Very Clinical: Caries Removal Concepts and Controversies!

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[00:01:06] [SPEAKER_01]: This is a production of the Very Dental Podcast Network.

[00:01:09] [SPEAKER_01]: Very clinical people, welcome to another throwback episode of the Very Clinical Podcast.

[00:01:16] [SPEAKER_01]: Now, the fellas are starting their fall recording sessions, I think tonight actually,

[00:01:22] [SPEAKER_01]: the day this goes out. So they're going to have some new content for you. I have quite a

[00:01:26] [SPEAKER_01]: new content coming out too. So our sort of sabbatical is a little bit, we're back at

[00:01:32] [SPEAKER_01]: content creation so you'll enjoy that. But I have to tell you that I was looking back through

[00:01:37] [SPEAKER_01]: some of the old episodes and we recorded an episode, Zach and Kevin and myself on

[00:01:45] [SPEAKER_01]: Carrie's removal. And first off it was funny. It was a clever, it was really a funny thing,

[00:01:51] [SPEAKER_01]: but also I think very substantive. I also think that every dentist needs to think and consider

[00:01:58] [SPEAKER_01]: Carrie's removal in a thoughtful way, kind of on the regular because it's something that we do

[00:02:03] [SPEAKER_01]: all the time and I don't know if we give it all that much thought. So we've actually replayed

[00:02:08] [SPEAKER_01]: this episode before. I think this might be the third time we broadcast this episode,

[00:02:11] [SPEAKER_01]: but I think it's totally worth, I listened to it again and it's all freaking brand new.

[00:02:15] [SPEAKER_01]: I don't even remember recording it. It's a really good episode on Carrie's removal, concepts and

[00:02:22] [SPEAKER_01]: controversies and all that stuff. So I think you guys are really going to enjoy it and then

[00:02:26] [SPEAKER_01]: get ready for a whole bunch of new content coming up next week. Thank you guys for listening

[00:02:30] [SPEAKER_00]: and we'll catch you next episode. Welcome to clinical hacks where real working dentists

[00:02:42] [SPEAKER_00]: talk real dentistry. Sit back, relax, tighten your toffle mire and prepare to be clinically

[00:02:48] [SPEAKER_02]: hacked. Booyakasha clinical hacks listeners and welcome back to another episode of the clinical

[00:02:55] [SPEAKER_02]: hacks. This is Zach Miners coming to you from Kansas City, Missouri and with me I have my

[00:03:03] [SPEAKER_02]: trusty co-host Kevin Hairfriar. What is up my man? Yo yo yo yo. Check it. Hey I brought

[00:03:11] [SPEAKER_02]: the same guest we had last week. People seem to like the guy. I guess he's got this other

[00:03:17] [SPEAKER_02]: fairly popular podcast called the dental hacks podcast. Have you ever listened to that show

[00:03:22] [SPEAKER_02]: before? I don't listen to that crap. Yeah well I guess a lot of people do for what it's worth.

[00:03:28] [SPEAKER_02]: Welcome welcome back to the show Dr. Alan Mead. Hey thanks for having me. Okay so I just

[00:03:37] [SPEAKER_01]: googled this as you said this. I'm sort of can't stop laughing. Did you guys ever see

[00:03:43] [SPEAKER_01]: the YouTube video of the poor bastard trying to do a sports casting the boom goes to the dynamite?

[00:03:52] [SPEAKER_01]: Yes yes. That's literally the best thing I've ever seen in my life and when you said

[00:03:57] [SPEAKER_01]: booyakasha I'm like oh god now I'm not gonna be able to. And I found it easily. We'll

[00:04:02] [SPEAKER_01]: probably have to put it up in the show notes. It's like the funniest thing ever.

[00:04:05] [SPEAKER_02]: The poor son of a gun just dying for minutes at a time. It's so good. He did die on that video.

[00:04:12] [SPEAKER_02]: Boom goes to the dynamite is really something. Oh man it is hard to watch. It is hard to watch.

[00:04:17] [SPEAKER_01]: Jude so far out of his element and trying so hard. He's like a college sportscaster and

[00:04:23] [SPEAKER_01]: he's trying so hard to be like his ESPN heroes and he's just terrible. He's horrible. It's

[00:04:28] [SPEAKER_02]: the funniest thing you'll ever see. Did like Tosh.0 ever do like redemption on him to like

[00:04:34] [SPEAKER_03]: another shot? I don't know. So good. I hope that guy is actually a sportscaster somewhere.

[00:04:42] [SPEAKER_02]: I kind of think it wasn't going to happen for him. I don't know though. People can get better.

[00:04:47] [SPEAKER_01]: It's funny too because like you know that a guy like that watches a ton of ESPN

[00:04:51] [SPEAKER_01]: and on some level in there in the back of their mind like I could do that.

[00:04:55] [SPEAKER_01]: I could do that and then you try it you freaking can't. It's not as easy as it looks.

[00:05:01] [SPEAKER_01]: It's much like podcasting. I just make this look that easy. I'm just saying.

[00:05:06] [SPEAKER_01]: But they don't always respect the bite. No no no he was on the bite was disrespected.

[00:05:13] [SPEAKER_03]: Let's change our bit here since Alan. Sorry I was sort of spontaneous.

[00:05:18] [SPEAKER_03]: I'm gonna introduce this on the fly. Let's talk about our favorite early internet

[00:05:22] [SPEAKER_03]: YouTube videos like Boom Goes to the Dynamite. I'm springing this up and we talked about

[00:05:28] [SPEAKER_03]: something else five minutes ago. I'm gonna go with Charlie Bitme. So my son's name is Charlie.

[00:05:37] [SPEAKER_03]: So the whole Charlie Bitme YouTube video, I don't know if you google it now,

[00:05:43] [SPEAKER_03]: it probably has 10 billion views. Yeah exactly. But that's cool.

[00:05:49] [SPEAKER_01]: Ouch! Charlie Bitme! And that really hurt. It's perfect.

[00:05:58] [SPEAKER_01]: On point Alan. I'll never forget that. It's literally the best. I mean oh my god it's so

[00:06:05] [SPEAKER_01]: good. That still makes me laugh to this day. Yeah you can't but you can hear it and laugh.

[00:06:11] [SPEAKER_01]: But the thing that really makes you laugh is you watch it and you see the little baby laugh

[00:06:14] [SPEAKER_01]: at his big brother. That's the funniest thing in the entire world. He thinks it's hilarious.

[00:06:18] [SPEAKER_03]: And then there's a lot of tribute videos with other people doing the same bit and there's one

[00:06:24] [SPEAKER_03]: Indian dad and son Jigunesh Bitme became a family staple. That's solid work.

[00:06:34] [SPEAKER_03]: You can google Jigunesh Bitme and imagine me and my teenage son at the time

[00:06:40] [SPEAKER_03]: seeing that to each other on long car rides.

[00:06:47] [SPEAKER_02]: You're up next Zach. I have several acts that I could go to. Oh man I gotta be honest. I wasn't

[00:06:52] [SPEAKER_02]: I was not prepared for the first internet video I could think of that just kind of

[00:06:57] [SPEAKER_02]: blew me away. The YouTube was like you remember that chocolate rain singer? Yeah!

[00:07:02] [SPEAKER_02]: He just came. I mean he's just. Taste on day. Chocolate rain. Yeah I know that one.

[00:07:08] [SPEAKER_02]: I mean it was one that I hit play and I was like wow I did not expect that. Could not look away.

[00:07:15] [SPEAKER_01]: Except he looked away when he had to breathe if you remember correctly.

[00:07:19] [SPEAKER_01]: Yes yes he did. He noted that on the video yeah exactly. I'm sure there's a whole bunch of

[00:07:24] [SPEAKER_02]: them that I'm missing but that's a good one. That's the first one that came to mind. Go

[00:07:29] [SPEAKER_01]: ahead Alan. Do you ever see the red house? Oh man there's so many. Or what about the

[00:07:35] [SPEAKER_01]: red house? The red house was a furniture store that they did a homemade video and it was like

[00:07:39] [SPEAKER_01]: it was actually it was either really racially insensitive or really racially sensitive. I'm

[00:07:47] [SPEAKER_01]: not exactly sure. It was basically how white people and black people shop at the red house

[00:07:51] [SPEAKER_01]: and it had this at the red house. It's like it was very southern so that was a really good

[00:07:57] [SPEAKER_01]: way to get that one. And the other one was just like a mini mall there's a dude like

[00:08:05] [SPEAKER_01]: Alabama who had like this it was like a flea market store and they sold furniture and they

[00:08:10] [SPEAKER_01]: sold clothes. And the guy had like a long remix version of him singing and dancing to the

[00:08:14] [SPEAKER_01]: it's just like a mini mall. My cousin and I, long story short, my cousin you guys know

[00:08:20] [SPEAKER_01]: who we know at Rotten Tomatoes is? Oh yeah definitely. My cousin his name is Tim Ryan if

[00:08:25] [SPEAKER_01]: you look him up he's a big wig it at he was in the ground floor at Rotten Tomatoes. He is

[00:08:30] [SPEAKER_01]: guy who decides whether or not a review is positive or negative and you wouldn't think that

[00:08:35] [SPEAKER_01]: that would be a hard job except for some years he would throw them to me to see okay is positive

[00:08:41] [SPEAKER_01]: or negative. So film reviewers are not that great at letting people know if they actually

[00:08:45] [SPEAKER_01]: like the movie or not. For as much as they write a lot of times hard to. So Tim for a

[00:08:49] [SPEAKER_01]: long time he was the guy who decided if it was a positive or negative review and of course

[00:08:53] [SPEAKER_01]: that's how the percentage positive is how you get your tomato. Sure yeah sure. So in any case

[00:08:58] [SPEAKER_01]: so he's he and I used to collect those horrible videos and we would spring them on each other at

[00:09:04] [SPEAKER_01]: any point. And the Red House was a classic as well as the just like a mini mall. We'll get all

[00:09:09] [SPEAKER_01]: that stuff up there worth totally worth a look. I literally could I could do episodes on top of

[00:09:14] [SPEAKER_03]: episodes of this so yeah. I want to throw out two honorable mentions one Baratz and Barretta

[00:09:20] [SPEAKER_03]: Mother's Day. I don't know if you've ever seen that they're taking a picture for their

[00:09:23] [SPEAKER_03]: mother for Mother's Day. We just played it at the house on Sunday and we're cracking up

[00:09:27] [SPEAKER_03]: though we hadn't watched it for 10 years. And also anything by Jake and Amir College

[00:09:32] [SPEAKER_03]: humor that Jake and Amir have warmed its way into a lot of the family humor here at this

[00:09:39] [SPEAKER_01]: household so. Well when we put the show notes together we'll put we'll put we'll just embed

[00:09:43] [SPEAKER_01]: the YouTubes right. This will be the most epic show notes that the the clinical hacks has ever

[00:09:48] [SPEAKER_02]: had. Fantastic good. All right well we're gonna pivot over to our clinical portion of

[00:09:56] [SPEAKER_02]: show and today's topic is comes directly from our guest. We're going to discuss

[00:10:05] [SPEAKER_02]: removal of carries. Yeah carries. That's right. That's right we're gonna get 23 minutes out of

[00:10:11] [SPEAKER_01]: this. We are well we are first off I thought I feel a little bit disingenuous being on the

[00:10:18] [SPEAKER_01]: clinical hacks podcast and I started a thread in the dental hacks nation instead of the

[00:10:24] [SPEAKER_01]: clinical hacks. Maybe we'll start an actual thread in the clinical hacks when this comes out

[00:10:29] [SPEAKER_01]: but I wanted to get some opinions. I wanted to get some opinions before we talked and

[00:10:34] [SPEAKER_01]: boy did I. There you go. But so like I asked I said how do you know when you've removed all

[00:10:41] [SPEAKER_01]: the carries or and then the second question was or enough of the carries. And this is

[00:10:47] [SPEAKER_01]: this is what I love about this it's not that first off I mean you could know that

[00:10:51] [SPEAKER_01]: you removed everything carries by just going to town and pulping every tooth and even then

[00:10:57] [SPEAKER_01]: you might not have removed all the carries I guess. But the reality is we have to make

[00:11:00] [SPEAKER_01]: judgment calls about this stuff all the time right? Like I remember when I got to die

[00:11:07] [SPEAKER_01]: Zach you might feel this because was there a time Zach that when you were practicing with

[00:11:11] [SPEAKER_01]: your dad you kind of knew that he knew all the answers and that if you had a question

[00:11:15] [SPEAKER_01]: he would he could give you an answer and you knew that it was right because he'd been

[00:11:19] [SPEAKER_01]: doing this for a long time. And yes absolutely and the other thing my dad was funny about this is

[00:11:23] [SPEAKER_01]: that he never he wasn't the guy who said well I thought you know what I'm not really sure there's

[00:11:28] [SPEAKER_01]: a lot of ways he always had an answer he had an answer and I asked him this one and he

[00:11:33] [SPEAKER_01]: didn't really have an answer for this one this was like you just kind of know and and

[00:11:37] [SPEAKER_01]: and I think that in dental school you um I think how do you think you learned it in dental

[00:11:43] [SPEAKER_01]: school? How was how was it taught to you that you knew all the decay was out? By the time I

[00:11:48] [SPEAKER_02]: was in school we definitely moved to the dyes they had they had they permitted the education

[00:11:53] [SPEAKER_02]: and so really okay we we definitely had the I had access to and was encouraged to use the

[00:12:00] [SPEAKER_02]: the dyes in school however the instructions they gave you on them were were somewhat

[00:12:06] [SPEAKER_02]: somewhat vague um but in but we were using those those dyes at that point I do remember

[00:12:14] [SPEAKER_01]: I learned and I'll bet you Kevin learned that it was used uh an explorer an explorer and you'd

[00:12:20] [SPEAKER_01]: scrape the surface of the explorer and you wanted a hard hard not giving surface or or you'd use

[00:12:25] [SPEAKER_01]: a spoon actually a sharp spoon refrigerator same thing and certainly some of the instructors

[00:12:28] [SPEAKER_02]: went with that that weren't as familiar with or weren't as comfortable with the dyes but I

[00:12:33] [SPEAKER_02]: definitely had one of my main operative instructors was was a fan of and encouraged

[00:12:38] [SPEAKER_02]: me to use those those dyes which I still use to this day okay all right let me throw

[00:12:43] [SPEAKER_03]: this out there when you were first at practice first couple years do you think you ever left

[00:12:48] [SPEAKER_03]: decay behind 100% significant that caused the restoration to fail yes 100% yes absolutely

[00:12:56] [SPEAKER_01]: probably probably but what you know it's really funny one of the reasons I brought this up is

[00:13:01] [SPEAKER_01]: I think leaving decay behind is a very loaded term now I didn't understand that but it's a

[00:13:13] [SPEAKER_01]: I have I ever have I left like actual decay that I just didn't see and maybe found later

[00:13:20] [SPEAKER_01]: for sure for sure guess what we're human I guarantee everyone you talked to did so um

[00:13:24] [SPEAKER_03]: whether they know it or not is a whole other story but my progression was early on in my

[00:13:29] [SPEAKER_03]: career realizing crap you know why did this thing fail at the six month recall I feel like

[00:13:36] [SPEAKER_03]: um to see to using dyes and seeing oh there's stuff there that I just couldn't feel

[00:13:44] [SPEAKER_03]: and think about the surface of it of a tooth and the diameter of a of an explorer how could you

[00:13:51] [SPEAKER_03]: possibly feel everything no you couldn't you couldn't right so that's why I needed to use

[00:13:57] [SPEAKER_03]: the dyes early on and um I will say that I don't use them as much anymore because I think

[00:14:04] [SPEAKER_03]: you just know now like like your dad said you just know but early on I think that's a great

[00:14:10] [SPEAKER_02]: exercise for you to see what you're missing but I think it goes even beyond that Kevin

[00:14:17] [SPEAKER_02]: I think some young clinicians at least me I think I've made the mistakes where I didn't

[00:14:22] [SPEAKER_02]: didn't open the tooth up adequately to even like really access or see all the decay when

[00:14:28] [SPEAKER_02]: I started practicing I didn't I didn't have a light I didn't have adequate loops um I mean

[00:14:34] [SPEAKER_02]: there's a there is a if it wasn't you know a vision related problem or a

[00:14:41] [SPEAKER_02]: tactical problem just inadequate preps we know I was designing the prep to fail you know it

[00:14:47] [SPEAKER_02]: wasn't set up it wasn't even set up right to have success so because we were taught to be

[00:14:52] [SPEAKER_03]: and I get that but in the real world the carries doesn't care about conservatism no

[00:14:59] [SPEAKER_02]: it just does what it does and you need to be able to remove it right so I think but I don't

[00:15:06] [SPEAKER_02]: think that's where you know Alan was meaning to go with carries I mean I think that's just a

[00:15:12] [SPEAKER_02]: there's mistakes and then there's like the deep lesion which I think we're getting to

[00:15:16] [SPEAKER_01]: I'm gonna argue too that a lot of like like to say that can you look on someone's x-ray

[00:15:23] [SPEAKER_01]: and say oh he left decay can you do that is that I know super obvious like super malpractice

[00:15:31] [SPEAKER_02]: I mean I I mean yeah people really mess up sure but most of the time here's the

[00:15:36] [SPEAKER_02]: thing especially with radio opaque filling materials how are you going to tell if someone

[00:15:39] [SPEAKER_01]: is if someone is sloppy with everything they do they're probably sloppy with carriage removal

[00:15:44] [SPEAKER_01]: right like like but but I mean I don't know that you can judge that from I don't think a

[00:15:48] [SPEAKER_01]: radiograph is probably place to do it I look at a lot of my radiographs especially if I've done

[00:15:51] [SPEAKER_01]: one of those selective cases like it we'll talk about later but and you look at it you go boy

[00:15:55] [SPEAKER_01]: if that showed up in anyone else's office they would they would say god whoever did this was

[00:15:59] [SPEAKER_01]: schlock man they were doing a terrible job you know on some level I like to use some

[00:16:03] [SPEAKER_01]: sometimes I'll use that what's the stuff from Cosman it was actually quirky well height

[00:16:10] [SPEAKER_01]: design it's called demark is what's called demark and it's like this it's a full

[00:16:14] [SPEAKER_01]: or radio it's like the most radio pig thing and it's like this is where I stopped you know it's

[00:16:19] [SPEAKER_01]: it's yeah I don't use it as often as I probably should especially on those cases that would make a

[00:16:23] [SPEAKER_01]: lot of sense but it's crazy opaque like like it'll change the color of your resin if you

[00:16:28] [SPEAKER_01]: don't if you're you don't have that much on top of it but it's an interesting concept to

[00:16:32] [SPEAKER_01]: put something super radio pick right down where you on your first layer but in any case

[00:16:38] [SPEAKER_01]: like I've changed a lot of how I look at carries because I always felt like this was there was a

[00:16:43] [SPEAKER_01]: there was a you did it right or you did it wrong and there's no in between and you left decay and

[00:16:47] [SPEAKER_01]: so everything you do is destined to fail and the reality is like you probably quote unquote

[00:16:51] [SPEAKER_01]: leave decay on someone who has really good habits and they'll never have anything you know

[00:16:56] [SPEAKER_01]: I think we're so quick to be judgy about ourselves and others on this deal that we you

[00:17:01] [SPEAKER_01]: point that finger I'm not I don't think leaving decay is probably as obvious as we'd like to say

[00:17:07] [SPEAKER_03]: it is we just see that on forums all the time some guy will show a crown prep and it'll be

[00:17:12] [SPEAKER_03]: some beautiful and the restoration is beautiful and then some joker will say you have decay

[00:17:17] [SPEAKER_01]: oh yeah how can you tell that from a photograph yeah you can't you can't I suppose

[00:17:24] [SPEAKER_01]: in certain situations if you could actually see like the loose like collagen shit you know

[00:17:31] [SPEAKER_01]: like maybe some dark stain that's not no no no that's right and I someone on my post said

[00:17:38] [SPEAKER_01]: it's like they said something kind of kind of funny like it's like it's like wiping yourself

[00:17:45] [SPEAKER_01]: if you see brown keep going like yeah it's funny but it's not real because like how many times

[00:17:50] [SPEAKER_01]: under a well-placed amalgam do you have brown to black stuff it's hard as rock you know like

[00:17:56] [SPEAKER_01]: all the time I mean that that happens so I think this is there's a lot more nuance involved here

[00:18:02] [SPEAKER_01]: I'm gonna first off I have no problem with people using caries dye I think there's some

[00:18:06] [SPEAKER_01]: weaknesses with it um I like altered if I'm going to use it I'm gonna use altered and

[00:18:10] [SPEAKER_01]: sable seat because it's green instead of red yeah and and green is not green is not biologic

[00:18:15] [SPEAKER_01]: I look at red or pink and I'm like man am I that that might make me I don't know I don't

[00:18:25] [SPEAKER_03]: read would be the great color for the caries dye but like did they not know what the color of blood

[00:18:32] [SPEAKER_01]: was and that's like the design on that is really it is a mystery to me but the other

[00:18:39] [SPEAKER_01]: thing that I understand is if the deeper the closer you are to the pulp the wider open the

[00:18:44] [SPEAKER_01]: actual dentin tubules are and so they're more likely to so the accuracy of those things I

[00:18:50] [SPEAKER_01]: think gets worse as you get deeper into the cavity is what I understand so I'm a fan of

[00:18:55] [SPEAKER_02]: caries dye but I try not to ever like double I won't coat the second time because then at that

[00:19:00] [SPEAKER_02]: point I feel like I'm probably might be asking for it yeah I might be asking for it now that

[00:19:04] [SPEAKER_02]: said I do like I like curare's it's pink but it's like a fluorescent pink it's like a it's

[00:19:11] [SPEAKER_02]: not you're not gonna mistake that with it's hot pink yeah it's hot pink yeah and and I'm

[00:19:17] [SPEAKER_01]: a fan of curare remember the Hart brothers in professional wrestling and they wore pink tights

[00:19:22] [SPEAKER_01]: with black tank tops it was that it's that pink and I think we need another picture it's

[00:19:28] [SPEAKER_01]: Jim the anvil knightheart and bret hart the hart foundation that that is a deep cut that is

[00:19:34] [SPEAKER_01]: a deep cut if frank plait was listening he's going to be going yeah that guy that guy came

[00:19:38] [SPEAKER_01]: up with it but that is the pink that curare's is I agree that's right I'm a fan of that

[00:19:42] [SPEAKER_02]: because I don't want to use more tips and yeah syringes I will say I will say I love

[00:19:49] [SPEAKER_01]: the syringes for applying that stuff it's fantastic ultra dent just take my money because I like I

[00:19:55] [SPEAKER_01]: like the syringes although Zach would probably tell you if you like the syringes you should

[00:19:59] [SPEAKER_01]: get the vista version which are pretty much the same and cheaper also true yes but I still

[00:20:04] [SPEAKER_02]: support the micro brush and curare carries dive I still think that's the way to go I like it

[00:20:10] [SPEAKER_02]: anyway I'm a fan so I do use it so you use ultra dense Kevin yeah I use use ultra dense

[00:20:15] [SPEAKER_02]: as well the green the ultra green I will say that I'm at a point now where I almost never

[00:20:20] [SPEAKER_03]: use carries die yeah and I almost never use it too but I did use it today and it was some weird

[00:20:29] [SPEAKER_03]: class three on a lower incisor where you can't always see up yeah yeah and towards the

[00:20:36] [SPEAKER_03]: incisal and there was a little bit of just a little bit of something there and I zapped

[00:20:40] [SPEAKER_02]: that away and we're moving on so well see I suck a lot worse than you guys because I use

[00:20:44] [SPEAKER_02]: it routinely and I'm always surprised by my how my tactile feel doesn't get the job done so

[00:20:54] [SPEAKER_02]: I'm a routine user I like almost every prep not the like like a shallow class one but

[00:20:59] [SPEAKER_03]: you know most of the time isn't it interesting that that is on a basic level big part of our

[00:21:07] [SPEAKER_03]: job and we all whatever Alan posted on dental hacks people have a different opinion and we're

[00:21:15] [SPEAKER_03]: I mean I think we're sort of all on the same page here with it but we're going to go about

[00:21:20] [SPEAKER_01]: it in a little different manner it's interesting yeah sure yeah um what's what I what I would

[00:21:25] [SPEAKER_01]: argue is for carries removal first off understanding what you're trying to remove

[00:21:29] [SPEAKER_01]: and why you're trying to remove it I still I've asked a bunch of times like why are we

[00:21:34] [SPEAKER_01]: removing decay why do you want to for someone who is not willing to do any kind of a quote

[00:21:41] [SPEAKER_01]: unquote selective removal which we'll talk about in a second I keep saying that but

[00:21:44] [SPEAKER_01]: like what's the what's the rationale for removing every last bit of decay and say a

[00:21:49] [SPEAKER_01]: deeper prep or whatever and part of the rationale to me is that in dental school

[00:21:54] [SPEAKER_01]: it's they'd fail your ass if you didn't that's kind of what it was it was a matter of and

[00:21:58] [SPEAKER_01]: it's wildly subjective but they would fail your ass so you're going to remove more than

[00:22:02] [SPEAKER_01]: less because you don't want it you don't want to remove too little agreed yeah that's fair

[00:22:08] [SPEAKER_02]: I think a lot of it's dental school PTSD type of type of stuff for sure when it comes to

[00:22:15] [SPEAKER_02]: actually us you know cleaning out decay are you stainless steel slow speed round burr are

[00:22:20] [SPEAKER_02]: you guys is that your method or do you guys do something different that's my jam so slow

[00:22:25] [SPEAKER_02]: speed number four number six round burr kevin i mean alan i use and this is within the

[00:22:32] [SPEAKER_01]: last couple years there's nothing wrong with that especially if you're using like a if you're

[00:22:36] [SPEAKER_01]: going to do it microcopy makes killer killer and yes yes they sponsor the show but they

[00:22:41] [SPEAKER_01]: also make killer single use they make really nice stainless steel round burrs they have

[00:22:46] [SPEAKER_01]: every size and type you could imagine and they are they're terrific if you're going

[00:22:50] [SPEAKER_01]: to use them it's nice to have a it's nice to have a sharp one because you know you

[00:22:52] [SPEAKER_01]: keep those around for a long time sterilize them a lot and they dull right out and it's

[00:23:02] [SPEAKER_01]: there they call them the i just i just typed it out and i can't remember what they're calling but

[00:23:08] [SPEAKER_01]: like the smart burr thing no they're not smart burrs they're okay smart burrs are a different

[00:23:12] [SPEAKER_01]: thing and i use a plastic plastic oh hang on i'll get you the name of it they're called

[00:23:16] [SPEAKER_01]: all right cereber is what they're called the cereber so it's a

[00:23:21] [SPEAKER_02]: the so basically oh wow smart burrs most expensive way to remove carries here you go

[00:23:26] [SPEAKER_01]: probably but i will say this those cerebers those cerebers they last for freaking ever

[00:23:32] [SPEAKER_01]: like they don't they really do they really don't dull so and you're not using them very much

[00:23:35] [SPEAKER_01]: either so but um i like those i did try the smart burrs in the beginning because of course

[00:23:41] [SPEAKER_01]: i had to because it was something expensive and i could buy it at chicago midwinter and i just

[00:23:45] [SPEAKER_01]: had no good luck when they're plastic and supposedly they they would only cut at a

[00:23:49] [SPEAKER_01]: certain hardness and once it got to that beyond that hardness they would they would

[00:23:52] [SPEAKER_01]: dull themselves down and they wouldn't cut anymore that was the concept i never found

[00:23:55] [SPEAKER_01]: that to be the case i honestly found that they dulled as soon as you touched them to any

[00:23:59] [SPEAKER_01]: you know because a lot of times it's sort of hard to only put it on what you're going after to and

[00:24:05] [SPEAKER_01]: decay so if you happen to like touch it to the side of the tooth with enamel you're going to

[00:24:09] [SPEAKER_03]: dull it out and we also develop some sort of tactile sense of oh that's that's hard done

[00:24:14] [SPEAKER_03]: and let's move into the softer but you're just sort of doing that all on the fly

[00:24:19] [SPEAKER_01]: because you've done it a million times yep i i will say that the cereber i heard someone

[00:24:26] [SPEAKER_01]: claim that the cereber did that where it was like selective on that way but i don't think

[00:24:35] [SPEAKER_01]: that's zirconi is pretty hard i zirconi doesn't dull down when you hit something harder so

[00:24:40] [SPEAKER_01]: but i'm a real fan of those i use them in a slow speed electric handpiece with i actually

[00:24:44] [SPEAKER_01]: use water because i like to remove that debris but i think it's more important

[00:24:49] [SPEAKER_01]: you might be you might not be surprised to hear that i think magnification is everything

[00:24:53] [SPEAKER_01]: it comes to this good lighting good magnification and dry and i think you can see what you need to

[00:24:58] [SPEAKER_01]: see in a lot of cases if you have a good bright light and it's dry that's what i think

[00:25:01] [SPEAKER_02]: oh i agree most of my like failures were like where the topic started with do you think you've

[00:25:06] [SPEAKER_02]: left decay on preps like unintentionally not like with intent and yes on those and it was

[00:25:13] [SPEAKER_02]: absolutely lack of light lack of lack of isolation didn't have rubber dam you couldn't

[00:25:19] [SPEAKER_02]: see blood was everywhere and i just didn't do a good job straight up you know so yeah absolutely

[00:25:24] [SPEAKER_01]: i agree with you on light and magnification and dry yeah so so yeah the isolation is a big deal

[00:25:31] [SPEAKER_01]: so the story is like if you set yourself up like that you have a fighting chance of removing

[00:25:36] [SPEAKER_01]: decay effectively but then the next question is why exactly um why exactly are we removing

[00:25:44] [SPEAKER_01]: like like i think part of it is that like you're worried that if you leave decay then it's seeded

[00:25:50] [SPEAKER_01]: with bacteria that's going to continue to rock the rot the tooth underneath the restorations

[00:25:54] [SPEAKER_01]: that what most people think about why we removed why do remove decay why why don't we

[00:25:57] [SPEAKER_03]: just leave it there i think it matters where you're leaving it i know we're dancing around

[00:26:03] [SPEAKER_03]: the selective we don't have to dance anymore let's do this topic but yeah i mean i i think

[00:26:07] [SPEAKER_03]: if i've left decay on the periphery that's probably going to make the restoration fail so

[00:26:13] [SPEAKER_03]: once you're sure the peripheral enamel and dentin is clean of of everything and that's

[00:26:20] [SPEAKER_03]: miles away from the pulp for a tooth that is asymptomatic and has deep decay i have no problem

[00:26:29] [SPEAKER_03]: leaving a little bit over over the pulp at all yeah over where you think the pulp is probably

[00:26:35] [SPEAKER_03]: likely to be yes peripheral decay i do want to i want to get all that out you can't i

[00:26:41] [SPEAKER_02]: think the bond to decay i think we can all agree the bond to decayed structure is going to be worse

[00:26:48] [SPEAKER_02]: than clean so we're definitely going to try to bond to clean so the important part like you

[00:26:56] [SPEAKER_01]: said is basically the peripheral area has to be clean as a whistle and as much of it on enamel

[00:27:00] [SPEAKER_01]: as possible of course in the gingival seat you're going to be in cementum at that point

[00:27:04] [SPEAKER_01]: in many to most cases i still tend to really i tend to bevel to a ridiculous point on on anything

[00:27:14] [SPEAKER_01]: that's going to be my my peripheral seal area uh in most cases but but the thing about it is i

[00:27:19] [SPEAKER_01]: feel like that's where visualization comes in because you can almost always really see a clean

[00:27:24] [SPEAKER_01]: periphery if you've got it dry and good light and you've really and so i think that's

[00:27:28] [SPEAKER_01]: what's important like david clark likes to describe the stuff underneath that's you know

[00:27:32] [SPEAKER_01]: that you might be leaving is a rotten salad that's what he which is really really paints a picture

[00:27:38] [SPEAKER_01]: but sometimes he'll go so far as to say if if the tooth is asymptomatic and you think you're

[00:27:43] [SPEAKER_01]: getting anywhere near the pulp leave that junk even if you could scoop it out with a spoon

[00:27:47] [SPEAKER_01]: just leave it as long as you've got it he says two millimeter and i always go i want to

[00:27:50] [SPEAKER_01]: go as far as i can but two millimeter would be the very least i would leave of peripheral

[00:27:54] [SPEAKER_01]: and i'm not gonna lie i'll get a perioprobe to make sure and i don't know that there

[00:27:58] [SPEAKER_01]: that's research-based as much as it just seems to make a lot of sense you're you're

[00:28:01] [SPEAKER_01]: leaving a lot of room for a good seal if you're bonding so if you've got good isolation

[00:28:06] [SPEAKER_01]: you've got a nice wide peripheral seal area that's clean as a whistle you can probably

[00:28:10] [SPEAKER_01]: leave whatever you want to underneath it more or less like it's it's not a guarantee but

[00:28:15] [SPEAKER_01]: when is carrier's removal ever a guarantee that you're not going to mess with the pulp

[00:28:19] [SPEAKER_02]: and kevin i mean uh sorry alan let's let's ask you some of the same questions will be

[00:28:24] [SPEAKER_02]: we brushed upon on one of our previous shows with uh dr liz uh dohman um

[00:28:31] [SPEAKER_02]: if we uh if you're getting close let's say you're you're gonna leave some carries but you're within

[00:28:35] [SPEAKER_02]: you know you didn't you didn't pull up the tooth are you gonna put any kind of a liner down

[00:28:39] [SPEAKER_02]: or are you going straight to bonding i don't i don't use a line i haven't used it

[00:28:45] [SPEAKER_01]: no i saw john kanka about a thousand years ago and he gave me permission to not use a liner

[00:28:50] [SPEAKER_02]: so i don't okay and let's say you mess up your selective carries removal and accidentally

[00:28:55] [SPEAKER_02]: uh nick a spot and see a little bleeding are you a are you a pulp capper i i know i'll no

[00:29:04] [SPEAKER_01]: i'm not i mean i guess i am but i don't i don't use a traditional pulp cap material typically

[00:29:10] [SPEAKER_01]: as long as as long as tooth's asymptomatic prior to me getting in there if they weren't

[00:29:14] [SPEAKER_01]: having trouble with the tooth i'm gonna isolate that bleeding i'm gonna get it to stop i

[00:29:17] [SPEAKER_01]: don't have a laser so a lot of times i'll use like an astringent or something like that

[00:29:21] [SPEAKER_01]: actually your best bet is to use um what's the word i'm looking for olie sergi delis uh peroxide

[00:29:27] [SPEAKER_01]: peroxide is a really good way to do it apparently basically you're stopping that bleeding

[00:29:31] [SPEAKER_01]: immediately or it's a super clean area and then i bond over it with composite and apparently

[00:29:35] [SPEAKER_01]: that's as good as you're going to get you know i know there's no liner that's necessarily

[00:29:39] [SPEAKER_01]: going to do any better although bisco has one how is it there you go there account they

[00:29:45] [SPEAKER_01]: claim that and so i mean if i had some of that close by i might use that as my first

[00:29:50] [SPEAKER_01]: layer but i i'm not typically someone who's going to a great length to do crazy durillon

[00:29:54] [SPEAKER_02]: pulp caps because i haven't had a lot of luck with them so all right that's all right so

[00:30:00] [SPEAKER_02]: he's somewhere in between ali with the bonding direct and i'm gonna bond direct nine times

[00:30:06] [SPEAKER_02]: out of ten though and uh kevin with uh no pulp caps a good good pulp cap and uh so that

[00:30:12] [SPEAKER_01]: there we go right right i guess it depends on what we call a pulp cap too so is that if

[00:30:18] [SPEAKER_01]: if it's a if it's a carious or mechanical exposure and you're not doing the endo that's

[00:30:23] [SPEAKER_01]: i mean you pulp captain yeah yes i would i would say that i probably do a lot of pulp caps i just

[00:30:28] [SPEAKER_02]: do them with composite okay all right that's that's the biomimetic uh recommended system

[00:30:35] [SPEAKER_02]: i'm pretty sure yeah yeah i kevin kevin's not a fan he vehemently disagrees with you

[00:30:40] [SPEAKER_02]: and he's looking down on you with disgust i mean i get i get that a lot yeah i just do

[00:30:46] [SPEAKER_02]: the endo well i mean that's why kevin's more productive than we are it's a say it's a safe

[00:30:52] [SPEAKER_01]: bet to do the endo on some level it's it's and the other thing is if it's a vital tooth and

[00:30:56] [SPEAKER_01]: you do an endo you're you're much more likely to have a great outcome with the endo but do

[00:31:00] [SPEAKER_01]: i want that in my tooth do i go to the endo or do i want to see if we give the tooth a

[00:31:05] [SPEAKER_03]: fighting chance before we go to the endo that's right i'm sort of joking there's plenty of

[00:31:09] [SPEAKER_03]: times where a mechanical exposure i've tried to help cap it but i'm so failed we are we

[00:31:16] [SPEAKER_02]: are running some shtick for for sure on that uh what else do you want to talk about with

[00:31:21] [SPEAKER_02]: selective carriers tell us more about what's going on in the dental hax nation there with

[00:31:25] [SPEAKER_01]: i'll pull it up what what's funny to me is that no one really gives a rationale as to why

[00:31:31] [SPEAKER_01]: we remove all that decay i'm not sure why we do i i think i think the simplest answer

[00:31:36] [SPEAKER_01]: because he told us to in dental school i think that's kind of kind of some bit so you're

[00:31:39] [SPEAKER_02]: getting a bunch of basically this is what i do rather than uh according to what what why

[00:31:45] [SPEAKER_02]: this is what we should do that's that what you're saying what's happening in the thread

[00:31:50] [SPEAKER_01]: yeah i like what's i think a lot of people say this is what we should do i will say

[00:31:54] [SPEAKER_01]: that it is a little self-serving to be the person who's going to remove every every stitch

[00:31:59] [SPEAKER_01]: of stain or anything like that you're going to do more endo if you do that there's no

[00:32:02] [SPEAKER_01]: doubt about that like if you're if you are really aggressive on carriage removal uh you're

[00:32:07] [SPEAKER_01]: definitely going to leave a lot of you're going to or you're going to probably be doing more

[00:32:11] [SPEAKER_02]: endo on that level hey that's how you take a 150 dollar filling and turn into a 1500 dollar uh

[00:32:16] [SPEAKER_02]: ruchina on crown 10x baby it is it is i would argue might not be the best choice all the time

[00:32:22] [SPEAKER_03]: but it is how do you feel about the black scuzz underneath the amalgam are you gonna i think i

[00:32:29] [SPEAKER_03]: think we use peroxide on that i think you get rid of i mean the the hard stain underneath

[00:32:35] [SPEAKER_01]: i think it doesn't bond it doesn't bond as well as as clean animal but i i if it's hard i leave

[00:32:42] [SPEAKER_01]: it alone i just i want like i said i want those margins man and sometimes i might use like a pink

[00:32:46] [SPEAKER_01]: opaque uh over top of it to make it look more like a tooth unless like um like there's like

[00:32:51] [SPEAKER_01]: you like you buried an insect in your filling something like that like something dark and

[00:32:55] [SPEAKER_02]: disgusting i agree i think there's more of a need now than ever for like either super

[00:33:00] [SPEAKER_02]: or pink opaque with people using all these bulk fills that are so gray yeah i mean your filling

[00:33:07] [SPEAKER_02]: will absolutely look like crap if you bond one of those like extra gray bulk fills over a big

[00:33:13] [SPEAKER_01]: amalgam stained up to it's actually one of the reasons i struggle with bulk fill because

[00:33:17] [SPEAKER_01]: they're so they're so translucent they don't i mean they may be awesome but they don't look

[00:33:21] [SPEAKER_01]: very good a lot of times they don't they don't look as nice they could once you go bulkies

[00:33:25] [SPEAKER_01]: you don't have to worry about that yeah but bulkies is bulkies isn't isn't bulkies actually

[00:33:30] [SPEAKER_01]: the shade is actually like kind of like a shade it's not it's not see-through no it's because

[00:33:36] [SPEAKER_02]: it's self-cure it doesn't have to rely on you know the whole bulk fill concept is you know

[00:33:41] [SPEAKER_02]: we're so translucent that's how you can get your light down deep on this and since bulkies

[00:33:44] [SPEAKER_02]: self-cure it doesn't have to worry about so it's a nice opaque if you like your composite

[00:33:49] [SPEAKER_02]: opaque like i think kevin i we we like that opaque look we don't want it to especially on

[00:33:54] [SPEAKER_02]: posterior ones bulkies provides that opaque yeah look for you such as not it's like a zirconia

[00:33:59] [SPEAKER_01]: yeah yeah you never it looks more like a gold crown on an x-ray than a gold crown does i don't

[00:34:04] [SPEAKER_02]: know how they do yeah yeah no no bulkies you don't need any d mark bulkies is 100% d mark

[00:34:11] [SPEAKER_01]: exactly got it the big d mark it's amalgam but i find it interesting though in the discussion

[00:34:17] [SPEAKER_01]: that like there there's no everyone kind of has their own style on this there's no like

[00:34:23] [SPEAKER_01]: there's no hard and fast rule to this and i think a lot of people say my my i'm back

[00:34:26] [SPEAKER_02]: research i'm like maybe do you think this was ever explained terribly well though in a textbook

[00:34:33] [SPEAKER_02]: i feel like this is this is something that is like so based on like feel and

[00:34:39] [SPEAKER_02]: i don't think any textbook can like put words in i don't even think this podcast can

[00:34:45] [SPEAKER_01]: know like adequately describe it borders on religion to be honest but yeah i agree

[00:34:51] [SPEAKER_01]: but i'll say this i feel like i feel like you're safe to if you're not sure and you're

[00:34:56] [SPEAKER_01]: attempting to avoid exposing the pulp you're safe to have you know two millimeters of of peripheral

[00:35:03] [SPEAKER_01]: you know bond you're probably safe to leave whatever is there i i and i think it does

[00:35:08] [SPEAKER_01]: depend on if the tooth comes in and it's already sensitive are you hurting well then

[00:35:11] [SPEAKER_01]: you do the endo because it's sure your your chances of making it better there are pretty

[00:35:16] [SPEAKER_01]: but if they're asymptomatic and that happens a lot in my practice that have a giant cavity

[00:35:20] [SPEAKER_01]: that doesn't hurt at all that's typical i see that like once or twice every i mean almost

[00:35:25] [SPEAKER_01]: every day really i see that i see that a lot so and then you're like does this hurt you no

[00:35:31] [SPEAKER_03]: um you know a bunch of questions like i want to make really sure and the other thing is

[00:35:35] [SPEAKER_01]: then you're like okay this tooth is non-vital at that point how can this not hurt you is

[00:35:39] [SPEAKER_01]: real question yeah yeah did you ever have swelling a pimple so do you think that selective

[00:35:48] [SPEAKER_02]: carries removal is going to gain acceptability steam as some of the like old guy die let's

[00:35:56] [SPEAKER_02]: just say it as the old guys die yes it will kevin the not no offense but like i think the

[00:36:03] [SPEAKER_02]: dentists in your age bracket and up most of them who maybe aren't as woke to like you know

[00:36:10] [SPEAKER_02]: you know current philosophies on it are going to say you know that that's that's garbage you

[00:36:15] [SPEAKER_02]: you've got to get all that stuff out of there you know would you agree with that or not kevin

[00:36:19] [SPEAKER_03]: yeah i i think i would agree with that but i think that if you're

[00:36:24] [SPEAKER_03]: if you're really thinking it all through and i think there's also a difference between

[00:36:28] [SPEAKER_03]: if you're leaving decay behind and you're placing an amalgam or if you're bonding something

[00:36:34] [SPEAKER_03]: to clean peripheral enamel i think that you you probably got a better shot so i think that may

[00:36:40] [SPEAKER_03]: be where it comes from from the old guys that those you know your amalgam is going to corrode

[00:36:45] [SPEAKER_03]: over time and whatever is going to happen underneath there's going to happen but if

[00:36:51] [SPEAKER_03]: you're bonding to clean peripheral enamel and you leave some decay there i mean who cares

[00:36:56] [SPEAKER_01]: i think that i think that's and the reality is is that when i wish we could get away from

[00:37:01] [SPEAKER_01]: the term leaving decay because in in my the way i try and do it is i try and i

[00:37:08] [SPEAKER_01]: am selectively removing decay and sometimes i selectively remove all that i can see a lot of

[00:37:14] [SPEAKER_01]: times but sometimes i don't so it's it's not it isn't left behind it's it's it's

[00:37:20] [SPEAKER_01]: strategically you know not removed is what it comes down to i agree that a rebranding

[00:37:25] [SPEAKER_02]: of the concept would would it would help you're right leaving something behind sounds we need

[00:37:30] [SPEAKER_02]: hashtag well because the kids love hashtags we need a hashtag there you go hashtag strategic

[00:37:36] [SPEAKER_01]: carries removal it doesn't roll off the tongue no it's not good all right well hashtag rotten

[00:37:44] [SPEAKER_01]: salad that might have a little that's head legs yeah well thank you alan mead for joining us

[00:37:50] [SPEAKER_02]: these last couple weeks it has been a pleasure to get a name big name guest yeah with the

[00:37:57] [SPEAKER_02]: golden voice on so thanks you know you're doing it man you know it's what i do it's what i do thank

[00:38:02] [SPEAKER_02]: you thank you kevin fryer for taking an hour out of your tuesday to talk teeth with a you know

[00:38:10] [SPEAKER_02]: dude from kansas city and thank you for having that hair too thanks ryan you're welcome and

[00:38:17] [SPEAKER_02]: thanks crazy dental for having nice dental supplies there we go there we go thank does

[00:38:23] [SPEAKER_02]: crazy don't have any calisade because i cannot find that stuff i want to know for real do they

[00:38:29] [SPEAKER_02]: for real okay i can get some i will that because that would be crazy that would that would be

[00:38:35] [SPEAKER_03]: crazy maybe they have some carries detector dye too i'm certain that they do at a crazy price

[00:38:41] [SPEAKER_01]: yep fantastic if you buy from somewhere else you're crazy see what i did there i do

[00:38:48] [SPEAKER_02]: i do for alan mead for and for dr karen karen karen karen see ya