Very Clinical: Dr. Nate Lawson Infiltrates the Podcast

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[00:01:19] This is a production of the Very Dental Podcast Network.

[00:01:30] Welcome to the Very Clinical Podcast, brought to you by Zerk Dental Products.

[00:01:35] 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.

[00:01:43] Here's Kevin and Zach.

[00:01:45] Hey, what is up? Very clinical listeners.

[00:01:47] And welcome to our second episode of 2023.

[00:01:50] I'm Zach Miners, coming from Kansas City, Missouri.

[00:01:53] With me, as always, my trusty co-host, Dr. Kevin Harefriar.

[00:01:57] Kevin, what's up?

[00:01:59] How'd the first week of the new year go?

[00:02:02] It's fine.

[00:02:04] I fixed some teeth and it was cold.

[00:02:08] How cold does it get there in good old Kansas City?

[00:02:12] Oh, the highs will be in the upper 30s, low 40s kind of range.

[00:02:15] How about you?

[00:02:16] 20s in Cleveland?

[00:02:18] Somewhere around there.

[00:02:19] All right.

[00:02:20] I mean, the greatest thing about Cleveland in the winter is the gray skies.

[00:02:24] The continual gray skies over and over again.

[00:02:28] So it drives you into a deep depression.

[00:02:31] But hey, we love it.

[00:02:32] Do you take your vitamin D?

[00:02:34] I do, actually.

[00:02:34] To keep it getting seasonal effective?

[00:02:36] Yeah, totally.

[00:02:37] I do that too.

[00:02:37] Yeah.

[00:02:38] I know who probably doesn't have to do that is our guest, Dr. Nate Lawson.

[00:02:42] What's up, Nate?

[00:02:43] It is not as cold where you're at.

[00:02:45] Am I correct?

[00:02:45] Yeah, and I'm in beautiful, sunny Birmingham, Alabama.

[00:02:49] So yes, it's...

[00:02:50] What's your January high looking like?

[00:02:52] 50?

[00:02:53] I'm not a person that checks the weather frequently.

[00:02:55] I don't have to because it's usually pretty mild.

[00:02:58] I don't own a winter jacket.

[00:03:00] You can get a great winter jacket from Summit Ice.

[00:03:04] Just go there and they'll have great winter jackets and fleeces for you.

[00:03:09] I don't know how many people are going to get that.

[00:03:10] It helps support your health costs.

[00:03:13] Yeah.

[00:03:15] Nate, do you have to take vitamin D in the wintertime?

[00:03:18] Do you play that game?

[00:03:20] No.

[00:03:20] I didn't know that was a shame.

[00:03:22] Yeah.

[00:03:23] It's for people who have gray, crappy skies.

[00:03:25] They don't need sunlight.

[00:03:26] So they get depressed.

[00:03:28] Love that depression, right, Kevin?

[00:03:29] Yeah.

[00:03:30] It affects everyone a little bit differently.

[00:03:32] But I think the vitamin D has some other health benefits.

[00:03:35] And I think it's good.

[00:03:36] You know what's really good, though?

[00:03:37] It's sunlight.

[00:03:38] Thanks a lot, Nate.

[00:03:39] Yeah.

[00:03:39] Yeah.

[00:03:40] Sunlight indeed.

[00:03:41] So that sunlight is not our bit for this evening.

[00:03:44] Kevin, what are we talking about?

[00:03:45] Yeah, so it seems like we talk a lot about TV when Nate's on.

[00:03:49] So I think we'll go with that theme.

[00:03:51] We're going to go with guilty pleasure slash stupid TV from kid from the childhood or just

[00:03:59] in general.

[00:04:00] If you want to, I can go first or we can go around the horn.

[00:04:03] Go for it, Kevin.

[00:04:04] So I'm just going to pick the Brady Bunch because that's a pretty iconic 70s TV show.

[00:04:11] I would stop and watch it if we were flipping through the channels.

[00:04:15] I would watch it now.

[00:04:17] Just I probably have them all memorized.

[00:04:20] And I definitely saw them all live or whatever as broadcasted.

[00:04:26] So I just think it's it'll definitely make me laugh in an ironic way.

[00:04:31] I'm all about the Brady Bunch.

[00:04:32] Is that like a TV land thing?

[00:04:33] Does anyone own the streaming package for the Brady Bunch these days?

[00:04:36] Do you guys have Pluto?

[00:04:37] Do you know what Pluto is?

[00:04:38] No.

[00:04:38] I do.

[00:04:39] I have heard of Pluto.

[00:04:40] It's one of those random free apps.

[00:04:41] It's probably on Pluto.

[00:04:43] So you could probably watch it on YouTube.

[00:04:45] Sure.

[00:04:45] Oh, sure.

[00:04:46] Probably that.

[00:04:46] Yeah.

[00:04:47] I just love me some Martian jam.

[00:04:50] So, you know, I've watched a decent number of episodes of that show because it was in syndication

[00:04:56] when I was a kid.

[00:04:57] But yeah, it was never.

[00:04:59] I can imagine they're like intro music like nobody's business.

[00:05:04] But I didn't.

[00:05:04] I can't say I love that show.

[00:05:06] Probably way too retro for you and seemed really stupid.

[00:05:11] When was the actual run of that show?

[00:05:13] Was it the 60s?

[00:05:14] Or is that the 70s?

[00:05:14] It was 71 to probably 77.

[00:05:17] And I will say that the, this is, I mean, this is embarrassing, but the first episode,

[00:05:24] I'm going to guess came out the week before my birthday in September.

[00:05:28] And we can fact check this.

[00:05:31] But anyway, it was a big deal, like heavily promoted on ABC and something that we had to

[00:05:38] watch.

[00:05:38] So I know for sure that I saw the very first episode and the Friar family was obsessed

[00:05:43] by the break.

[00:05:44] What else was there to watch?

[00:05:47] You had a lot less options in 1971.

[00:05:49] That's for sure.

[00:05:50] Nate, you got something?

[00:05:51] Yeah.

[00:05:52] What's your guilty pleasure show?

[00:05:53] So I guess my generation, I graduated from high school in 2002.

[00:05:58] So I remember at that point in time, I remember when I was in high school, my dad was, maybe

[00:06:06] my freshman or dad told me about the internet.

[00:06:08] I was like, oh, the internet's for nerd.

[00:06:09] Who would ever want to do the internet?

[00:06:11] And then there were probably some things that led me to the internet.

[00:06:16] But one of my, one of the big ones was when I was in college, you could get all the, there's

[00:06:21] some kid that came to the dorm and he uploaded all of the family guy, like every single family

[00:06:27] guy.

[00:06:27] And that one of our shared network was whatever.

[00:06:29] And now all of a sudden I can watch family guy in demand because before that, I just had

[00:06:33] to wait until it came on TV.

[00:06:36] And I just remember just binging and watching so much family guy to the point where it's

[00:06:40] barely even funny anymore.

[00:06:41] Cause just like watching it nonstop consistently.

[00:06:44] And then now it's funny.

[00:06:46] Now where I see family guy is on Instagram or Facebook, they have like two stories and they'll

[00:06:51] show like the little snippets of quagmire or something doing something quagmire-ish.

[00:06:57] And yeah, it brings up the memories of like college, just like binging so much family guy.

[00:07:03] That's awesome.

[00:07:04] As a child of the late eighties and nineties, Saved by the Bell.

[00:07:09] Oh yeah.

[00:07:10] It was my guilty pleasure.

[00:07:11] My sisters and I, we didn't really catch it on Saturday mornings on, on first run because

[00:07:16] my parents had us doing something different by the time that came on TV.

[00:07:20] But if we caught it on TBS all, all the time, we'd watch it after school.

[00:07:26] That's what we'd try on TBS and there were Saved by the Bells and we watched a ton of those.

[00:07:31] Weren't we just talking about the drug one behind the scenes?

[00:07:34] Yeah, probably.

[00:07:35] Yeah.

[00:07:36] Yeah.

[00:07:36] So funny.

[00:07:36] Yeah, sure.

[00:07:37] So I loved, I loved that one quite a bit.

[00:07:40] I'm going to throw in like a little side note of the retro things where I'm flipping channels.

[00:07:44] I love MTV classic where they just show music videos.

[00:07:50] I liked those.

[00:07:51] I like watching that kind of stuff.

[00:07:52] I, we watched a lot of that in college.

[00:07:55] I mean, you know, TRL, that kind of stuff.

[00:07:57] I know it's not a show, but I said,

[00:07:59] I might as well stop on that channel when there's nothing else on TV and I can watch 90s music videos for a long time.

[00:08:07] It's hard to imagine what a big deal MTV was when it first came out.

[00:08:11] Oh, huge.

[00:08:12] It was huge.

[00:08:13] And it was until the late 00s.

[00:08:17] Yeah.

[00:08:17] Those music videos were like must-see TV, even if you didn't have YouTube.

[00:08:23] Well, when you didn't have YouTube, when YouTube didn't exist, that was that.

[00:08:26] I just think that they still make music videos.

[00:08:30] And it's, I never thought about like, I guess the purpose is just to release them on YouTube now because.

[00:08:35] Yes.

[00:08:36] Yeah.

[00:08:36] That's the only place.

[00:08:37] Yeah.

[00:08:38] The whole industry has changed so much.

[00:08:41] Yeah.

[00:08:42] Very cool.

[00:08:43] Blast from the past.

[00:08:44] All right.

[00:08:44] Let's move on to our hardcore topic of the day here.

[00:08:47] Nate, what are we talking about today?

[00:08:48] What's one, some of the other things that you have been researching?

[00:08:50] What are we talking about?

[00:08:52] So this, what I'd like to talk about today is a procedure known as resident infiltration.

[00:08:57] It's known by its commercial name of the product, I think, because there's only one commercial product available that does this technique.

[00:09:06] It's called ICON from DMG.

[00:09:09] And it's, to tell you my understanding of the history of the product, it was developed by these two German scientists that were clinician, academician, scientist people.

[00:09:19] And they developed this technique in Germany to actually arrest small incipient interproximal lesions.

[00:09:27] And they had this whole apparatus they designed so that you could, essentially the concept behind this is that white spot lesions or an incipient interproximal lesion is just where the tooth has become demineralized.

[00:09:39] The enamel is demineralized.

[00:09:41] And a white spot lesion is a subsurface demineralization.

[00:09:44] So you could think of it as a subsurface porosity of the enamel.

[00:09:47] So there's these little pores underneath the healthy layer of enamel where the tooth has been demineralized.

[00:09:53] And the first step in resin infiltration is you put an acid on there to create some channels from the outside down into that porosity.

[00:10:00] The second step is you've got this alcohol that dries out that channel in the porosity.

[00:10:07] And then the last step is you have this unfilled resin that kind of sucks up in there through capillary action and it fills in that porosity.

[00:10:14] And really the intent of it was to fill in the porosity to prevent the progression of caries.

[00:10:20] And they did clinical trials in Germany to show that you can halt the progression of interproximal lesions.

[00:10:28] The big disadvantage of it though is you can't see it radiographically.

[00:10:33] So you treat these small E2 lesions with this treatment and then you never know that it got fixed until you took x-rays a year later and just didn't see it progress and say, okay, it worked.

[00:10:44] So they tried to bring that to the United States and we were supposed to do a big clinical trial of it at UAB in Alabama.

[00:10:52] And we tried it for a while and then what would happen, we'd treat these lesions with this icon system.

[00:10:57] And then the patients would go see their dentist for cleaning.

[00:10:59] The dentist would take an x-ray.

[00:11:01] They'd see a dark spot on the x-ray and they'd do a filling.

[00:11:03] Try to fill it.

[00:11:04] So they come back for recall and they're like, filling you there now.

[00:11:09] So we can't really monitor how well this is working.

[00:11:12] Hey, it's Kate and it's time to get very clinical in this episode's very clinical corner.

[00:11:17] Are you ready, Dr. Mead?

[00:11:18] Let's do it.

[00:11:19] When people are building or remodeling a practice, dentists often invest tons in their cabinetry and they oftentimes don't have a plan for what goes in them.

[00:11:28] I actually avoided adding a lot of cabinetry to my rooms for this very reason.

[00:11:32] Less is more in the treatment rooms.

[00:11:34] Some cabinetry, however, is essential.

[00:11:36] Excess cabinets lead to clutter, wasted money and inefficiencies.

[00:11:41] And expired materials.

[00:11:43] I found a bunch of them hiding in the back.

[00:11:46] And it happens all the time.

[00:11:47] And it's often due to legacy errors.

[00:11:50] Systems that have been passed down without evaluation because it was working for some person.

[00:11:55] But it is avoidable.

[00:11:57] You just have to start with the right cabinetry configuration.

[00:11:59] How do I know what's right?

[00:12:01] Leave that to the efficiency experts.

[00:12:03] Then standardize your setups.

[00:12:04] Each treatment room should have the same essential disposables strategically placed for the optimal workflow in every practice.

[00:12:12] I haven't put that much thought into it, but I'm inspired.

[00:12:15] Awesome.

[00:12:15] And listeners, if your cabinets are overflowing with who knows what, it's time for a change.

[00:12:20] Check the show notes for links to upscale your team.

[00:12:25] And there's a lot of work to do these.

[00:12:27] And insurance doesn't reimburse one.

[00:12:28] And so I think in Europe, maybe it was more popular.

[00:12:31] In the United States, the interproximal arresting of caries didn't seem to really catch on.

[00:12:37] But as it turns out, the same steps and the same product could be used for anterior lesions.

[00:12:46] So for white spot lesions, a lot of times you get them after ortho.

[00:12:52] And aside from just the rest of the caries, it also makes the tooth look better.

[00:12:56] And then all of a sudden now, that's something patients would pay out of pocket for is to do treatment of anesthetic concern.

[00:13:03] And so that's when I started off, I would go to a DMG conference or something.

[00:13:07] And at UAB, we were the ones talking about the posterior lesions because we were trying them on the clinical trial.

[00:13:12] And everyone else was talking about anteriors.

[00:13:14] And so I was seeing all these fancy cases.

[00:13:15] And I was like, those are guys, a bunch of cosmetic driven people.

[00:13:20] And I'm not interested in anterior.

[00:13:21] And I'm the posterior guy.

[00:13:22] And now I'm like, ugh, I never do posteriors anymore.

[00:13:25] I only use this product for the anteriors.

[00:13:28] And yeah, so that's it.

[00:13:29] Now, Icon's not new.

[00:13:30] How long is it?

[00:13:31] Has it been around 10 years?

[00:13:32] Yeah.

[00:13:32] Almost that.

[00:13:33] I remember like my sophomore year of dental school.

[00:13:37] So I started dental school in 06, like probably 08, seeing someone do this treatment.

[00:13:43] It might have been even before that.

[00:13:44] But that's the first time.

[00:13:45] There was another product.

[00:13:46] I can't remember the name, but it wasn't as effective, like way back in the 90s.

[00:13:52] Okay.

[00:13:54] I'd have to look it up.

[00:13:55] There was another product.

[00:13:56] But the results that I saw, and I did use that other product.

[00:14:01] But the results that I've seen like on Instagram and some other social media areas with Icon, seems like the results were much more consistent and better.

[00:14:13] Has Icon had like a different generation come out in the last few years?

[00:14:18] Or is it the original product that launched back in the late O's?

[00:14:22] I think it's the same.

[00:14:24] It's funny.

[00:14:25] It's all these companies.

[00:14:25] They always do this with these products.

[00:14:27] It's always like, oh, we've got the new version of this product.

[00:14:30] And since that election, we get sponsored by companies sometimes.

[00:14:32] Oh, why did you talk about the old formulation?

[00:14:34] And we got the new version.

[00:14:35] I was like, because you just released it.

[00:14:37] I never tried it before.

[00:14:38] And it's like, what was wrong with the old version?

[00:14:40] We like the old version.

[00:14:41] Actually, two versions ago was even better.

[00:14:43] But you decided to change it.

[00:14:45] And so it's actually neat that they've – I don't think they've stuck with it.

[00:14:49] No, I like that too.

[00:14:50] If something works, it works.

[00:14:52] Nate, what I've never seen – and you tell me if you've studied this.

[00:14:55] I've seen, just like Kevin's seen, I've seen a lot of great Instagram results that were probably like the day it was done or maybe a six-month recall.

[00:15:06] But for a product that's been out as long as it has, what I've never seen is someone show me like a five-year result or something like that.

[00:15:14] And so I want to know, does the result hold up?

[00:15:17] Do you know?

[00:15:18] Does anyone know?

[00:15:19] Yeah.

[00:15:19] Do you know?

[00:15:20] I don't know.

[00:15:22] No, that's probably the number one question that gets asked when we do this.

[00:15:27] Yes!

[00:15:28] Number one.

[00:15:30] Ten points for Zach.

[00:15:31] Yes.

[00:15:32] Yep.

[00:15:32] No, there's one study that – there's a German orthodontist named Michael Knosol.

[00:15:38] I don't know.

[00:15:39] I'm sure I'm screwing his name up.

[00:15:40] But he's published two years of results of this in an actual clinical trial where he's shown that, like, the masking effect of resident infiltration is held steady.

[00:15:52] I'm trying to think – so this treatment is not something that we've researched at the school.

[00:15:58] A lot of things we – when I talk about stuff we've been researching on, this is just, like, something I've been interested in clinically.

[00:16:03] And I have a really – the other guy that I do dental to, but this guy named Augusta Robles is, like, my clinical mentor.

[00:16:10] He's, like, the guru at the clinical aspects of doing this.

[00:16:13] And so there's a number of cases that he's done, and they've documented with pictures and stuff.

[00:16:18] And so we've got some cases that he's treated that are probably, like, three or four years out.

[00:16:26] And he's done a number of dental students, so they've, like, held captive in the building so they can follow up on that.

[00:16:32] And, yeah, it seemed like they've held constant.

[00:16:36] I just was doing some review of some literature that you can actually bleach after you do resident infiltration.

[00:16:42] So coffee and wine and stuff can stain a little bit more and infiltrate the teeth, but you can actually – you can bleach teeth.

[00:16:51] Yeah, it's a good question.

[00:16:52] There's another treatment called microagrasion, which is, like, where you rub off these things.

[00:16:57] Is that, like, opaluster?

[00:16:59] Like, opaluster.

[00:17:00] That's what I was using back in the night.

[00:17:02] Okay.

[00:17:02] That can let – the guy – Ted Kroll is a pediatric dentist from Pennsylvania and wrote a textbook on it.

[00:17:09] He's got, like, four-year follow-ups on that.

[00:17:11] That will last forever.

[00:17:13] The resident infiltration, I don't know.

[00:17:14] Yeah, I don't have documentation of things that are even five years.

[00:17:19] But I think the good thing is it's super conservative.

[00:17:22] What's the harm?

[00:17:23] Yeah, that's a great point.

[00:17:25] Sure.

[00:17:25] No, you're right.

[00:17:26] The downsides are opaluster is essentially stripping off an outer layer.

[00:17:30] And then Ray Bertilotti always talked about a technique where you mixed – you made a slurry of a phosphoric acid.

[00:17:38] Like, the same stuff you used to etch teeth and aluminum oxide and used that on a profi cup.

[00:17:45] And I've had some pretty good results of that.

[00:17:47] But same thing.

[00:17:47] You're basically stripping off, like –

[00:17:49] It's like 25 –

[00:17:51] The outside layer.

[00:17:52] With microagrasion, it's 25 microns per application.

[00:17:56] So –

[00:17:56] That's not a ton.

[00:17:57] Yeah.

[00:17:57] Yeah, because if it's like your tooth is 1,000 ohms, like a millimeter of enamel.

[00:18:02] But yeah, honestly, the thing with resident infiltration is that it is not – we did an Instagram poll last – or no, this is last month.

[00:18:13] And we had asked people if the outcome that they got with resident infiltration is always good, sometimes good, sometimes bad, or always bad.

[00:18:23] And I'd say 80% of the people that responded said sometimes good, sometimes bad.

[00:18:27] And that's pretty true with me.

[00:18:29] It's not like it always works.

[00:18:31] And there are a couple of little, like, tips and tricks for making it work better.

[00:18:36] A big one is that the instructions say you only etch one time, but you get better results if you etch multiple times, like seven, eight times.

[00:18:47] Oh, wow.

[00:18:48] Okay.

[00:18:48] So it can – which takes a while because it's two minutes of etching, and you rinse it off, and you do it again.

[00:18:55] And then after you're done, you put this resin on there, which stays on there for, I wish it, two or three minutes.

[00:19:01] You have to cure every tooth for 40 seconds.

[00:19:04] And you put the resin back on there and cure every tooth for 40 seconds.

[00:19:07] So it's not like this is, like, a 10-minute thing.

[00:19:10] This is, like, booking a solid hour or maybe more if you're doing six or eight teeth.

[00:19:16] You're right.

[00:19:17] In that time frame, you're decent with the interior composite.

[00:19:20] You can just drill out those white spots and bond over them pretty quickly, too.

[00:19:25] Or just do a bunch of veneers.

[00:19:28] Totally kidding on that.

[00:19:29] You know, that –

[00:19:29] Totally kidding.

[00:19:31] Yeah.

[00:19:32] So, I mean –

[00:19:33] Make sure you do your roundhouse sealants at the same time you get those 12 veneers.

[00:19:36] That's for –

[00:19:37] I don't know.

[00:19:37] All on X.

[00:19:38] Yeah, or that.

[00:19:39] All the one thing that I have – I've started to come to realize with this treatment, too, is that sometimes I do have to, like, find – figure out what the patient motivations are because I'm very conservatively driven.

[00:19:50] That's what drives me.

[00:19:52] I don't even – I'll lose money to save tooth structure because I – in a weird situation with the dental school, like, I just – I don't – yeah.

[00:19:59] So, I'm very conservatively driven.

[00:20:01] Not all my patients are.

[00:20:02] Like, I've done this on patients and I've gotten 80% better.

[00:20:05] And then I look at it, they're like, I'm not satisfied.

[00:20:07] I want this drilled out and I want a filling to cover the whole thing.

[00:20:10] I want it 100%.

[00:20:11] And I forget that it's – I guess it's their mouth and I'd rather do this where I don't have to have composite margins.

[00:20:17] But, like, is the patient's, like, cosmetically or aesthetically driven?

[00:20:21] I guess I don't get to make that determination.

[00:20:23] Like –

[00:20:23] Zach, on some of your composite veneer cases, are you covering over some of these lesions?

[00:20:28] How is that –

[00:20:28] Oh, for sure.

[00:20:30] Yeah.

[00:20:30] Because if you put a – if you put a – if you put a layer of resin over them, especially if it's a kind of a – usually use one of, like, maybe the opaque-ish shades to cover those types of teeth.

[00:20:41] Yeah, for sure.

[00:20:42] And on the conservative o-meter between resin infiltration or opluster.

[00:20:46] I thought you were going to say between Ronald Reagan.

[00:20:48] A really thin composite veneer.

[00:20:51] Is it more – where I probably did drill out some of the white.

[00:20:55] Is that more aggressive than resin infiltration or opluster?

[00:20:58] Yeah, you bet.

[00:21:00] But – but it's a lot less invasive than a veneer.

[00:21:06] Sure.

[00:21:06] And less costly and all that.

[00:21:08] And the problem is going to be solved.

[00:21:11] Especially if – like I said, if you're decent god, it's going to end it.

[00:21:14] And I guess that's one of the things that's kept me from eye-cunning is the unpredictable – it's almost like with what you were talking about in the last episode with the onlay business.

[00:21:25] It's like you – it'd only be a great choice, but you're not 100% sure it's going to, like, hold up versus the crown where you're, like – your confidence level is, like, sky high.

[00:21:34] I guess that's where I'm at with icon.

[00:21:37] That's not really fair to the product considering I haven't even bought it.

[00:21:41] So, I guess I'm basing it on Dentaltown posts and things like Nate's talking about where it's like, yeah, pretty good.

[00:21:49] But I also think, like, what we talked about with the onlay discussion that this is a good tool to have in your toolbox.

[00:21:55] It's another modality that, you know –

[00:22:25] So, that one's cheaper.

[00:22:27] Icon it is.

[00:22:29] 100 is – I don't know.

[00:22:32] It's – because it's only for one patient.

[00:22:34] So, you can only use that for one patient.

[00:22:36] But, yeah.

[00:22:37] Oh, okay.

[00:22:37] So, it's 100 bucks.

[00:22:39] Perp.

[00:22:39] Just – okay.

[00:22:40] I thought it was like buying – like a bottle of bonding agent for 100 bucks.

[00:22:44] Like, you're going to get, like, a bunch of uses out of it.

[00:22:47] Yeah, 100 dollars is for one patient.

[00:22:49] Okay.

[00:22:50] All right.

[00:22:51] Yeah.

[00:22:51] So, I'm not too far off.

[00:22:53] That is – that's a little bit – like you said, between the time and then the material cost, you've got something.

[00:22:58] Yeah.

[00:22:59] So, you have to figure out a way – and that's the tricky part, too, is figuring out how to charge for it.

[00:23:03] And that's why I have no expertise because I'm – I sometimes think I lose money doing it.

[00:23:07] Actually, I checked my account balance.

[00:23:09] The last month of dentistry went down.

[00:23:11] Like, my balance went down and my faculty practice broke because of lab bills and what they charge me for assistant use and stuff.

[00:23:19] I think I gave away a lot of dentistry for Christmas season.

[00:23:22] Sure.

[00:23:23] But, yeah, now, the – what you charge for – I've been charging – if it's a single tooth, I have to charge more because the kid's $100.

[00:23:30] Right.

[00:23:31] Right.

[00:23:31] Sure.

[00:23:31] I can't charge $100 for it.

[00:23:33] I can't have to charge $200 if it's more for the single tooth.

[00:23:38] But if I'm doing, like, eight teeth, I'll charge – maybe charge, like, $100 with two.

[00:23:42] So, $800 if I'm doing eight teeth.

[00:23:46] And that's where you run into the expectation quotient, too, because that's going to be enough that, like, people want to see something.

[00:23:52] Yeah.

[00:23:53] Something happen.

[00:23:54] Kevin, I'm curious.

[00:23:55] Since you do all your Invisalign work to straighten teeth, and you've got to – I know that Invisalign doesn't have the white spot problem.

[00:24:01] Like, brackets do.

[00:24:03] It'll occasionally happen.

[00:24:04] You have whites – huh?

[00:24:05] It'll –

[00:24:06] With, like, your little buttons that you put on there.

[00:24:08] With the buttons, yeah.

[00:24:09] Okay.

[00:24:10] Occasionally.

[00:24:11] What are you doing, then, to solve that part of the problem?

[00:24:14] So, we're doing a lot of – part of our package for Invisalign is free whitening.

[00:24:20] So, a lot of times we can mask those to the patient's satisfaction with bringing everything up.

[00:24:27] So, yeah, that's how we've been managing that so far.

[00:24:32] But one of the issues for that is that it's sometimes hard to know that you've got all the resin off from the buttons.

[00:24:42] Like, we do a really –

[00:24:43] We think we do a real thorough job, and then someone will come back after the whitening, and there'll be some two-tone, or you can see the margin or whatever, and feel bad about that.

[00:24:55] But, yeah, that's the way we're managing it now, just with the whitening.

[00:24:59] Okay.

[00:24:59] I think that's – I mean, so, you know, I mentioned this again in the pre-show kind of conversation is that we've got a course that we – honestly, we used to run it hands-on at the dental school, or kind of over the shoulder, where we would talk about the product, and then we would do it on a patient.

[00:25:20] And, again, it's with my partner, Robles, who's, like, the clinical – he thrives on clinical pressure in a difficult case, and I get weak in the knees, and, like, I just want to leave and pee my pants and quit when people are watching me do dentistry and it starts to go bad.

[00:25:35] And he loves it.

[00:25:35] He just figures out how to fix it.

[00:25:37] So he does a lot of the – people watch him for the overshoulder, and then we lecture together on the topic.

[00:25:42] But the reason I'm saying that is that one of the big things when we talk about it is that you can do this treatment for white-spot lesions, but you can also do it for, like, fluorosis and other types of weird neuralization type of things.

[00:25:54] And one of the things I always say, again, because Robles is very brave, and he'll use this a lot of different things, and he figures out a way, a solution to make things work.

[00:26:02] But for me, I felt like IV is a lot for white-spot lesions after ortho, and it's a little bit more predictable.

[00:26:08] And then also, even if it doesn't completely improve the aesthetic appearance, I can tell the parents, hey, this is a cavity.

[00:26:17] It's a small initial cavity, and so I'm fixing the cavity in this – if you're so vain that all you care about is the aesthetics, then I didn't fix your problem totally, but I fixed your child's cavity.

[00:26:27] When the $800 bill comes, it's a lot easier to go down.

[00:26:31] What's the limit on – is there, like, a white-spot diameter or, like, depth of –

[00:26:38] Yeah.

[00:26:38] Size or, like, how intensely white a white-spot is before you're going to say this just isn't – this isn't a good candidate for something like this?

[00:26:47] Yeah, so that's, like, a big part.

[00:26:48] That's a healthy chunk of the course that we do is, like, trying to diagnose these lesions.

[00:26:54] And it's – what you said about depth is how I think about it, Zach, is, like, you can – if they're too deep, then it's not going to work.

[00:27:06] They've done some studies showing that you can infiltrate about 500 microns into the tooth, which is, like, half the depth of the enamel.

[00:27:14] That's not consistent, though.

[00:27:15] So, yeah, it's a little bit of a trick trying to figure out which are the lesions that are going to be able to – this treatment will work with.

[00:27:24] There's a couple – there are some tricks, but still, even with those tricks, it's not, like, foolproof.

[00:27:30] And so that's why I think that the white-spot lesions are a little bit more predictable, I guess.

[00:27:35] There's some unpredictability, which makes things – which is challenging.

[00:27:39] Dental things have unpredictability to them, though.

[00:27:41] So, I mean – but, yeah, that's a definite factor.

[00:27:45] Yeah.

[00:27:46] Kevin, what thoughts do you have on this infiltration idea?

[00:27:51] I think it's a great thing to have in your toolbox.

[00:27:53] It's definitely something that I would reconsider looking at because it comes up a lot, especially if you have teenagers in your practice that have had ortho.

[00:28:04] So, it happens a lot, and you have some conversations with the moms or the teens themselves.

[00:28:11] Sure.

[00:28:12] They want a solution for that.

[00:28:14] Yes.

[00:28:14] Yeah.

[00:28:14] Yeah.

[00:28:15] Yeah.

[00:28:15] They want a solution for it.

[00:28:16] Nate, what about the – if it's, like, a brown spot?

[00:28:19] Does it have any chance with something like that, or does it have to be a – does the color of the spot matter?

[00:28:26] So, sometimes with brown spots or a white spot that had external staining on it.

[00:28:31] So, like, with microabrasion, we have to be actually excited about brown spots because sometimes those are easier to get off than white spots.

[00:28:39] With Icon, you can – I've seen people get brown spots off.

[00:28:43] I'm trying to think if I've ever gotten a brown spot off with Icon.

[00:28:46] I don't know that I have.

[00:28:48] I know it's possible to get those off, but it just depends, again, the depth of that spot.

[00:28:55] If it's real deep into the tooth.

[00:28:58] Yeah.

[00:28:59] Just one – I don't know how close we are getting to the end of the show, but, like, one of the things that I think about with this treatment is that – and I'm not saying that – I mean, I'm not a salesman of anything.

[00:29:10] We do run this course where we teach how to do this treatment, and the course – I don't – we donate all the money that we make from the course, like, to our students for travel and stuff, so they don't make any money.

[00:29:21] So, I like it.

[00:29:22] It's not like a care if people – I have no financial incentive, really, for running this course.

[00:29:27] But, like, I do feel if you get the box and you buy it and you try it, it's frustrating.

[00:29:30] People have bought it and tried to use it, and they just didn't like it or didn't work, and it was – it's embarrassing.

[00:29:36] But, like, that was the point of, like, when we put this course together, like, try to – because Robles explains things as kind of a master clinician.

[00:29:42] I explain them as, like, a more novice or timid clinician of, like, how I worked my way through using this product to find the certain applications where I could have some predictability and success.

[00:29:53] I don't know, like I was thinking about today.

[00:29:55] We have soft tissue laser in the faculty practice, and I don't know how to use a thing.

[00:30:00] Like, I never got any training on it, but I pull it out.

[00:30:02] Like, I know how to use it, and every once in a while I want to use it, and I can't figure out how to initiate the tip.

[00:30:07] And every time I put it in there, I'm just waving around like a moron, just, like, making things worse.

[00:30:12] And I'm just like, man, if I just spent, like, an hour, probably even just finding a free YouTube video of how the thing worked, I could actually – I wouldn't hate that laser so much.

[00:30:22] It's nice to hear someone in academics that have – it's hard to read the instructions sometimes or follow the instructions.

[00:30:30] It happens even to you, Nate.

[00:30:32] Yeah.

[00:30:32] We've all been there.

[00:30:34] Yeah.

[00:30:34] Nate, would you say then that ultimately at the end of the day that, like, the case selection component of this is probably the biggest driver towards success or lack thereof?

[00:30:45] And so maybe that's the most important part of your course?

[00:30:47] Yeah, yeah, yeah.

[00:30:48] And I'm not trying to hide information.

[00:30:50] There's, like, a lot of information in there.

[00:30:52] But, like, one of the big things with case selection is that, like, a very predictable way to use it is, like, immediately post-de-bond ortho cases.

[00:31:02] That's been probably my biggest success for using this material is using immediately post-de-bond for ortho cases.

[00:31:08] It would be a very easy place to start, I feel like, with case selection.

[00:31:13] And then, yeah.

[00:31:16] Kevin, as someone who does brackets from time to time, I know you've mostly gone towards aligners, but I know you've done a lot of bracket work.

[00:31:23] What – what's the biggest driver behind teeth to get a white spot, braces, leech, versus not?

[00:31:31] Is there a –

[00:31:32] I think it's hygiene and diet.

[00:31:35] Mostly that.

[00:31:36] Yeah, it's amazing what – on a day-to-day basis, we all see an amazing lack of oral hygiene.

[00:31:45] Sure.

[00:31:46] And especially on a teenager.

[00:31:48] It's just –

[00:31:49] Oh, yeah.

[00:31:49] It's brutal sometimes.

[00:31:51] Decide.

[00:31:51] We all do what we do.

[00:31:53] But have you ever stopped and just, like, how did your mouth get like this?

[00:31:57] How is this –

[00:31:58] Oh, yeah.

[00:31:58] I was –

[00:31:59] There was a guy in today that I needed to do an occlusal adjustment on.

[00:32:02] It's something simple that we did last week or a couple days ago, whatever.

[00:32:06] And I'm like, how is this guy's mouth so dirty after –

[00:32:10] Yeah.

[00:32:11] It's making sense to me.

[00:32:12] It's –

[00:32:13] It can definitely be wild for sure.

[00:32:16] If someone's listening to this and they say, hey, I –

[00:32:20] Sorry about that.

[00:32:21] Microphone malfunction.

[00:32:21] If they would like to give ICON a shot, where can they find your course?

[00:32:27] When are you giving it?

[00:32:28] Tell us how to find it.

[00:32:30] Yeah.

[00:32:30] So, it's –

[00:32:31] I'm presuming I can give you a link to maybe include it on this.

[00:32:33] Yes.

[00:32:34] We definitely will do that.

[00:32:35] But, yeah.

[00:32:36] If you just Google, like, UAB continuing education.

[00:32:39] So, we run it through the school.

[00:32:41] We have –

[00:32:41] It's funny because we have set this up to have this thing where people can come into Birmingham

[00:32:46] and you can stay the night and you would do the didactic part of the course in the morning.

[00:32:51] In the afternoon, we bring in a patient.

[00:32:53] And we really try to push it through Instagram and social media and everything.

[00:32:58] And then two weeks before the course was supposed to go on, we asked the continuing education

[00:33:03] department.

[00:33:03] They didn't even sign up.

[00:33:04] They're like –

[00:33:05] Yeah, like two people.

[00:33:06] I was like, man, all these other people, like, sell out courses like crazy.

[00:33:09] But I realized that nobody wants to come to Birmingham, Alabama.

[00:33:12] Like, it's just –

[00:33:13] It's a hard sell.

[00:33:14] I'm not going to take it personally that they don't want to see the course.

[00:33:17] But it's just like no one wants to come to Birmingham.

[00:33:18] So, then we just made it an online on-demand course.

[00:33:22] And, like, instantly we had –

[00:33:23] Oh, great.

[00:33:24] It was like 16 or 18 people signed up.

[00:33:27] Because it was just like the idea of, yeah, coming here wasn't worth it.

[00:33:29] But it's sunny there.

[00:33:30] I would go.

[00:33:31] Okay.

[00:33:32] Sure.

[00:33:32] Yeah.

[00:33:33] We've got good restaurants.

[00:33:34] But, anyhow, it's going to be offered on-demand.

[00:33:37] But we're going to run it a little different where we'll offer it certain times throughout

[00:33:40] the year where you can watch the lecture on-demand.

[00:33:43] And then we'll have a Q&A period for an hour and a half, whatever it takes.

[00:33:46] Scheduled for different dates.

[00:33:48] And then eventually we might try to have it.

[00:33:49] So, if enough people watch the course and I'd like to see over the shoulder, we'll schedule

[00:33:53] an over the shoulder.

[00:33:53] Honestly, I think that's –

[00:33:55] And it's not – they're not going to be watching me.

[00:33:57] They're going to be watching Robles do it.

[00:33:58] And every time I watch them operate, I pick up all these little tips and tricks that he does.

[00:34:03] So, that's the way we're trying to think to do it.

[00:34:05] So, I think the course is a range of bucks for like an online on-demand.

[00:34:10] And then you get three hours of this course.

[00:34:13] And then this hour and a half of Q&A.

[00:34:16] And then the school issues you your CE credits.

[00:34:20] You get the CE plus the Q&A as far as credits.

[00:34:24] Awesome.

[00:34:25] So, if you just Google UAB, continuing education department, and just look for the website.

[00:34:30] And then our names will be on there.

[00:34:31] I think we're having another one in March or something like that.

[00:34:35] Okay.

[00:34:36] Coming up in just a couple months.

[00:34:37] Cool.

[00:34:38] Awesome.

[00:34:39] Nate, thank you for – I know your schedule is busy, especially getting ready for all these

[00:34:43] lectures that you do.

[00:34:44] Thank you for taking a couple hours out of your evening to chat with us.

[00:34:47] Thanks so much, Nate.

[00:34:48] Thanks, Nate.

[00:34:50] Thanks, Nate.

[00:34:50] All right.

[00:34:51] Kevin, any last thoughts on resident infiltration or another kind of infiltration?

[00:34:55] Take the course.

[00:34:57] Take the course.

[00:34:58] All right.

[00:34:58] I am going to relook into it as well, just like with the onlays.

[00:35:01] Sometimes it's good to talk about some of these concepts that you don't utilize to revisit

[00:35:06] them.

[00:35:06] All right.

[00:35:07] Thank you guys for listening.

[00:35:08] Nate is on our Facebook page, Very Clinical.

[00:35:11] If you have any questions for him about this or any of his other cool topics.

[00:35:14] So, we thank you for listening.

[00:35:16] We will catch you next time.

[00:35:18] See you.

[00:35:18] See you.

[00:35:19] See you.