VC: The Changing of Very Clinical Minds

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[00:00:56] Welcome to the Very Clinical Podcast. In about the time it takes to do an M.O. on three, we will entertain and amaze you with tips and tricks on regular daily dentistry. Here's Kevin and Zach. Zach. What is up, Very Clinical listeners? And welcome back to yet another episode of the Very Clinical Podcast. I am Zach Miners, coming to you from Kansas City, Missouri. With me, as always, my trusty co-host, Dr. Kevin Harefriar. Kevin, what's going on in Cleveland?

[00:01:24] The Indians slash guardians are in first place and we went again tonight. So your Royals are in second place still. Hey, and we're winning tonight too. You guys are on a heater. We're on a heater. When do they start playing each other? Yeah, I know. It seems like the way the divisions were lined up way back when that we played each other a lot, but it hasn't happened yet. So whatever.

[00:01:47] There will be plenty of matchups. I'm looking forward to it. So we brought on a multiple-timer guest, our most expensive guest, Dr. Alan Mead. What's going on, man? A huge fan of sports ball here. Huge fan. You can come down to Cleveland and we'll go to an Indians slash guardians game. I would 100% do that. And I don't love baseball,

[00:02:11] but baseball live is so fun because food and hot dogs and all that stuff. Do you identify with Detroit Tigers as your team? Yeah. I mean, I don't follow them at all. Honestly, we have a minor league team in my town. So when I go to baseball games, it's a loons game because I can, I mean, it's literally, I drive past it every day on the way to work. It's fun. Are the loons in the Detroit? They're Dodgers. They're a Dodgers farm. Yeah.

[00:02:38] What A? One of the meeting places in there is called Lasorda's Loft. Nice. They're all Dodgers. And it is the frigging nicest stadium I've ever been in my entire life. It is nuts. Minor league baseball is, it's amazing how that culture continues to, I mean, they, they do great. That's Americana. Yeah, it is. What A is it, Alan? Is it single, double? I don't even know. Don't even know. All right. No, bro. I'll find out. I'll Google. No worries.

[00:03:05] Maybe triple A. I don't know. Oh, okay. Wow. That's hot. That's big time. Nice. Kevin. Why don't we, why don't we use that as the bit and just get into it and we'll look and do the other one next time. That's a good idea. Yeah. We talked about baseball. Yay, baseball. All right. Yay, baseball. The loons are the high A affiliate of the Los Angeles Dodgers. Okay. Single A ball. Okay. Interesting. So we're doing something a little different tonight,

[00:03:33] Kevin. Why don't you bring in the idea? So we were talking behind the scenes about dentistry and life in general. And we came up with this idea of things that we might change if we had the chance. And it's a kind of bounce back between all of us in different forms. So what we're going to talk about is things that we would have changed clinically. That's going to be today's episode.

[00:04:02] And then next time stuff that we would change business wise in our practice. And then the third thing will be what we would have changed in our life. So that's the big one. It's things that it's things maybe that we do now that we didn't know then, or things that we've changed our mind on over changed our mind. Yes. Yeah. Yes. Okay. Okay. So in clinical dentistry, Alan, we'll, we'll put you in the,

[00:04:28] the hot seat. What is a, what is a clinical either, you know, a material, an idea concept? What's something you've changed your mind on something that you did it a certain way early on in your career. And you're like, you know what, that I got it. I got, I got a good one. Kevin's probably going to be on board with this one too, because we, I don't, I don't know, maybe you are too, Zach, but in dental school, um, margins were meant to be subgingival in dental

[00:04:55] school. Uh, I, I remember that they, I, I sort of learned that, uh, you prep your margins a little, just a millimeter sub G as the ideal. Okay. And, and, and of course, so then that, that, you have to, you had to be really good at packing cord. And of course in dental school, I wasn't good at prepping. I wasn't good at packing cord. I wasn't good at any of that stuff. So it was all ugly, but, but then when you're, you know, dealing with subgingival, you're technically, you're going to be dealing with more bleeding. Potentially you're going to be dealing with more tissue beat up and

[00:05:24] stuff like that. And so over the years I have found that I, I mean, obviously if, if the preparation dictates subgingival, I go subgingival, you know, that's obvious, but I, my ideal is going to be equal gingival if I can do it. And it really depends on the material. It depends on, you know, the kind of preparation I'm doing. I don't, I don't do a ton of onlays. There was a time I tried to do a bunch of onlays, but I generally, I generally do full coverage zirconia and with sort

[00:05:50] of minimal prep now on, on my regular posterior units at this point. And of course, you know, that earlier on in my career, I didn't do that. I did a lot of porcelain-infused metal and stuff like that, but, but the standard, I feel like at University of Minnesota, uh, sub G was, that's where you went. You, you wanted to bury your margins because you didn't want to show a metal margin, uh, if you could avoid it. And so you'd go sub G. And so, and, and so I did that earlier on and

[00:06:15] that's tougher. I think it's tougher to manage if you can keep, if you can keep an equal gingival margin. Now, I don't know if you guys had that, but that's kind of how I started. I mean, you drop your margin sub G and you pack the hell out of it with cord and you, you get the best impression you can get that way. But, you know, there, there are complications in sub G margins that, that, you know, are, you know, if you, if you don't have to do that, you sort of avoid some of that visualization and, and, you know, uh, the kind of retraction you have to do and all that stuff.

[00:06:43] So something I have changed clinically over the years is I tend to, you know, I avoid sub G whenever I can and I'm going to keep it equal gingival generally. And now that, now that I'm scanning, I like that a lot because, you know, I mean, it's easier to, you know, retraction's easier and all that sort of thing. So, so I changed my mind on where I, I mean, my, my goal for where I place my margins. Obviously you place your margins where you have to place your margins on some level, but it was just kind of, I think I sort of learned that in dental school. Kevin, it has his finger up.

[00:07:12] I have a comment. Yes, I know we like to, um, make fun or sort of chide our, uh, dental hero, God, Bill Strug, but way back in the day when I was a subscriber to his newsletter, there was a blurb in there about where to put your margin. And I would, I would say that I would, I was taught the

[00:07:41] same thing in Ohio state at the Ohio state university. Yeah. What he said was to keep the margin out of the patient's biology. So while you were talking about that, that's what went through my head because that stuck in my head more than, Oh yeah, that makes a lot of sense. And then, Oh, the, uh, those newsletters were also talking about onlays and stuff that I got away from, but

[00:08:07] the premise is still the same. If I keep the margin out of the patient's biology, yeah, it tissue is going to be better. Um, definitely. So, well, I mean, he would go so far as to have do, he'd get his, his periodontist, um, Danny Melker to, to, you know, like they, his favorite thing was, you know, although he always has exquisite cord backing, honestly, he's his, his retraction is always amazing, but, but his margins are always, they're not,

[00:08:34] you know, it's rare that you see him bury a margin like that. So, you know, I get it. It's a good point. What are you going to say? Okay. I'm going to, I'm going to challenge you on this. I want to know if you changed your mind on it or did the material changes with time, you know, because Emacs didn't come out until what? 2000. I never, and I never got, I never got into Emacs either. I never, okay. Or whatever. Either way that you practice the first eight to 10 years of your career

[00:09:04] with, with PFM and gold dentistry. Yeah. And then, and then it was another couple of years of porcelain fused to zirconia, which, which you prepped kind of the same way as a porcelain fused to metal. But so did you change your mind or did the materials allow you to, to do things in a different way that you hadn't before? Well, okay. So zirconia can be kept a bit like gold, right? It can. And, and I mean, you wouldn't bother dropping a margin super low for gold

[00:09:31] unless you had to, cause you know, it's not like you're trying to, it's not, it's not like you're trying to hide a metal margin. Gold is a whole different animal, but I mean, a PFM is my 10% I did a ton of gold in the first 10 years of my career. Sure. I did a lot of gold. So, uh, and it, you know, so yeah, I actually, that's a good point. Maybe the materials are such that, and, and I'm going to tell you that I, um, I mean, bonding crowns in sub gingival is a biggest mess ever. And I mind you, I don't do a lot of bonding at posterior crowns, but it's like, that's, so I

[00:10:01] don't know. That's a good point. A good question. Why is everyone? Because Kevin only bonds. Yeah. So, you know, that's, that's not easy. I'm sure he fights that. Yeah. No, but Kevin also knows that. Mind your mind, your cruvicular fluid. I love that. Sometimes it ain't easy. Yeah, no, that's right. That's right. All right, Kevin, you're up, you're up next. What's something that you have changed your mind on? Mine, my two are going to be very closely related, but. Okay. Then go do both

[00:10:30] of them. Go for it. Go back to back. I am going to say that what, well, first I'm going to say that what my mind changed on was that I was as a general dentist placing implants was not my realm or that whatever the fear was, I know exactly what the fear was back way back when, but changing my mind on that,

[00:10:58] and learning how to do that safely and predictably and all of those things. That's something it took 25 years to change my mind on. And, you know, now it's a big part of my practice. And part of what, when I'm at 3D Dentist and you have all these younger dentists there that are learning this for

[00:11:23] the first time, I'm jealous of them because I think it's a way for, to really transform your practice and give you some financial freedom. You know, there's a whole lot of things that happen when you move your practice in that direction. So I wish I would have done that way sooner, way sooner.

[00:11:49] Would you go, would you go so far as to say, you know, specialty procedures, for instance, Yes. I've been thinking about this all night and I was going to say just specialty procedures in general, but that one specifically is moves the needle more than everything else. In my opinion. Alan, what's, what's, you've, you've dabbled with implants, but it didn't stick. What's,

[00:12:16] what's your like, I didn't get a CT. Uh, that's, that's probably the main thing. Okay. So that's, let me, let me just say the second part now I should have got the cone beam, um, five years before I did, there was way too much, um, worrying about the cost. There was the cone beam and the implants and the transformation of my practice from 2016 on those,

[00:12:44] all those things are related. And I've told this story before, but I'll say it again. At one point, uh, T-Bone texted me and said, when are you going to buy the effing cone beam already? Just out of the blue, I was sitting on the couch watching TV and that's the text I got. Um, that sounds like to ruin to me also. No context at all. No context. No context. That was it.

[00:13:09] Um, so, uh, getting the cone beam, you know, Zach, you real, you, you have this experience where I, yes, I'm, I'm loving it. Things. It just changes everything in terms of your diagnosis. One of the things I like to say in the, uh, in the, uh, endo class or the implant class is if, uh, Missy tells me

[00:13:33] to go to the refrigerator and get ketchup, I will open the refrigerator door and it's a 2d plane to my male brain. Like I'll look in there, there, there's no ketchup. And then I'll say, Oh, there's no ketchup. And then she'll walk over, open the door and move stuff around in three dimensions. And it's right here behind the milk. And dummy. Yeah. Right. So that, that is what the cone beam is to me. It's

[00:14:01] enabling me to see everything and why I dragged my feet and why I was hung up on the cost and all. I, I know that those are valid concerns, but in reality they weren't. A technology like that, that you will use. I'll go. So, I mean, I know CT is a perfect example of it, but a technology like that, that changes the way you do things. I mean, I will go so far as I'll say the inter-oral scanner too. I mean, honestly, technology like that, that first off, yeah, they're more expensive.

[00:14:29] Don't steal my topic. I'm not stealing my topic. Don't steal it. I'm just, okay. But, but it's, it, the payoff is, is worth it. And honestly, they don't, it always seems like, it always seems like it costs a lot. Like the cost is what sits, Oh my God. But, but I mean, you don't generally drop, you know, and they'll finance it and you're writing it all off and it's, it's a business expense that's, and you never even look back once you got it in there. You know, we talked about this

[00:14:55] over the past couple of days. I was in the shower. I'm like, it was just a payment. I got the return every month on one implant or one sleep case or whatever. All right. We're stealing Zach's. Oh, Zach. What's yours? I, we know what you're going to say. You know what? I'm, I'm no, Kevin, do your second one. No, they're both. That was it. Okay. All right. Okay. You guys went, uh, well, Kevin, you went a little bigger. I was going to, I was

[00:15:22] going to break it down a little small. Actually, I'm going to save what I was going to say. I'm going to save that for the second one here. Let me, I'll tell you this. Here's something I've changed my mind on. Uh, and I should have changed my mind on this within the first five years of practicing, but it took closer to 15 to get it right. I was taught the way I was taught in school. And then, and then my dad kind of reinforced that, that training was that crazy dental already has the lowest prices on dental supplies anywhere, but when you use the coupon very ship, you'll get free

[00:15:52] shipping on every single order. It's the easiest way to keep your overhead low while supporting the very dental podcast network, head over to crazy dental prices.com and use the code very ship at checkout. That's crazy dental prices.com using coupon code very ship. When you're taking out teeth, you know, you, you, you fight with all your elevators and forceps and all that. And the hand

[00:16:16] piece is the last option. That's like, Oh man, you're going to have to break out that hand piece. That's that's, I can't believe it had to come to this and you know, and I credit Kevin for a lot of this, but I've all, I also took some, some classes associated with associated with it. But now that's coming out, uh, much more often and much sooner in the process. And unless it's a perio situation or

[00:16:45] a single rooted tooth, um, it's at least going to be sitting out as, as, as something that's set up. It's not going to have to be like a, Oh great. Get me the hand piece out. It's going to be like, I'm there's a decent chance I might use this. And maybe I won't if, you know, I'm not quite as quick as Kevin to immediately section. I will at least give a, I'll give a cow horn a try or a few wiggles a try just to see if I don't have to use it. Cause I'd rather not, but I'm very quick to,

[00:17:12] I worry very quick to cut in section. And the result has been more predictable extractions, me willing, willing to take on more extractions and less trauma to the page. And I'm not even an implant placer. I know you guys are trying to preserve the buckle plates for, uh, your, your implants. Okay. But let's say you're not just, just for, just so I don't have to crank on the person as much, you know, they heal better. If you don't freaking heal better, like I am to the

[00:17:40] point where if it's a molar tooth and unless the, unless it's a lower molar with like super fused sometimes upper moles, really fused roots where, where the, the handpiece isn't probably going to get you a huge advantage. I'm sectioning and I'm not, I'm sectioning like Kevin's I'm sectioning till I can barely see the burr. And then honestly, what I really do, particularly on lower molars, I take a bite wing before I ever put an instrument on the tooth anymore. Cause I want to be sectioning what's dead on the money before I even put an instrument on it. Let me throw this out. If I can

[00:18:09] see it in three dimensions and know exactly where the roots are and go down through my axial view and like on an upper molar, when you know that the roots aren't fused that, or sometimes there's only a buckle and palatal root, like the two buckle roots are fused. That's going to change where I'm going to section. So all of that. Uh, so I agree with you, Zach, um, when you said taking out the

[00:18:36] handpiece, I was like, Oh my God, that, um, that's how I felt like, Oh my God, we've, we've failed. And now it's the first thing I pick up. Like we're just going and I feel like my whole approach is like, I'm dissecting the tooth and bone in a different way than I was ever taught. Atraumatic extraction start with a handpiece. Correct. Yes, they do. Absolutely do. And that's,

[00:19:02] that's the quote of the night boy in dental school. Like they wouldn't even give you the handpiece unless you're in serious trouble. They had to get a handpiece out. Yeah, no, they didn't. They didn't do that for one. And, um, like I said, then, uh, that I was doubled down on that and, and we didn't even have a, we didn't even have a regular handpiece or the right kind of handpiece to do it with. It was a whole thing. Yeah. I mean, even on a case when I'm not going to section like a primo or something

[00:19:29] like that, I still sometimes will take out a handpiece and just do that slice thing in between the teeth, just so that I have room. Yeah. Oh yeah. I'll use a regular or take off the crown or something like that. I just break the interproximal contacts if it's a pre-molar. Break the interproximal and I break them down as yeah, way down in there and give yourself a nice fat spot to put an instrument in there. I call that the final IPR. Yeah. That's it. That IPR doesn't have to be nearly as precise as some of the other ones. You can use whatever fucking burr you got in your hand. Yeah.

[00:19:59] So, so I would say I've, I've changed my mind on, and I, and I don't know how it's being taught in dental school these days, but, uh, God, you should be, you should one, have one of those surgical hand pieces that has the, doesn't have the air shooting onto the tooth. And then two, like have the right burrs and, and three, if you do that. And like I said, if that's being taught in dental schools now, and that's old hat, cool. But that wasn't how it was taught to me, uh, or any of the people I went to

[00:20:28] uh, it's just something I just didn't, didn't know enough about. And it held me back on extractions for well over a decade of my practicing life. For sure. Same here. Alan, what's your second thing you've changed your mind on? God, I've got, I've got a couple of them in there. They're hard, but, um, I think you guys will probably agree with me. Um, you need to go to an indirect restoration more sooner than I used to. Like it's one of those things. And I, I still, I still struggle with that.

[00:20:55] I still struggle with that a lot, honestly. But, but the reality is, is like, what are the best fitting indirects you do, whether it's a crown or on there? They're the ones where you're not making a, like a hail Mary save, you know, in your, uh, I need to do that sooner than you think. And that's not to say that every tooth that walks in your door is a crown, but I'm just saying that like, you know what, if you've done, if there's been a decent size composite filling in there in your replacing that, you probably ought to go right to an indirect at that point. You know,

[00:21:25] there's not every time, but in a lot of cases, and I struggle with that still, but you know, the ones that I feel the best about, and I, the ones that I would, I would take a picture of and show the preparation to you are the ones where, where I'm not like, I'm not sure if I can make this work at all because it's so bad. Like, so I feel like I need to go to indirects sooner than I used to like, like, like the crown was, was at one point was kind of the last ditch effort, you know,

[00:21:53] like the last ditch restoration. Like, well, if you're doing that, you're making all you're ever doing is making saves, you know, and you're just like, that's, it's not fun. And, and your results are not as good and all that stuff. So I feel like I've learned that I need to go to an indirect restoration sooner than I used to. I love that. I, yeah, I think Kevin would second that. And I would say I've, I would say I've come to, and I love your, I love your, you're wrong, but I think

[00:22:21] let me bare my soul that back in the dental town days, you had guys like Kanka and some of these other people that like, and nothing against them, but like, they made you feel bad about, they made you feel bad about crowning it too. Yeah. Yes. And, and so I guess my response to that is like, I've, I've said this analogy before I can play guitar, but I'm not Eric Clapton, you know? So if you're

[00:22:47] Eric Clapton of placing posterior composites, God bless you. But, um, I think overall, I will side with our Lord and savior Bill Strupp on this. They're crappy. Like even the best ones I've done some of them lasted a long time or some I see come in from other offices. They look like crap over time. And if I can't contour it properly or my Afta can't contour it properly. Uh, and certainly if it has

[00:23:16] an MO in it and there's decay on the distal, it's getting the crown. I'm not replacing a filling with a filling. This is not happening. So I think that's, I think that's, I think it's a smart move. It's some days it's a harder pill for me to swallow than others, but I think it's probably the right move. Yeah. I've done way too many, you know, mega, mega, mega fillings where I didn't even give the person the opportunity. It was more just the, wow, I feel bad about recommending a crown. I'm

[00:23:42] done. I've really done a better job. As recently as today. You just jogged my memory for episode two. Thank you. Oh, okay. All right. Thank you. Very good. Very good. Um, okay. All right. I guess I'll go with my, my second one here. I was between two, but I'm going to go with it. Of course it's, I think it's well documented on this podcast that I was, uh, you know, very analog and almost to the,

[00:24:07] almost kind of anti-digital in a way because it had been burned in me for so many years that like, ah, that stuff doesn't, you know, like, like Sarah generation one stuff, we'd see it come in. It looked bad. You know, you're like, ah, digital, digital's not, not ready for prime time. And I think it took, it took, uh, me seeing everything that Kevin posts and everything he talks about talking to you, Alan, and seeing enough people having success with it to be like, well, if they can

[00:24:35] be successful with it, why not me? But it took you, Alan, let me try out one of your, you know, scanners you'd retired. And I was like, oh, oh wow. You know, and you don't know what you don't know. And it's, it's absolutely changed the way I practice and makes me look more modern. And my assistants think it's cool. It's like, it's, it's just a win in so many ways. And there's so much more I can do with it that I haven't been unlocked yet. So yeah. Oh yeah. It's, you know,

[00:25:04] I'm only on, I'm only on step one. I am too. And I will say that I still, I don't know if you guys feel this way, but I still went just in using it and I go in and I mark the margins and, and like, I think to myself, this is amazing technology. It's not so much of works at all, but, but like, like the analog, I mean, when you think about it, there's a lot less that can go wrong in a digital

[00:25:29] format than analog. When you go from an impression to a, to a model, to wax, to, you know, metal or, or model in a scan and all like, there's a lot of things. And I always wondered in dental school, how does anything ever work at all? But with digital, man, you know, it's electrons, baby. This is the third time I've brought them up. Our Lord and Savior, Bill Stroup, totally against digital, although I think they may have implemented a little bit now, but it's zeros

[00:25:59] and ones. It's digital data. It cannot distort. Yeah. All the things that you said, Alan, the wax, the stone, the impression material, it can't distort. And these scanners just are, are better and better. I'm using, like, I scanned a denture case today. That's how we do everything now. It is the hub that our whole office revolves around. That said, that said, you can do really crappy

[00:26:28] dentistry analog. You can do really amazing dentistry analog. You can do really crappy dentistry digitally and, and, and it's just a, it's just a tool. It is a tool. And, and I mean, like I've, there are some days I wouldn't want you to see my scans and there's some days I'm going to put them up on screen. Yeah. But that, but that's, but that's not, that's not it though. It's, it's, it's, I do, I think my margins fit a little bit better with the digital. I do. I really do. I do too.

[00:26:53] Um, do I all of a sudden look back at my analog work? I'm like, what was I doing for all those? No, it's not like that though. It's like my, my crowns fit. I took good impressions. I did. I stand by the work that I, that I did before I had the thing. What it unlocks is just a smoother patient experience. Um, all of a sudden stuff like instead of saving models for people, it's all, it's like, like, uh,

[00:27:20] I did a crown on 19 on someone. And then, uh, a few months later they broke 14. It was like, we already had that scan that was in the system. It was like, Hey, just clone this case. You've already got that scan. So now we just have to just scan the new crown we did. And then we'll prep this up top one. It's like that kind of like data that's stored for you in the cloud. If you keep patients longer term, they're going to get some benefits from that. Or, you know, if you've got that, that you've got that scan of them, they break a front tooth. You've got a copy of that. And if

[00:27:49] you, if you're cool, like Kevin and have a printer, boy, you really got a solution for a temporary or something for them real quick. I haven't gotten to that level, but the other thing is though, is that the workflow, the workflow is just, is just hot sex, you know, like, I mean, like it's typical 45 minutes from literally when they're seated to when they leave with a provisional. And it's, I mean, it's just because it's boom, boom, boom. And, and I mean, you could, we've got our workflow, particularly for single or two units down to a science. So, and I do,

[00:28:19] I never felt like I had the same workflow in the analog. On the, on the ones that you were talking about where you're proactive, the crowns that aren't, you know, a train wreck. Yep. That's the best appointment. You can scan that in literally seconds. Yep. Yes. Yes. On the ones that are a little bit of a train wreck, instead of taking an impression and waiting and then realizing you missed your margin, doing that over and over, you cut out a

[00:28:48] little, that little area and you scan it again. So it went from seconds to maybe a minute or two. And $20 in impression material. Yeah. When you think about it, even with a two and a half minute set, Yes. You missed that first impression. And by the time you get it all cleaned up, you've wasted at least, at least six or seven minutes. So now that you're on the other side of it. Second time, you know, huh? Now that you're on the other side of it and we made those arguments, whatever. Now you see that that is really, you know, that's true.

[00:29:17] Sure. Well, yeah. Like missing a margin or you fixing a margin, fixing a reduction thing. Oh, the other day, you know, I got done with my temporary. I was like, oh crap, there's a thin area. So, Hey, crop this out. We're going to just going to reduce it again real quick. Yep. Where's that option before with an impression? Is it now it's a, oh my God, I got to repack this. Oh my God. You know? So yes, it's a smoothness thing more so that if you tell me your analog,

[00:29:45] I don't think you're doing bad dentist. It's just that I think you can be doing it smoother. Yeah. And the work, the workflow is the workflow. It's definitely the best. All right. That's my thing. And I'm glad I did it. All right. Um, any, uh, any double downs, take backs, apologies. This was a good format. Yes. Okay. Super. Can't wait till the next episode. Thank you guys for listening. Um, it's going to be the three of us again next week talking,

[00:30:12] uh, what we would, what things we've changed our mind on in terms of like business staffing, that kind of stuff. Yep. Yeah. Thank you guys for listening. Check out the very clinical Facebook page if you want to hear more and we will see you next Tuesday.