dr. Hessam Nowzari DDS, PhD on 2/21/2019

Johnson, Marcus. "The Truth About Endodontic Treatment and Your Health.

Thursday, January 17, 2019

HIPPA Compliance and SSE Patient Reports

At Superstition Springs Endodontics, we have been discussing the secure, electronic reports that we send back to our referring offices.  As you can imagine, when working with different offices with different email services, each computer with different mail settings, security settings on different networks, doctors and team members reading reports on handheld as well as desktop computers and last but not least, human error, there is likely to be some complications along the way.  Our recent upgrade to TDO endodontic software was significant technology investment was meant to improve our HIPAA compliance.

What is HIPAA?  Title II of the 1996 Health Insurance Portability and Accountability Act (HIPAA) has broad implications in health care - which includes dentistry.  This law created multiple rules & regulations for various purposes.  These regulations include a privacy rule, security rule, breach notification rule and an enforcement rule with civil authority to levy monetary penalties for HIPAA violations.

The Privacy Rule: You are likely most familiar with this rule.  This rule gives patients certain rights over their personal health information which includes dental records and billing records.  This rule gives patients the right to ask for a change in their records, ask health care provider not to disclose their health information to others, or accommodate the patients requests regarding how they communicated with the patient.

The Security Rule: This rule puts the burden on the dental practice to have a written risk assessment and develop practice safeguards to protect the confidentiality, integrity and availability of electronic patient information.  These safeguards are categorized as 1. Administrative 2. Technical 3. Physical  This is a tall order in that these safeguards must make sure that patient data is not corrupted or changed without authorization, and that only authorized people have access to patient data while at the same time making it available for authorized persons to access the information whenever needed. "The HIPAA Security Rule also requires ongoing maintenance of safeguards, periodic risk assessments, workforce training, and documentation."

Breach Notification Rule: The new law enforced the adoption of EHRs for Medicare and Medicaid providers which had a greater impact on our physcians colleagues.  The Health Information Technology for Economic and Clinical Health (HITECH) Act also created the Breach Notification Rule which requires dental practices to provide notification of breaches of unsecured patient information to the patients, the federal government and in some cases the media.

Enforcement Rule:  The enforcement rule has authorized enhanced civil monetary penalties for non-criminal violations of HIPAA rules since February 18, 2009.  While there is not a big history of dentists being fined for non-compliance issues, Dr. Joseph Beck was the first dentist to be fined $12,000 for non-compliance with HIPAA rules by the office of the Indiana attorney general.  The Health and Human Services Office of Civil Rights (OCR) also has the ability to audit dental practices and issue fines/penalties.Omnibus Final Rule:  On January, 17, 2013 the HHS published the HIPAA Privacy and Security Omnibus Rule which created a compliance deadline of September 23, 2013.  The Omnibus Final rule reinforces the HIPAA rules and regulations and:
  • extends the privacy and security rules to the dental practice's business associates and their contractors (any contractor who has access to patient information)
  • establishes new limitations on use of patient data for marketing and fundraising purposes
  • prohibits sale of patient's personal health information without authorization
  • expands patients' rights to request and receive electronic copies of personal health information
  • broadens patients' ability to restrict disclosure of personal health information to health insurance plans

Does HIPAA apply to your practice? Yes! HIPAA rules apply to your practice if you are a "covered entity" under the law.  You are considered a "covered entity" if you or a third party clearinghouse that you hire transmit electronic claims to a dental plan.What doest that mean for my practice?  If you are a "covered entity" then you need to take steps to comply with the HIPAA law which includes:
  • Appointing a practice HIPAA privacy official
  • Appointing a practice HIPAA security official
  • Familiarizing yourself with the law
  • Creating a HIPAA compliance team
  • Performing a risk assessment
  • Deciding on your practice policies and procedures
  • Training your workforce
  • Update business associate agreements to comply with privacy and security rules
  • Maintain
You can order the ADA HIPAA compliance workbook to help walk you through the process of becoming fully HIPAA compliant at: click here

How does SSE secure patient communication work?  Our current software gives every referring doctor a username and password - allowing them to access all their patients reports, radiographs and relevant clinical data by logging into a secure server.  When a consult or treatment has been completed in our office, you will receive an email to view that specific report or log into the server to access any patient report/data.  However, every step of security also comes with the cost of added steps and login. Here are some of the trouble spots people have reporting using our secure communication tool:
  1. Clicking on the wrong hyperlink:  One hyperlink will take you to your specific patient's report and another hyperlink will take you to the server where you can access all of your referred patient's data.
  1. Offices with multiple doctors: Each doctor has their own login credentials to access the reports of the patient's they referred.  Team members logging in on the doctor's behalf need to login with the correct doctor to access their patient reports.   If you have multiple doctors, make sure you are logging in the with doctor's credentials who referred the patient to SSE.
  1. Email settings:  Your email client (outlook, gmail etc.) may have a setting to string together emails from one source making it harder to find each individual report.  Go to your preferences/settings to make changes in your email software application.
We are committed to making sure your patient's information is protected and that it is available to you when and where you need it. If you are having any problems accessing your reports, please contact us so we can make sure our electronic communications are working seamlessly.