Very Clinical: Dr. Craig Harder Changed His Mind About Fiber Posts

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

[00:00:29] What is up Very Clinical listeners and welcome back to another episode of the podcast with me as always, my trusty co-host Dr. Kevin Hairfriar. Kevin, what's up, man? Zach, I just got an email. We got a new sponsor. Oh, awesome. That's great.

[00:00:45] We're going to be we're going to be sponsored by AG2. It's one better. It's one better than AG1? Wow. Yes. And since they're a upstart, is the they bringing in the big bucks? Is this big money?

[00:00:59] Yeah, yeah. You'll get a royalty check probably just in a couple of weeks. Oh, man, I can't wait. I'm planning on my retirement already. We have got a premium returning guest this week. Premium. Premium. Dr. Craig Harder, all the way from Washington. Craig, what is up, man?

[00:01:17] Hey, fellas. Does premium mean I'm old or how does that work out? No, it means you're getting a big check. The AG2 check. Oh, I'm part of that sponsorship. Yeah, yeah, yeah. AG2, they're very generous. Yeah.

[00:01:29] That's kind of like when insurance sends a refund check for like two cents. Is that how that works? That's right. It's the two cent insurance check. The one that you frame rather than cash for spite. For spite. Hold on to those for years.

[00:01:44] So I hope you listeners are enjoying our Changing Our Mind series, because if you're not, it's going to be a long, long summer. Long, long summer. It's going to be a long summer. So we brought Craig Harder in.

[00:01:57] We're kind of targeting, you know, mid to late career, Dennis, and because getting that perspective of wisdom. And so we got we got Craig in here and we're going to do our clinical topics first.

[00:02:12] But Kevin, I think you had a little bit to go before we start talking teeth. So, Craig, suppose just suppose, use your imagination, that Zach and I were on a road trip and we ended up in Moses Lake, Washington. Tell us what we need to do.

[00:02:29] Where are you going to take us when we arrive at your doorstep? Well, first you've got to go see some of the restaurants in town just because we've got good food here, surprisingly. What's the best one? Enzo's, which is owned by my orthodontist buddy.

[00:02:44] And it's just right out my back door. What kind of cuisine is that? It's Italian. Our buddy Brent stopped by last summer and he enjoyed a meal with us. But yeah, Enzo's in Moses Lake. Fantastic food. Great people.

[00:03:02] And then we got to just stop by the lake because, yeah, it really is a lake. We were founded by Native Americans here. We're found and not Moses. Give Chief Moses. OK, instead of Moses, the Walker, you know? Yeah. How big of a lake is this, Craig?

[00:03:19] Oh, that's a great question. We are the third largest lake by shoreline in the state. Well, OK, so you're talking about a pretty darn big lake. OK, it's got a lot of small channels, weaves here and there and things.

[00:03:34] But yeah, it's a it's one of the top destinations for summertime fun from for people from Seattle. They come over and we've got sand dunes that are at the end of the beach that go for over like 30,000 acres.

[00:03:48] So and then we've got boating, all kinds of things going on. When we come to visit, Zach should bring his boat. Exactly. I'll tow my boat all the way there. What do we fish for there? Walleye trout. Yes. Excellent. Man, I love walleye.

[00:04:02] That's my favorite freshwater fish right there. Excellent. Just had a bass tournament here on our lake last weekend. So cool. I'm all about that bass. All right. So to the arch are changing our mind series. Dr. Craig. Yes, sir.

[00:04:19] You change your mind about anything clinically over the course of your career. This was kind of a tough one, because, you know, we all slowly change over time and we don't really notice that change, I suppose. But one of the things that definitely changed in the last

[00:04:38] five years after going for 15 with them was I no longer use fiber posts. Those suckers have such a high failure rate when initially I was sold on the idea. I thought the flexural strength was going to be perfect matching up with the tooth.

[00:04:54] I thought it was the savior of everything. And I put them in everything. And boy, they have been a disaster over the years. OK, so I also made that that move several, several years ago. What catastrophic failure was the straw that broke your back on that?

[00:05:16] Probably for the hundredth time, a number seven snap. Yeah. Mm hmm. Yeah. And, you know, especially if you're already putting a porcelain restoration over the top, you're going to hide any shadow of that metal, which is also a big selling point

[00:05:31] was that you were going to be seeing the dark root or whatever. Yeah. Zirconia has kind of eliminated the need for that masking. Exactly. Yeah, I'm for sure. I've gone back to metal posts that work great. You know, we just don't see those snap off.

[00:05:47] Sure, you've got the other alternative of snapping the root, but it sure happens way less than we were seeing snapping the posts off at the top. All right. I got I got some more questions about that, Craig.

[00:05:58] So what what fiber posts were using the fiber core or using something different? Or do you not remember? We don't remember. That's OK. I like bulk order these ones that look like a Christmas tree on the top. And then they had a post going down.

[00:06:12] They're awesome because you could countersink them on those flat teeth that you might have. And they were they were fiber. Yeah. Oh, OK. I've seen metal ones. I have metal ones like that. Yeah. So I think it was access dental at the time, which is

[00:06:25] an old, old version of access dental made those. And I bought a ton of them and yeah, use them over the years. What metal post did you switch to? That's the big question. The same one that was in my office when I bought it 30 years ago.

[00:06:41] All those those are still there. And yeah, you know, tried and true. Yeah, I yeah, I mean, they work. Do you bond those in when you put them in? I do actually. Yeah. I use a dual cure for the whole build up and,

[00:06:56] you know, do the whole thing all in one shot. Kevin, have I know you don't place a lot of post in the I don't think I don't. Yeah, I'm either. But I mean, when you need them, you need them. Yeah, you need them.

[00:07:08] I'm still you ever mess around with those or do you? Oh, yeah. I definitely use some fiber posts in the past and I had the same experience as all you guys. They broke off and I actually didn't use them for that long because of that reason.

[00:07:26] It just didn't like you could bend them in your hands. It doesn't seem like I can't bend titanium in my hands. Actually, I can now because I'm working out every day. Yeah, nice. So one of my theories, and I think I read this also.

[00:07:41] I thought it myself for a while and then Lane Ochi like described it. I think one of the reasons those failed, because that that flex that flex that they had, they said was going to be so great for the tooth.

[00:07:51] I felt like over time that just caused your bond. Yes. Debond. And then and then all the bacteria got in there and then and then it was over or if because if it didn't snap off

[00:08:03] what the person came in with the crown and the entire post out all at once, then you're screwed, right? I mean, that's that's what I noticed. At least, yeah, definitely saw a lot of those. Yeah, I just think overall they're

[00:08:17] space maintainers for I mean, you do the best you can, but true. A lot of a lot of them fail for a lot of reasons, but you do what you can to do. But I've I've seen so many ones that I did well with the good old fashioned.

[00:08:35] Yeah. Titanium post. Yeah, I've lost a very long, very long period of time. And again, we're mostly targeting premolars and anterior teeth. Yeah, those are the ones that snap off post the endo. But yeah, Kevin, what post system? What are you using that screw in post?

[00:08:52] I can't remember the name. We talked about this. Is that the dentatus? Yes. The dentatus. Yes. OK. Yeah. And it's funny because pulled those out for the old associate the other day. He's kind of looked at me like, what is this?

[00:09:05] And then I showed him one very similar to. I think it was lower bicuspid. I showed him one that I had done like eight years ago. Like this is the same tooth. It's still there. This guy just came in for a recall. It works.

[00:09:22] But, you know, whatever it's to me, it's just a space maintainer for a future implant. You're buying buying the patient some time. Craig, did you have a second one or were you one hit on that? You know, it's they're kind of related.

[00:09:38] One of the things that I learned not to do over my period of time was I stopped doing upper molar endo. And those are for my specialists. They they get all of those up from me anymore. And that's simply because of over time

[00:09:55] you get to see your failures enough and see that even when I thought I got in B2, it still wasn't cleaned out well. And just seemed like my failure rate was way too high. And even, you know, 25 percent of them failing over a 10 year period

[00:10:11] just wasn't good enough for me. So that's one of the things I definitely changed on. And I'm all about predictability when it comes to scheduling. And upper molar endo was one of those that was an unpredictable for me on how long it was going to take.

[00:10:23] So do you still do the rest? Yeah. Yeah. I may send, you know, those converging root second lower second molars or something. Yeah. I'll send those out. But everything else is fair game for us. Craig, what endo system do you use? What have you settled on after?

[00:10:41] Oh, gosh, I still stay old school with mine. I've got the old Tri-Auto ZX, which is got a... Oh, I like it. Yeah. It reads the depth, does everything. And then I use the old twisted files as well. OK. I always knew you were a little twisted.

[00:11:00] A little twisted. I sure like those things. You got to be careful not to overuse them. I mean, they're a two use at most kind of material. But yeah, I like those. And then, of course, I'll go back and still old school, shape them up with regular

[00:11:18] file type things. But yeah, I'm a single cone guy. You know? Yep. Love it. I like the easy stuff. Do you have a cone beam in your practice? I don't. No. OK, that makes the upper molars. Yeah, definitely. One more reason for me not to do it.

[00:11:36] Sure. It makes them more predictable, but always ringing in the back of my head. Remember when we interviewed Brian McGugh and we talked about the multi-rooted teeth? We had that series of, you know, it needs a... It's a deep margin, etc., etc., etc.

[00:11:53] And, you know, as I was extracting a number 14 that I did five or six years ago with a big abscess on it yesterday, I thought about that little podcast. So there's something different about those multi-rooted teeth. So I get it. But I do a lot of endo anyway.

[00:12:13] You told me, Kevin, I got the cone beam that I was getting ready to see endo failures. I didn't even know it happened. Yeah. I have, but like I was, I was like nervous. I was like, oh my God, I'm going to start taking these things

[00:12:27] and it's going to be horrible. Fortunately, knock on wood, now I'm going to see a failure tomorrow, I guarantee you now that I said this, but it hasn't been that bad. Yeah. Like most of it's working, you know, so that's good. What do you guys think of as...

[00:12:40] This is a big, broad topic that probably isn't worth doing now, but what is your thought on what is the definition of a failure in endo? Has it changed or are you more like when you look at a cone beam now

[00:12:54] and you can see every last little bit yet, there's no symptoms, there's no big problems that the patient notices. Are you still calling it a failure when you see something off that? Or is it now you're like, oh, that's an acceptable thing that we see. What's your thoughts?

[00:13:11] Kevin, you go first. Well, let me take that one. So here's what my standard go to. We take a cone beam on every new patient and first thing we look at is the endos. It's just like that's where we go to.

[00:13:24] And oftentimes you'll see some sort of periapical radial lucency, let's say around an upper molar or even a lower molar. The first thing I'll do is ask the patient, does this tooth ever hurt you? Because that's my decision tree in this conversation.

[00:13:42] If they say no, then and it's relatively small. There's no way for me to know whether that's the way that's always looked or this endo was done last year and it had a giant periapical lesion and now it's shrinking. I don't know what's happening there.

[00:13:58] So if they say it doesn't hurt them, I look them in the eye and say, hey, we're able to see this now. If this tooth upper bothers you, we're going to need to do treatment. And then I sort of leave it at that.

[00:14:11] But we've had and I make sure they recognize we have this. We've had this conversation and we noted in the chart. But if I see something big and by big, you know, that's a subjective thing. I'm definitely going to have a conversation, particularly on upper molar.

[00:14:27] I'm thinking of from a new patient recently where the whole floor of the sinus was starting to be eroded again. No pain, but, you know, you can't let that go. So that's a different conversation. And, you know, unfortunately for this guy, he wasn't having any pain.

[00:14:47] I don't know how, but he will. And those, you know, we're going to go straight to extraction and graft. So I think it's a subjective thing. That's my opinion on that. The more cone beams you take, the more old root canals you see,

[00:15:04] the more you're going to see stuff that you wish you didn't see. What do you think, Zach? To answer Craig's question, I mean, I agree with Kevin. If it's a big enough problem, you've you definitely got to start calling that a failure.

[00:15:17] But in general, one of the things my dad has always said, he's like, it's not it hasn't failed until it's not in the mouth anymore. You know, and so those little ones, those I almost kind of treating those like,

[00:15:30] you know, the real incipient lesion you see on like a bite wing. It's like this is a watch. We'll watch and see what happens. I know that like some people are like, oh, it's only going to get worse. You can't watch anything. And I don't believe in that.

[00:15:43] I think there is there's plenty of time not to take out. You don't take action on every single thing that you see. And that's why I had some treating those. So basically almost exactly like Kevin is letting people know.

[00:15:54] But not going to do something just because I see a little dark line. And it's interesting. I send stuff to my oral surgeon sometimes and he'll take a cone beam on him and every single little abscesses, he's like, do you know about this? Have you seen this?

[00:16:07] Like they're they're super concerned about it. But here's here's the thing. Devil's advocate. And I'm not saying that I would do this, but those little things sometimes become big things and the grafting portion becomes way more difficult, which then translates to the implant.

[00:16:23] You know, like it creates a cascade of things that and again, I'm not advocating for a little periapical lesion to extract that tooth right away. Plus, you're going to have a big mountain to climb in the patient's mind, especially if it's not hurting them.

[00:16:40] But it's it definitely is a judgment call. I get it. You bring up a good point in that like when's the next time you're going to see that apex? Because I mean, what three to five years cone beams are three to five years, right?

[00:16:53] And a lot can happen in that time frame. Yeah. What do you do, Craig? When you see him on PA like full mouth surveys or whatever you do. And I think so kind of my question is leading towards we've always based these decisions off of 2D PA's.

[00:17:09] Yeah. And now we've got a much better vision. So should that be changing our look at these and trying to develop a when is it right? When is it wrong? I don't know. But yeah, it's always been first off. Like Kevin said, does this hurt?

[00:17:25] Has it been giving you any symptoms? Have you noticed any issues when you're chewing on that side type of thing? But then there are the ones where, yeah, you can see that it's blowing up the bone and interproximal or whatever.

[00:17:39] I wish I could show you the cone beam from my first patient yesterday right now. This is remarkable. I'm amazed at what doesn't hurt. Isn't it amazing that it doesn't hurt? It's absolutely amazing. After I took three teeth out on this guy, he said, and I've known

[00:17:54] this guy's name's Joe, I've known Joe for a long time. He said, you know what? Every once in a while, those teeth would hurt me. And I thought that's just the way it was. And I never said anything to you about it. And I'm like, OK, wait,

[00:18:06] you're not going to hurt you anymore. Oh, that's that's that's an interesting thing in and of itself. Like, you know, some people are sensitive tooth is a call you emergency and another person, a massive abscess. They're just they've been living with for years. These were massive. Yes.

[00:18:25] Yeah. Fascinating. Yeah. All right. Craig, did you have did you have do you have a third one or was that it? No, that's it. That's it. OK, awesome. Very good. I was kind of a and Kevin, you like an you like an endo topic.

[00:18:38] Craig brought the two sides of endo the restoration part in the. Well, the endo. Go come at endo pilot. Hey, Kevin. Yeah. Do you do you occasionally teach a course on endo? I occasionally do. But, you know, I let's let's put it as I occasionally do.

[00:18:56] OK, none coming up anytime soon. Yeah. None coming up soon. Unscheduled. OK, correct. Well, none scheduled in the arena that you might think I might be teaching that. But there are I did one last week in Chicago, by the way. All right. Yeah. Cool. Very cool.

[00:19:14] All right. Well, I hope you are enjoying listening to Craig because you've got him for the next two Tuesdays. Yeah. So next time we'll hear what Craig has to say about how his business has changed over the years, and I bet he's got plenty on that.

[00:19:27] Kevin, any final thoughts? No, I love this conversation. Perfect. All right, Craig. Thank you. Thanks, guys. See you guys next Tuesday.