AME: Endpoints

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[00:00:49] [SPEAKER_00] Alan Mead is a dentist with too much time on his hands and too much recording equipment in his basement. Armed with an obsession to bring entertaining and informative content to the dental world in a way that's never been done before, I give you the Alan Mead experience.

[00:01:35] [SPEAKER_00] Alan Mead is a production of the Midwestern thing, which is to go up to the lake. My parents have a place up north that we go to all the time in the summer, particularly the 4th of July. And my expectation is there will be cooking out. There will be fireworks at the lake. It's really kind of funny. The lake itself doesn't have any kind of official governing body, but there's always really good fireworks. Historically, there's always been really good fireworks, which is kind of cool.

[00:02:04] [SPEAKER_00] So we'll be doing the 4th of July thing up north. Be leaving actually after work on Thursday and coming back home on Monday. So, and that is that this year for the first time in maybe forever, we didn't end up taking any time off because it, because the holiday landed on a weekend.

[00:02:22] [SPEAKER_00] So, and I know that this year is the big 250th birthday of the United States. So it's kind of exciting. We'll be, I'm sure we'll be doing all of the typical 4th of July things. I'm kind of excited about it.

[00:02:36] [SPEAKER_00] But I will say that I feel like there has not been as much hype as I thought there would be. And I, just to age myself, I remember a little bit, not a lot. I remember a little bit of the 200th.

[00:02:53] [SPEAKER_00] So 1976 was, I mean, the 200th birthday was, I just remember being a very big deal and everything was, was very much about, you know, the 200th birthday of the, of the country and everything had red, white and blue all over it. And it was, I remember it being a little bit more hyped at the time. I don't know if our political realities have made it so that it's less hyped than it, than it was or what I, I don't know, but it seems, it, it seems less hyped.

[00:03:23] [SPEAKER_00] At this point, which is fine too. I'm okay with that as well. But it's, it's always for the United States. It's always a great holiday. And, and in my case, it's, it's a holiday that I see a lot of my family that I don't necessarily see much during the rest of the year. So it'll be fun. I'm looking forward to that.

[00:03:40] [SPEAKER_00] Um, I have an interesting topic that I want to talk about. I've been kind of working this in my brain. I, I come up with these monologue ideas. A lot of times I'm inspired by, by clinical things that actually happened to me, uh, you know, as I'm working or, or, or things, sometimes maybe things I see on social media, but, um, I've always told the joke or I don't know if it's a joke or it's like one of the great things about.

[00:04:07] [SPEAKER_00] Extractions. And I have to, I've been getting, I've been doing more and more of my own surgery lately. And I think that's a good thing. And I'm, I'm, I shouldn't even say it out loud because I'm sure the next extraction will be brutal, but I've been doing well with them. I've been enjoying them. Um, I, I feel like I've, I, after recording with Kevin and Zach about it and hearing them talk about it on the, on the very clinical podcast, I've gotten, my strategies have gotten a lot better.

[00:04:32] [SPEAKER_00] And I, I am in most cases I'm sectioning multi-rooted teeth before I ever put an instrument on it. Now I don't even play around anymore. And I feel like my patients are benefiting, benefiting from that strategy.

[00:04:46] [SPEAKER_00] And so I, I'm really enjoying extractions or one of the reasons I really like extractions is the clinical endpoint. Like there's no margins to worry about. There's no, you know, wondering if you've left decay, there's no, you know, you know, when you're done, when the tooth is out and, and you've treated the socket in whatever way you're going to treat it and you're done.

[00:05:06] [SPEAKER_00] Like there's, there's no, uh, there's no regrets. And I, so I've, I've been thinking about clinical endpoints in dentistry and how, how in some cases it's honestly, it's one of the reasons I like surgery because when you're done, you're done. I don't think in dental school, they prepared me or I prepared myself enough for the fact that dentistry does not have that many obvious endpoints.

[00:05:33] [SPEAKER_00] One of the best things about extractions is it's kind of binary. So either the tooth is in the mouth or the tooth is on the tray. It's a, it's, it's either done or it's not done. And that is, I like that. It's not to say that, you know, you don't, extractions don't have complications. In fact, surgery probably has more, a higher complication rate than, than most dental procedures.

[00:05:58] [SPEAKER_00] But, but I will say that at least surgery has that binary thing where you know, you're done. The goal is to get the tooth out. And once the tooth is out and, and you've kind of treated, treated the surgical site, you're done. Um, and whether that means you have to treat a complication, well, that's fine, but, but it's the tooth isn't growing back. That's the story. You're not gonna have to retreat that spot. And I love that. I love the fact that there's an endpoint.

[00:06:23] [SPEAKER_00] I think it's, it's one of the more satisfying parts of dentistry that there is an endpoint, uh, there. If you think about it, there aren't that many dental procedures that give you such a binary endpoint as an extraction. So it's kind of beautiful. I, I will say that, um, you know, in dental school, I don't think I never really thought about it that way.

[00:06:47] [SPEAKER_00] I didn't, you know, I might've joked even then that, well, you know, one of the reasons to like extractions is there's no margins to worry about. You know, it's not, it's not like you're, um, the, the fine detail is, is I think fine details and extractions are real, but the fine detail for me typically is finding the spot to push to get that final movement. And frankly, is there anything more satisfying than a root tip you've been working on or a tooth you've been working on when you know it's coming out?

[00:07:17] [SPEAKER_00] You're like, okay, well, I haven't found the spot yet, but then you find the spot and it, and it gives, even though you might have to chase it around a little bit to get it out. You know that it's coming out. That is wildly satisfying. One of the more satisfying things in dentistry, if not the most satisfying thing. And it's, it's just interesting. I thought about it. There's, there's a lot of other procedures that don't offer such a frank and obvious endpoint.

[00:07:40] [SPEAKER_00] And I think maybe some of the hangups that we get in dentistry are because of that, because we don't get such obvious endpoints. So, as I said, I really have been enjoying extractions a lot lately, maybe because of the endpoints, maybe because I am now approaching them a little differently than I did back in the day. Um, multi-rooted teeth. I'm not gonna, I'm not gonna see if I'm gonna section it. I'm gonna section it.

[00:08:08] [SPEAKER_00] I, the, the surgical handpiece is out. There's always exceptions. If there's very conical roots, the tooth is loose already periodontally involved. I don't necessarily need to section those. But, but I mean, if, if, if there's bone there and the tooth isn't flat wiggly, I'm gonna section that thing because I know for the patient, it's, it's better. It's, it's less traumatic to the patient. I can do a less dramatic extraction if I section rather than trying to take that thing out in one big piece.

[00:08:34] [SPEAKER_00] Um, but like I say, that magic point where you know the tooth is coming out is, is, I don't know, that's a dopamine rush as far as I'm concerned, knowing that you, you've reached, you know, or you can at least see that end point where you're going to be done. Uh, so it's, it's making me kind of love extractions. So as some of you have heard me talk about, um, I've had some struggles keeping

[00:09:01] [SPEAKER_00] hygienists and finding hygienists. I used to have a one day a week part-timer that, that quit on me earlier this year. And I've, I've sort of, our solution has been having some subs, but also dumping some people over into my second column to do hygiene. So I've done, I've done more hygiene this year than I've probably done since dental school. And there's an interesting concept. Um, hygiene is one of those things that you wouldn't think of has obvious end points.

[00:09:27] [SPEAKER_00] But one of the things is that as well as you try, even with high magnification, in a lot of cases, you can't see, you can't see biofilm. It's kind of invisible. It doesn't, doesn't show up. But if you, if you stain it, if you put a disclosing solution on it, which is, I mean, I know they, it's, it's funny how disclosing solution is very hot right now. And in social media with all the guided biofilm stuff and everything like that. And what's funny is I

[00:09:53] [SPEAKER_00] remember as a kid, my dad's hygienist used to put disclosing solution on our teeth before she would clean our teeth. And it was, I think she probably showed us the mirror and, you know, was trying to explain to us that we weren't doing as good a job or whatever, but also, you know, she used it to make sure she knew that she was getting the biofilm off or, or cleaning the teeth well. And what's funny with the, some of the newer disclosing solutions. And I have to say, I use a, I use a GC one.

[00:10:22] [SPEAKER_00] It's, it's a, they call it a gel and it's one of those, it, it, it stains, I think it stains older biofilm, darker and newer biofilm, not as dark or whatever. But, but I mean, it's, it, it really does a nice job. It's easy. It doesn't, and it comes off nicely when you're, when you're cleaning things. It's, it's pretty cool actually. And what that does is it takes the, it takes sort of biofilm removal in hygiene and it, it sort of, first it sort of gamifies it, right? Like you, you basically know, are you getting it? Are you getting it or you're not getting it? If you,

[00:10:52] [SPEAKER_00] if you are going in and just assuming you're getting it after without staining it, you really don't know where this gives you a, like a, it gives you an end point. It lets you know. It's very cool. It's, it's, um, you might even say like, if you're a video game person, it's almost like you're, it's like a progress bar. Like when you're fighting a final boss in a video game, you know how much longer you have before you, before you, you kill them. You know how much longer, you know, how much more you have to do and how hard you're going to have to work because you've sort of,

[00:11:19] [SPEAKER_00] you sort of drawn, you sort of by staining the biofilm, you know what you have to do. And you also know when you're done and it's beautiful. It's one of those things where an end point like that makes me happy. I kind of like that. It's, you get a checklist of, of when you're done and that's pretty cool. You're, you know, as long as you see pink or purple, you need to get that off of there. Once you get it off of there, you know, you're done. Um, it's a great end point. It's another, you know, like in, and I'm coming to realize that

[00:11:47] [SPEAKER_00] satisfaction in a job well done is a nice thing to have. And, and having an end point like that is kind of awesome. So I sort of love that. I'm not sure why I crave these end points so much, except maybe it's, it's sort of a peace of mind thing where you know that you're done because other parts of dentistry, a lot of times do not give you such an obvious end point. I got a couple, I got a couple of classic examples of it. Um, carries removal. So

[00:12:16] [SPEAKER_00] when I, when I was in dental school, I, I felt like there was going to be a time where once I did this long enough, I would know when I would know when I've removed carries and when I haven't removed carries and, and that it would be obvious. And so I remember, I remember for boards, the biggest thing, the scariest part about boards was the idea that you, if you leave carries, uh, in your preparation for your class two amalgam, that you're going to send your patient back to be

[00:12:45] [SPEAKER_00] valid, you automatically fail. And, and I thought to myself, oh, he better not leave carries. And of course the solution was to choose, choose a lesion, choose a cavity that was barely big enough to qualify. Cause that way you knew that the reality is, is this is, this is a lesion that is not very big. And so you, it won't be that hard to know that you've removed all the carries. Well, I mean, when you're working on actual patients, it's nothing's quite so simple. You're actually treating them

[00:13:11] [SPEAKER_00] for the sake of, you know, removing decay and, and having tooth health, not so you can pass a test, which again, ethically is a frigging nightmare, but it's a whole other podcast. Um, I carries removal is, you know, I've been doing this for 27, 28 years now or even longer than that. Wow. Uh, 29 years. It's never so simple as that. It's always a matter of, it takes, it takes, uh,

[00:13:38] [SPEAKER_00] it takes experience. It takes a feel, it takes, you know, a high magnification. And in the reality is, is that one person might think they're done removing carries and another person may not. I think we've come a long ways with that. And I think knowing that, knowing that it's more important to have really clean margins of your preparation than knowing that you've, you've removed every last bit of carries. In other words, I, I will routinely leave what others might consider carries or at least,

[00:14:04] [SPEAKER_00] you know, dentin that's affected, uh, over the pulp. If I have really clean margins and that's my standard. I don't, I don't, I don't dig any further than I need to with the idea that I'm going to avoid pulpal injury when I can, but you know, all of that said it's there's your end point is still kind of vague. Your end point is not super obvious. And some people might say, well, if you use carries dye, it's like, it's like disclosing, except I would argue that it's not because the reality is

[00:14:33] [SPEAKER_00] carries die, the deeper, the decay, the more that carries die will stain the, you know, the wider, the dental tubules are into your preparation, the more of that stuff stains. And so all of a sudden you can kind of get, I don't know if you call it false positive, but it's, it's easy to use carries dye to be more aggressive than you meant to. That's real. Crazy dental already has some of the lowest prices on dental supplies anywhere, but you know, it's even crazier free shipping, head over to crazy dental prices.com, load up your cart and use coupon code very ship.

[00:15:03] [SPEAKER_00] That's very ship for free shipping on every single order. Plus every time you use that code crazy dental kicks back support to the very dental podcast network, save money, get free shipping and support the show. Use code very ship today. And just even knowing that that's the case, all of a sudden this, this, you know, this end point, the point where you've got the tooth on the tray or the biofilm is all gone is not so obvious in this. And this is where I think there's

[00:15:31] [SPEAKER_00] a certain amount of anxiety that comes with that. Like the, have you removed all the decay? That's the question you're asking. Have you removed the right amount of decay? So even if the question isn't, do I, have I removed all of it? Have I removed enough that the tooth's going to do okay? And are my margins clean enough? And I, again, I'm perfectly happy for people to use, uh, carry's die. I think that's great. Uh, but also I think it takes a lot of experience. It takes a lot of tactile feel. It

[00:16:00] [SPEAKER_00] takes really good magnification helps a ton too here. But the reality is like, we still have to, we still have to use our best judgment. It's, it's not as simple as, well, the tooth is on the tray and that's, that's frustrating as a dentist. I think there's some frustration that comes with that. And frankly, I think sometimes that frustration, the fact that there's not a clear end point can sort of throw us into that mental spot where we're stressed out because we're, we're, we want to believe that we did everything exactly right. And we follow all the rules, but sometimes the rules are

[00:16:30] [SPEAKER_00] not that obvious. That's, that's very frustrating. I think as a dentist, it's, it's worth remembering that physicians, surgeons who are doing like a cancer resection surgery have literally histologists on, on call for, to read the margins of their, of their surgery, their, their removal. So they know that they got it all. Wouldn't it be nice to have something like that? I mean, the, obviously the stakes are quite a bit lower when you're talking about removing decay, but it is funny that in medicine, that's,

[00:16:58] [SPEAKER_00] that's not a bad analogy that you're, you know, you're removing malignant tissue, but you want to know that you got enough of it. And, and, you know, it's microscopic section would be tough because you'd pretty much have to take the tooth out to do a histological reading of it. So I don't know. It's an interesting concept. And I do think sometimes the, the perfectionism of it, of holding yourself to a standard and not knowing if you got it all. And it is very subjective. I,

[00:17:24] [SPEAKER_00] how many times have you heard, you know, you look at what looks like a pretty nice preparation or, or a preparation you're looking at going, man, it looks like it left decay. A lot of times you'll see, you'll see people put stuff where I'm like, man, that the discoloration I'm looking at, I'm wondering if that's all, if the decay has been removed well enough. It's so we're always doing this stuff. I, whether, whether you think you are or not, I think in dentistry, we're,

[00:17:49] [SPEAKER_00] there's not an end point that's super obvious. The visual end point might not be the only story. If you're seeing something on social media where you feel like they've left decay, well, you weren't there. You don't know. Maybe, maybe that tooth is just discolored. It's, it's wild. It's, it's a wild thing. And I do think that, uh, I think that the perfectionism that a lot of dentists kind of have, this is hard. It's not an, it's not an easy thing to deal with.

[00:18:15] [SPEAKER_00] Another analogy in dentistry that is, that's kind of funny for this is, is your crown margin. How do you know, how do you know that you've placed your crown margin in the right place? Because, you know, for every patient that it's obvious and they're super easy to work on and you can put that margin wherever you want to, whether you feel like you need to be slightly subgingival or you want to do a beautiful onlay prep or whatever. There are patients that are really difficult to work on where you are, you're lucky to get any kind of a margin. I'm thinking of a heavyset person,

[00:18:44] [SPEAKER_00] you're working on lower second molar and you're just like, you're, you're praying to the dental gods that, that your margin is going to be okay in a place that you can, you can scan it or impression it or whatever. And like that end point, you know, is that an end point? That's a, that's a hope and pray and think, think you've done. And, and I mean, I'm always impressed by, by, you know, Instagram dentistry, people who have done what I'm like, man, that's a difficult spot to do as well as

[00:19:13] [SPEAKER_00] you have. Cause I think real dentists that are working on real patients on, on a regular basis, maybe don't have that. I look at that and I go, that's a hard thing. That's a hard thing. It's, it's hard to know when you're done because how much more can you tolerate? How much more can your patient tolerate? I mean, is the margin where you want it or is your back hurting bad enough where you're just going to do the best you can with it? And that is, I'm not proud to admit that that's not, I'm not proud to say that that's something that I, that, that I've done, but I also know that

[00:19:41] [SPEAKER_00] reality requires that. And it is interesting. This, this brings in just difficult patient stuff. We don't, we don't charge a difficult patient typically any more than we charge an easy patient. And I don't know how you could, but we probably should a patient that's super difficult to work on. Probably, we probably deserve to be paid more for working on someone and getting a job well done on someone like that. Then, or maybe we should be, you know, if the other side of that is

[00:20:11] [SPEAKER_00] for someone who's really easy to work on, maybe we should charge them less. I don't know. I'm not sure that, I'm not sure that I want to, I want to stake a claim on that, but I, I do know that that's another situation where what's your end point. Your end point is basically like, will it work? That's, that's not a great feeling as a dentist that you're, you're just, instead of going, this is an excellent clinical service for my patient, you're going, God, well, will this work? Cause that's as good as I'm going to be able to get it. That's a tough,

[00:20:37] [SPEAKER_00] that's a tough spot to have your end point. And the reality is when you're having a hard time sleeping at night, because you're thinking about it, that's not an end point. That's like a, well, we did the best we could. That doesn't feel so good. It's funny because I'm recording this at, at the office and I'm recording it kind of in between patients. And yes, I literally just cemented a crown, a number 15 on a, on a patient that struggles to open. Uh, she's great patient,

[00:21:05] [SPEAKER_00] but she, you know, I, of course I'm working on 15 cause it's like that. And, and I'm thinking to myself, man, you know, uh, seating this crown is a lot more fun than prepping this crown. And I'm sort of remembering it, getting those margins was, was a real challenge, a real challenge. I remember just struggling with that. And by the time when you don't, you know, do same day crowns, like a CEREC and you are counting on your lab to come through with a product,

[00:21:34] [SPEAKER_00] you've got to live with what you did the first appointment, you know, like on some level you've come to grips with, with the good, the bad, and the ugly, because you've got a crown that's got to fit the margins you placed last time. And it is, it's funny. I mean, when you think about that, um, that's your end point is you don't even know if your end point is going to be okay until, until that seat, you know, seat seating bite weighing and checking the bite and making sure, you know, I just have to laugh that it just happened the way that it is. I, so as a dentist,

[00:22:03] [SPEAKER_00] I would much prefer procedures that have a really obvious end point where, you know, the job is done and, and then, but there's a lot of dentistry, particularly in restorative dentistry that doesn't, doesn't allow the, the, the easy and simple, yep, this is the end point. I just, I just find that very funny and it's no wonder we're all a little crazy because, you know, we're having to accept compromises in a lot of cases because the end points aren't so obvious.

[00:22:32] [SPEAKER_00] Honestly, this is kind of spectacular talking about end points. You'd think, Hey, well, at least with a crown when you've seated it, you know, that's the end point, you know, when it's seated, it's done. You'd think so. You would think so. So I tried in this crown. I, uh, uh, it fit great. It was really good fit. So I went ahead and seated it. It was a zirconia crown on, on a, on a tooth number 15 with plenty of tooth structure. So I just used a

[00:22:58] [SPEAKER_00] resin modified glass ionomer to cement it. I got it in there. I went back in after, after I had cleared the cement and everything like that and saw that it didn't seat right. I had about a millimeter and a half open, open margin on the paddle. Even when I, I put the crown in prior to seating, it was perfect. And so the crown moved either. I didn't get it seated all the way when I, when I cemented or the crown moved, uh, before I cleared or something. So my end point has just

[00:23:27] [SPEAKER_00] shifted. I just can't even believe it's hilarious to think that this is what I'm talking about in this podcast and literally within the podcast, this happens. So yeah, it's no wonder we're all crazy. It's no wonder. It's no wonder that, uh, I'm craving end points. We're knowing that when I'm done, I'm done. And I just have to say that, you know, the resolution of this is that, um,

[00:23:55] [SPEAKER_00] dentistry selects for perfectionists on some level we're doing, you know, particularly restorative dentists we're doing, we're doing surgery in a really small place and we're trying to keep it really dry and the mouth wants to stay really wet. And it's a tiny space and you're looking in a mirror and you don't have very much light. And we ask a lot of ourselves. So we kind of have to give ourselves a break. And literally, um, just, you know, when it's two o'clock in the morning and I can't sleep and I have imposter syndrome and I've been doing this for

[00:24:24] [SPEAKER_00] 28 years and I still feel like I'm a beginner. Sometimes we have to realize that that's the nature of the beast. It is what it is. And, and, uh, Instagram dentistry isn't helping. Um, you know, the insurance companies paying us less and not keeping up with, with, uh, how much things cost that's not helping either. None of it's helping, but we have to give ourselves a break and we have

[00:24:50] [SPEAKER_00] to realize that we are human beings doing the best that we can. And as long as you're doing the best that you can, all of a sudden the end points don't seem quite as bad because the situation you're working with is the situation you're working with and you're doing the best that you can. And sometimes you just have to give yourself that break. And, uh, I'm not, I'm, it's great to appreciate the wins. It's great to appreciate the, the end points when you've, when you've gotten

[00:25:17] [SPEAKER_00] all the purple stain off the teeth, when you're cleaning them or when you, when you've gotten that beautiful, you look at the, you look at the root tip that you just took out and it has a beautiful rounded end and you know, you got the whole thing and you can just clean out that socket and be done. It's awesome. But you know what? Uh, you know, when you cement the crown, it doesn't go in straight and you got an open margin, you're still a good person then too. You're doing the best that you can. What am I going to do? I'm going to have this crown remilled. I'm going to cut the doggone

[00:25:44] [SPEAKER_00] thing off and I'm going to, I'm gonna put it on again in the right way. Cause, cause that's what, that's what I have to do. That's what I have to do to be able to sleep at night. And that's what I have to do to, you know, to get the best end point that I can on some level. Your, your end points are not necessarily what you would choose, but sometimes you just have to, you have to live with the end point that you get. Uh, I think, I think it's a, it's a bit of a lesson. Um, it's awfully funny that

[00:26:10] [SPEAKER_00] this happened as I was recording this podcast. I think it's, it's, uh, it's kind of perfect actually. So I hope you guys came off a great, uh, 4th of July holiday. If you're in the United States and celebrating, um, I hope your end points are all obvious and wonderful. If you have any questions or comments, you want to talk about this, my, my taking my beating on the podcast, go to the very dental Facebook group and join. Uh, you can, uh, you find it on Facebook and just look for very dental and they'll come up and it's going to ask you for a password. You can give me

[00:26:40] [SPEAKER_00] one of several passwords. I'll throw out a couple of them here. Timmerman, Hornbrook, BioClear, Gary, Frank, uh, what other ones are there? Papa Randy, Lipscomb, McQuethy. There's a bunch of them. Give me one of those. We'll let you in. It's great. It's a great place to talk about stuff. It's a great place to talk about how, when you cemented a crown and you thought it was perfect. And then when you went in to look at it

[00:27:03] [SPEAKER_00] again after the seat bite wing and it was not perfect because it moved, which I just probably happened to me like three times in my entire career. And of course it happens to me when I'm literally recording a podcast about this stuff. Kind of perfect. Thanks a ton for listening. Really appreciate you guys. Appreciate you listening to the show and we will catch you next time.