Very Clinical: Amalgam in 2025 with Dr. Kevin Donlan

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[00:01:30] This is a production of the Very Dental Podcast Network. Welcome to the Very Clinical Podcast, brought to you by Zerk Dental Products. In about the time it takes to do an MO on three, we will entertain and enlighten you with tips and tricks for regular daily dentistry. Here's Kevin and Zach.

[00:01:55] What is up, Very Clinical listeners, and welcome back to another episode of the Very Clinical Podcast. I'm Zach Miners, coming to you from Kansas City, Moe. And with me, as always, I'm my trusty co-host, Dr. Kevin Hare-Fryer. Kevin, what's up? How are you doing, Zach? I'm good. 2022. How are things going? So far, you know, a little shaky, but, you know, probably that way for everyone. Are you meeting resolutions? Did you start smoking and drinking and doing illicit drugs?

[00:02:23] Yes, I'm up to about three packs a day. I'm already half a bottle into a bottle of Jack, and my meth dealer actually has COVID, so I'm a little behind on that. I hate it when that happens. Yeah. So, we got a guest this week, and things are going to get confusing, because it's going to be the dueling Kevins. I think we can handle it. You know, in undergrad, there were four Kevins on my dorm floor. Oh, wow. Yeah.

[00:02:52] What was the differentiating? What did they call you? I was Kevin F. Just Kevin F. That jerk, mostly. Welcome from South Dakota, Kevin Donlan. Dr. Kevin Donlan, how are you doing? I'm doing great, guys. Just trying to stay warm here. It's about negative two degrees and windy. Negative two. Yeah. Love it. Yikes. Kevin, give the listeners who may not have heard of you or seen any of your posts on Facebook, give us the rundown of who you are, where did you go to school, where do you practice, what do you do?

[00:03:23] I practice out of Madison, South Dakota, and I've practiced there since 2013. I went to school at Midwestern University out of Glendale, Arizona for my dental degree and been in private practice pretty much the whole time. And that's kind of what I've been doing. What is your practice like, Kevin? Are you by yourself? Do you have an associate? Like, what's your...

[00:03:46] By myself, with two hygienists, two assistants, just kind of that bread and butter small town dentist practice, I guess. Right on. Right on. Kevin, we got a... Do we have an exciting bit to discuss before we get into our clinical topic of the night? So we all had some time off around the holidays, and that's a good time to watch some movies, even if you could or could not go to the movie theater. So let's go around the horn.

[00:04:15] Kevin, you're our guest tonight. We'll go first. Did you watch any good movies over the Christmas break? Yeah, we went and saw Spider-Man in the theaters and saw that in our small town theater. And that was about it. Haven't seen Sing 2 yet, but probably just watched that online. And kind of, yeah, just doing that. Was your theater full for Spider-Man? Was it a packed house? It was pretty full, yeah. Yeah, and I guess we just started the Boba Fett series, too.

[00:04:45] Oh, yeah. I also just started watching that as well. All right, we'll keep with the Kevins. Kevin F., how about you? So you can see my list of movies and TV shows on my Facebook page. But over Christmas break, after long last being begged by my nephew, I finally watched the movie Pig, starring our Nicolas Cage, which is really a thriller.

[00:05:13] Sort of a love affair between a man and pig. And, you know, his quest to get his pig back. It's a truffle-snipping pig. And it's a very valuable commodity. It gets stolen from him, and he goes on a quest to get it back. And the best thing about... Is this a kid's movie? It is not a kid's... No, this is... Was this loosely based on something new or a true event? I don't think so, no. This wasn't? Okay. Maybe it's loosely.

[00:05:43] Is it a horror movie? I'm not sure where we're... It's a thriller. Okay. Mystery, revenge film. And the best thing about it is you probably won't guess the ending. Like, I thought we were going one way, and we completely did not. Which I love that. So, highly recommend it. Pig it is. Did you binge any series?

[00:06:06] Yeah, we went through all of John Wilson's How To on HBO, which is another really avant-garde TV show. And, yeah, that's another one I highly recommend. Okay. Lots of TV viewing over that period of time. I also saw Spider-Man in the theater. It was... I saw it on the opening day because it came out on a Thursday. I don't work on Thursday.

[00:06:36] So, I saw it at the first showing, and it was great. That was a... It was kind of a love letter to the character, especially the cinematic character. If you've watched all the other Spider-Man movies, it was definitely a lot of homages to all the other Spider-Mans, which is... Which was... It was really cool. It was a fun movie. It was a very fun movie. And we just completed season four of Cobra Kai on Netflix. I'm into the Karate Kid extended series.

[00:07:04] It's getting more absurd as the seasons go along. Really? Yes. It's like... It's... I... Like, there's multiple seasons where it's like, oh my god, I can't believe... I can't believe they just did that in the weirdest way. But, hey, it's a lot of fan service, but I love that franchise. So, I'm all in until they stop making them. So, those were my... Those were my binges and TV and movies. That's great. With a break. I don't think any of those are going to make your list. And I don't think you're ever going to see any of those, Kevin. Probably not.

[00:07:33] No. That's all right. There's something for everyone out there. There is something for everyone. Indeed. Yeah. All right. So, we've got a topic tonight, Kevin, that is... I'm not sure if this topic is super relevant in 2022 or is it? Or is it? That's where we're going to find out. We're going to find out. We're going to talk about a material tonight, Kevin. I'm going to describe this material to you and see if it would appeal to you.

[00:07:59] This is a bulk fill filling material that is extremely low cost, that has an extremely high compressive strength. It's really easy to get in contact with. It rarely has any sensitivity. It has some antibacterial features to it. And it's pretty carries resistant. What do you think? I think it's awesome. It's probably right up your alley, Zach. Yeah. Especially the cost. Yeah. Yeah.

[00:08:28] No, it's good stuff. And we're talking about amalgam. Amalgam. In 2022. That's how we bust out 2022. Talking about amalgam. We're talking about amalgam. Let's do it. Does amalgam... We're going to talk. Does amalgam still have a place in dentistry in any scenario? In more scenarios? Should we be using it more? Is it underused? We'll find out. Kevin Donlan, do you use amalgam in your office? I do. Yes. Yeah.

[00:08:56] Tell us the... Tell us what factors into your decision tree to use it. When do you use it? Run us through some scenarios. You know, I think the first one is isolation. I mean, at the end of the day, isolation or isolation access. You know, the buckle on 15.

[00:09:20] You know, maybe an MO on 32 that for some reason that patient's still keeping or they're 78 years old and you're not going to refer that out to get removed. Something like that. So, maybe it's just getting that or getting the contact that's perfect, that works. Closing the access on a gold crown after a root canal. Yep. I mean, there's really nothing better on that.

[00:09:49] Just closing that access up and you know it's sealed. So, you know, I'm not buying the 500 count jug by any means. But, you know, it's just... I don't think you need to throw that tool out yet. Just for that. Do you do any pedo in your practice, Kevin, at all? Yeah. Not really? Do you use it on pedo? Some, but honestly, when in doubt, it's getting crowned. Okay. I mean, honestly. The chrome steel crowns. Yep. Yep.

[00:10:19] Or stainless steel crowns. Yeah. Okay. So, you're using it more in the kind of the almost what I call like the Hail Mary kind of areas, like the buckle 50. Okay. Are you... Do you even offer it to people for like your garden variety MO on number 19 that you could easily do in composite? Or do you not even... Do you just do the composite? No, I'm doing composite there. Okay. And that's doing composite.

[00:10:48] And honestly, I'm doing on 19 MO because of you. It costs me more money. I'm using a lot of bulkies on those. Yeah. And that's on any patient, whether fee for service, Medicaid. Insurance, you know. And that comes down to... It's everyone the same. Yeah. And it comes down to the KISS principle. I just got to keep it easy throughout the day. Yep. You know, just keep everything the same. Keep everything, you know, predictable for everyone. Less materials. Yeah.

[00:11:18] And just easier for the team. I mean, it's less quicker setup. Kevin, do you still have... Do you have true traders in your practice? Kevin F., do you have true traders? Yes, I do. What I'm curious about is what... Because I'm the old man in the group here, what was your guys' amalgam education in school? Kevin, what year did you graduate? 2012. Okay. So mine was... More than all of us.

[00:11:47] So mine was very light on that. And that probably had to do with my dean who held the patent for sealers, for sealants. Oh. He was the patent holder for that process. And so subsequently, that plus composites were very strongly taught. It was 2012.

[00:12:14] I mean, 2008, 2012, I mean, it's the height of cosmetic, height of composites. Mm-hmm. You know? So the original dean, you know, taught was, you know, was that. So I was a push, you know, pushed harder that way. So you were doing your, like, even class twos? You were doing class twos in resin? Yeah. Oh, yeah. Wow. Yep. Resin. Okay. With garrisons. Yeah. I mean, sectional matrix.

[00:12:43] A lot of our structures were all private practice that came into the dental school. We didn't have, we were a brand new dental school, so we didn't have that tribal, institutional, you know, buildup of group think, I guess. Okay. Huh. So they were, so, and that's good and bad. So the other problem is you get 15 private practice guys who want what they wanted because that's what they used in practice.

[00:13:12] Hey, it's Kate, the dental assistant, and it's time to get very clinical, and this episode's very clinical corner. Are you ready, Dr. Mead? Let's get to it. Forehanded dentistry, in my opinion, is one of the best advancements that we've had in dentistry. Efficiency alone is a reason to have extra hands. I agree. When you have an extra set of hands to use, it's a good thing, especially if you're short-staffed.

[00:13:33] Yeah, the dental industry is in a really fragile state when it comes to staffing right now, with some states actually reporting a 2 to 100 candidate to open position ratio. How are we supposed to do our jobs without hygienists or assistants? I can work solo, but it takes a lot longer. Yeah, and it decreases your revenue, right? Even as dental assistants and dental hygienists, we can use the extra hands during some procedures to become more efficient. I can list several procedures that I need for hands or more for proficiency.

[00:14:01] Isolation devices really help replace the lack of hands during procedures, and every provider can actually benefit from using them. Even hygiene? Especially hygiene. So how many times has your assistant been stolen by your hygienist to suction during scaling or sealants or something like that? I appreciate that they're helping out, but I'm always stuck waiting for the assistant to return for our procedure. Yeah, and we hate leaving you waiting. Trust me, it never feels good for us.

[00:14:26] But listeners, if you're looking to up your isolation game and create additional opportunities to provide care, check out the show notes to learn about how our isolation devices can help. All right. Kevin, I assume that your education was composites only for anterior teeth. Right. And I did some occlusals in a composite, but if it was a class 2, that had to be...

[00:14:55] My first occlusal... My first MO or DO composite was after I graduated. Yeah. So... So all of my posterior direct restorations in school were amalgam. Yep. And I didn't place any direct composite in the posterior until a few years out in private practice. I remember the first class 2 I did on an office manager at an office I was with...

[00:15:24] I was so proud of myself because it looked like a tooth, except it had a wide open contact. And she didn't care and I didn't know how to correct it back then anyway. But I think that some of this comes down to... I've been thinking a lot about this today because I knew we were going to talk about it. There's some confirmation bias and politics and propaganda and all sorts of things that all sort of go together.

[00:15:51] You know, I think that we all see amalgams in our practice that have been in patients' teeth for 30, 40 years. That's not uncommon to see. I don't know that my composites are going to last that long. There's a part of me that... You know, I had one mentor tell me way, way long ago, you know, a year or two into practice.

[00:16:19] You know, if you're going to restore a car, you're going to buy parts that are, you know, to that car's ear. And you're going to paint it to the original paint and all that stuff. So if you're going to restore a tooth, why are you putting a hunk of silver into something that's essentially, you know, white? And that's stuck with me.

[00:16:42] But I don't think that amalgam should have been as demonized as it is. On the other hand, I don't know how your patients are, but I still get it every week, maybe every day. Are these fillings going to be, you know, white? That's what usually patients say. And, you know, that's what the patient wants. So that's what they get.

[00:17:05] But, yes, I have certainly been asked that question, even though, you know, 9.7 out of 10 of my fillings I do are resin and glass ionomer. I still get that question from time to time, especially when I'm working on kids also, you know. So I've gotten that before. I also had the same experience as you, like, as soon as I did my first MO, it was like, oh, wow, that came out really nice.

[00:17:35] And same thing, no contact. Because I didn't have it. I did the filling, but it was using a Toffelmeyer. Yeah, I didn't know any better. Narvage. No. Right. It was total. The fact that you, Kevin D, the fact that you use sectional matrices in school is amazing. That's big time. I don't even know if they had sexual matrices in 2001. Or maybe they had the first iterations of them. We didn't have them in school.

[00:18:02] So, Kevin F., when did you kind of transition from dipping your toe in to most of your fillings being composite from Amalgam? So it was probably in the late 90s, near 2000, really influenced probably by Dental Town and some newsletters that I was getting. You know, people were advertising themselves as Bond Adonis, which I didn't even know what that meant.

[00:18:29] But I remember reading one thing, like, you know, that being told that amalgams leak and all this sort of stuff. And just this concept of etching the enamel, applying a bond, and then putting the composite in the bonding agent and then the composite. And that being like sealing the tooth as tight as a drum and like really believing that.

[00:18:54] And some of the things that you'd read from John Kanka and those sorts of things. But we all know that over time, that's not really what's going to happen. Those things are going to degrade. So, but there was definitely a transition where I put away the amalgam and only brought it out for the things that, you know, Kevin mentioned. Wait, so say, when do you use it now? Do you use it in the exact scenarios that Kevin did just mentioned? Yeah, same scenario. I can't keep it dry.

[00:19:25] That's usually, you know, the overriding factor. I can't keep it dry. I'm going to place an amalgam and I'm not going to think twice about it. Kevin D., do you have any, do you use glass ionomer at all? Is that in your practice? I use it some, probably not enough. And it's more of a, it's just getting it in the workflow, I guess.

[00:19:54] And figuring out the best material, you know, you know, it's, it's a change of gears midstream that you're like, oh, I could use it here. Yeah. Going that way. But, you know, it's just kind of just figuring out. I do have it, but I just, I probably don't use it enough, especially on the class five, posterior class fives. You know, that's a real good spot, you know.

[00:20:18] But if I can usually get cord placed, you know, tracks, something in there, some human agent, you know, allyserges, peroxide to meet the area. You know, if I'm really, really struggling at times. And Kevin, Kevin F., you know, I know you, you don't have, you haven't added any glass ionomer into your, your mix, have you? No.

[00:20:42] So that's the one thing I would say that took my amalgam percentage down, like another notch was when I started really using a bunch of Equia. Then all of a sudden the like buckle of 15 that you're talking about or like the inclusal on the, the 12 year molar where there's still gum covering them, you know, and you can't get a clamp on it because it's barely erupted.

[00:21:05] Like Equia has kind of taken over for amalgam for better for, I've had good success with it so far, but certainly don't, I don't have those 30 year ones in there. And it probably won't last that long to be honest with you, but that's kind of been my, that's, that's cut my amalgam down considerably more. How about if you guys are patching a crown, like a PFM or a gold crown, like buckle margins got decay. You're not going to remove the crown. Are you using amalgam on those spots, Kevin D.? Yeah. Yeah, definitely.

[00:21:32] And that's, I'm probably trying to do that less, you know, it's kind of all those things you think you're, you're doing a service to the patient. In reality, there's decay mesial distal on that crown and you should have just taken it off, redone it then when it's more predictable. Because if one spot's failing, most likely somewhere else is failing, you know, you know, do it before it's hogged out with decay.

[00:21:59] And then you're like, wow, can I even save this a year down the road? Absolutely. I do think there's that subset of geriatric patients or there's another patient in my practice who's in recovery, alcoholic, that it just, I just started replacing everything with amalgam on him. Because everything I put in that guy's mouth fails except for the amalgam.

[00:22:24] And he's got a lot of, you know, just a lot of decay that, you know, it's hard, hard to control. And I've replaced a lot of my composites with amalgam on him. So there, I think there is some patient specific uses for it that, you know, there's a lot of people that I think are proud to say, I don't have amalgam in the office at all. And, you know, that's, I don't think that's.

[00:22:50] Yeah, I don't think, I don't think having, you know, if the patient's okay, 75 years old and M115, maybe it should be amalgam. Yeah. You know, you know. I probably don't, I don't think I do enough, you know, amalgam. I probably am not honestly like, you know, considering what is probably the best material in an area a lot of the time. And some of that's from just laziness of not wanting to have the conversation about it.

[00:23:15] Some of it's like, oh God, I'm so, I'm so into my workflow on resin or glass ionomer that like stepping back to amalgam requires a little more mental energy on my part. I don't know if that's factors into it for you guys. It is funny in my practice because the triturator is in the sterilization room, like in a drawer somewhere or a cabinet somewhere. And it's like you're bringing out a rotary phone or a typewriter. People are like, you know, the employees are like, what's that?

[00:23:43] You know, it's a nostalgic piece of dental equipment. Kevin D., do you think that your amalgams will outlast your composites? Or do you think that they'll be about equal? Or what is your like gut feeling on those? I say on a conservative amalgam, maybe a primary lesion, you know, a real class or classic black. Yeah. I think they will probably go the test of time.

[00:24:13] They'll probably go longer. But it's also patient specific, you know, good patient, good hygiene. You know, it's probably a horse piece. But, you know, I mean, that 75 year old patient, you know, they can be very active. But in 10 years, things can change. Right. I mean, you know, a stroke, a fall, admittance into the nursing home. We've seen those patients. Yep.

[00:24:38] We've seen the ones that, you know, five years ago, they were really just getting along great. Five years advanced, dementia, going to the nursing home. And all your good dentistry is literally just going south very quickly. Oh, yeah. Big time. I want to circle back to something Kevin said right at the beginning, isolation. Like, I removed a composite today that as soon as I touched it with the burr, the whole thing just exploded out. Boom, it was gone. Yeah.

[00:25:06] So, you know, there was nothing really holding that in. That sort of thing rarely happens with amalgam. Whether you, you know, I'm going to assume that most of the ones I replace or remove or I crown weren't put on with a rubber dam. Um, it's just, uh, you know, that, that, uh, ease of placement and not really having to pay attention to every little complete detail.

[00:25:34] It's, it's not a bad material for that at all. And I, I, I have a new employee now, a new dental assistant. She's been with us three months and, you know, she was, um, a little new to the rubber dam. And I'm like, well, what did your previous dentist do? How did you keep this dry? And pretty much the answer was that they didn't. And I think we see a lot of that in our practices. Um, sure.

[00:25:58] And, you know, if it's difficult to isolate just for a regular old MO on number 19, I just can't imagine what people are doing for the, you know, some of these other situations. Do you think the, uh, the, the numbers of people that say, well, I don't even have amalgam in my office. Do you think that's completely a patient driven thing? Like people saying that we don't want those anymore. Or do you think some of it is dentists assuming that people don't want them?

[00:26:26] Cause I don't think people are as resistant to amalgam as maybe we think they are, but I'd also live in the Midwest. So I don't know. I think it's, I think it's, it's dentist thinking. Drinking versus patient demanding. Um, because I look at, okay, you're a orthopedic surgeon. You don't tell them what implant, what part he's buying. You just say, my knee's not working. Fix it. Yeah.

[00:26:51] You don't care if it's a striker, Johnson and Johnson, you know, they just, you wake up and you get a big old scar on your knee. And in four to five months, you feel a lot better. Uh, it's just, you know, same way with your general surgeon. You know, you don't tell him how he's going to take your gallbladder out, things like that. Just, you know, take care of the problem. And I think some days you've got to kind of be like, for your situation, the best one is this.

[00:27:21] And this is why I can do a light one, but it's going to fail in six months. And you're going to need a root canal crown or loose a tooth because this feeling is going to fail. Yep. I think if you look the patient in the eye, I can't keep this dry. This is the best way to fix this tooth. Um, this is how we're going to do it. You know, a lot of, we've talked about this before, Zach, a lot of it is just the way you say stuff to people and the confidence you have in your voice. And I agree with Kevin a hundred percent on that. Yeah. It's the same.

[00:27:49] People say, oh, well, my patients won't accept rubber dam. It's like, oh yeah, somehow shockingly enough, like a lot of mine do and all of mine, you know, yeah. Every endodontist does too. Yeah. Every endodontist does. They're not going to do it. Yeah. Right. Um, you know, and this, it's the same for amalgam. Like, um, I think that there are some people who are going to say no to it regardless.

[00:28:12] And in that case, that's why that glass item are so damn nice to have around because that's, it doesn't, that just doesn't have the moisture requirements that, uh, the composite has. But, uh, I do think that the majority of the people, if you, especially on a second molar, if you say, hey, this is, it's, this is going to work and the white one's not going to work. I think they would probably just say, do what's going to work. You know, at least I'd like to think it's that way. Yeah. Well, they don't want to come back twice. Right. Yeah.

[00:28:40] They want to, they want to be done and never touch it again. And that's one of the qualifiers. Like, like Kevin said, you know, if, if I do this with a white filling, we're probably going to need to redo it in a few months. And it's probably going to be worse. If you use those words and you know that that's true, the patient picks up on that. They're just going to follow your lead and you don't want to do it again either. So no, no, you don't want to do it for free. That sucks. You know? So yeah. All right. Any other amalgam points I missed out on us?

[00:29:09] We're moving towards wrapping, wrapping this up for the week. I wonder what CE would be like if there was no composite and we had to go to amalgam CE, like, you know. It'd be like those University of Michigan videos you find on. Yes. Yes. You've seen that channel too. Yeah. The nine step amalgam polishing. Right. Would be, would be the, would be the headline lecture. Yeah. Break up the fine cuddle and the tin flower.

[00:29:38] Or, you know, the, the correct, uh, pounds per square inch of compression or whatever. I don't know. Um, it's just, uh, it's funny. Can you imagine how many fewer threads on like dentaltown there would be though? On like, on like my composites, uh, or my composites are getting sensitive. What, what should I do? Where, what step in the bonding process or which generation of bonding agent should I use? Or on all those topics.

[00:30:04] The thread would be on that would be, do I use my thumb or do I use my index finger before I go out golfing on Wednesday? Yeah. You know, I was delayed by 10 minutes to make my tea time on Wednesday because of those two amalgams I had to do. And how many bottles of Copalite are digitally? Oh, you know what? That's, that's what we should hit before. If you, if you were going to do an amalgam or when you do an amalgam, Kevin, do you put anything underneath?

[00:30:33] Gluma, anything, or do you just drill and shove it in? I would, I still did use Copalite. So I still have it in the office. You're the guy. Okay. The previous Dennis still had it, used it. Yeah. And his work is, his work is still going strong. Like, okay, don't change it. All right. You know. And maybe it's the smell. It's the, it's the smell. It's the varnish. The smell of nostalgia. Yeah. Yeah. So you would, you would Copalite under an amalgam if you were placing one tomorrow.

[00:31:02] Okay, Kevin, how about you? If you were doing an MO on 15, would you put anything under it or just pack it in? I'm happy to say I just shove it in. Shove it in. Mm-hmm. All right. I would probably put the, the Gordon Christensen two coats of Gluma, except for instead of Gluma, I'd use the Vivid Prime. But I'd probably put that underneath there just for cleansing and desensitizing and all that good stuff. Yeah. But that's, that's about it. Otherwise I'd just also just pack it in.

[00:31:32] So, all right. Well, uh, there it is. Amalgam in 2022. Still alive. Still kicking. Still working. Still a tool that most dentists should still have around. Do you guys agree? I agree. I hope we get some great, uh, uh, comments on this, uh, podcast. I hope someone posts one of those carving videos where they carve in the like tertiary anatomy into the amalgam or the, or like one of those amalgam crowns. Yeah.

[00:31:57] Well, I could do as well as Dino out of, uh, his work is, yeah, I would take him. He could teach him about in CE. That's an artist. That is an artist. That's the next level. All right. Well, we are going to have, uh, Kevin D back next week for a different topic. And so, uh, uh, thank you guys for listening. We'll catch you next Tuesday for, uh, Kevin Donlan for Kevin Fryer. This is Zach Miners. And...

[00:32:27] See ya!