Very Clinical: Pediatric Dentistry Basics with Dr. Russell Schafer

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[00:01:38] will entertain and enlighten you with tips and tricks for regular daily dentistry. Here's Kevin and Zach. Yo, yo, yo, Clinical Hacks listeners. This is Dr. Kevin Fryer coming to you from beautiful Cleveland, Ohio, the home for right now of the Cleveland Indians. Who knows what will happen in the future? Joining me tonight is my trusty co-host, Dr. Zach Miners. How's it going there in Kansas City, Moe?

[00:02:09] Just waiting to see if the Chiefs moniker has to be removed at some point as well. You know, I mean, you never know. At this point, as we're recording this, we don't know the Redskins new name. So we'll see. But we're both on the hot teams for our favorite teams. But it is what it is. Can't fight the power. So anyway, that's really not. This isn't a political podcast. We're talking about clinical dentistry here. Can it be a baseball podcast or football podcast, though? I mean, I could go for that.

[00:02:39] I think we should have an episode. In fact, NFL preview. Can we do that? Have you ever treated any professional athletes in your office? No. I'll save that for the next episode. OK. All right. All right. So also joining us tonight is Dr. Russell Schaefer from the great state of Louisiana. How's it going down there? It's going fantastic, Kevin. How about yourself, my friend? I'm doing great. We're very happy to have you.

[00:03:07] Tonight, we're going to talk about pediatric dentistry in the general dentist's office. But before we get to that, since we're approaching going back to school, maybe. Who knows? Let's talk about school for the three of us. Did you guys bring your lunch to school or did you buy? Zach? A mix, but I would say my mom packed me. I brown bagged it more than I bought. All right. Well, that's really what I was getting at.

[00:03:37] Did you brown bag it or did you have a lunchbox ever in your school? Oh, no. I had a couple of cool lunchboxes for sure. Yes. What's hair bottom? Transformers was one of my favorite lunchboxes and a He-Man lunchbox. Those were my two that immediately jump out. And was there a thermos inside? There was, although my mom, I was very much in the Capri Sun era.

[00:04:05] So that was kind of the drink du jour at the time. Yeah. So you're sucking on a straw. I like to suck that straw from a bag. A bag. Capri Sun. That's right. Yep. A little IV bag of delicious sugar water. Russell, did you go to school? Elementary school? Actually, I didn't go to school at all. Oh, anyway. But no, when I went to elementary school, I always had lunch brought for me.

[00:04:33] Like, I guess I never bought lunch at the cafeteria. And I always had like a really kind of a crummy lunchbox. Like it was always like a gray or like a really boring, just a boring color. Like never like Ninja Turtles, never He-Man. I mean, like Zach, you're making me feel kind of jealous right now, honestly. Like, man, you just lived a good life. Yeah. Great lunchbox, man. Were you guys on like a super tight budget? What's the deal, man? No, we were just Catholic. Oh, hey. Yeah. Hey, I have the Catholic background as well.

[00:05:02] But I guess I was allowed to worship those. Yeah. Those false idols on the lunchboxes. No, I think honestly, it's probably because I was a pretty boring child. Like, I know I could have gotten any lunchbox I wanted, but I just wanted the very conventional lunchbox that would, you know, last me for until I was an old man. Clearly. You didn't want to stand out in the crowd. Yeah, exactly. You know? So. How about you, Kevin? I had a Harlem Globetrotters lunchbox from the cartoon Harlem Globetrotters because that

[00:05:30] came out in the 70s, obviously, because I'm way older than you guys. Yeah. It was really my favorite lunchbox. And because of just who I was, I also put stickers on it. And I had a bunch of NBA stickers. So I mixed the NBA stars with the Harlem Globetrotters because I really didn't know that there was, you know, I thought they're just playing basketball, right? Yeah. Are you going to start whistling us some sweet Georgia Brown?

[00:06:00] I will not start whistling. However. Ah, okay. I had a sticker of, do you guys know who Austin Carr is? He's one of the first Cleveland Cavaliers. He's one of the best friends around here. Many well. Austin Carr was on my lunchbox. And, you know, I got a lot of, the kids really loved me because I had a actual NBA star on my lunchbox. But I love that Harlem Globetrotters lunchbox.

[00:06:26] I often look at it, look for it when I go to like thrift stores and stuff like that. Somewhere out there, our lunchboxes exist either in a landfill or at Goodwill or in someone's collection. You know, things that keep you up at night. Yeah. I mean, the real thing you got to worry about is like who actually wanted your lunchbox, Kevin? Like who actually said, I want Kevin Fryer's lunchbox? Oh, my DNA is probably all over it, you know. Exactly.

[00:06:53] Crumbs and ho-hos and, you know, all that sort of good food that I ate back then. Exactly. Kevin, I got a question for you. Yeah. You said we were going to talk about pediatric dentistry and I want to know why you got the denture guy on for pediatric dentistry. This seems like a tough, tough look for us. Well, you booked the guest. So, I'm going to turn it right back. Russell Schaefer, why are you on a pediatric dentistry podcast since you're like, you know,

[00:07:21] known as our, you know, removable guru? True. So, the real reason is just because I hate myself. Yes. You know, like honestly, like I think I was talking to one of y'all earlier, I think it was Zach, how my ideal practice would be pedo in the morning, dentures in the evening. And I guess it's pretty much because I cut my teeth on just doing pedo for the first few years of being a practitioner. You know, I worked for Cool Smiles for a few years.

[00:07:48] And unfortunately, Cool Smiles, it's a really bad name just because they're pretty well known for being aggressive and doing a lot of papoosing. Anything. And I was a huge fan of like early on, like I did some papoosing and I hated it. But then like I learned how to use like nitrous and how to like just give good anesthesia and how to do good treatment plans and like how to do good behavior management. And I really loved pedo a lot. It's just like a really fun part of my practice. Like whenever I get to do it.

[00:08:18] I'm pretty sure I saw you on the 60 Minutes documentary where they roasted the place. Was that in the background, right? I was. I think you were the guy behind the guy. One sign like being like, yeah, we're number one. No. Anyway, thankfully, I don't work for them anymore. Not because I didn't like them, but because they might fire me if they heard me say that. But, you know, I enjoyed the company. We did good work. But like there were a couple there were some bad apples there as well. And I see what they did. And I was like, really? You know, like you look at the individual practitioners and you think, come on, like it's

[00:08:48] not worth it, you know. But that's another episode, if that makes sense, because you see bad dentistry wherever you go. So, but anyway, like all saying, I love pedo. It was a lot of fun. You get to learn how to do behavioral management. You know, I feel like dentures and pedo is kind of the same thing because neither patient really wants to be there. You know, they always hate the dentist. And anyway, it's just a fun thing. I've always enjoyed it. I like seeing. Let's get into it.

[00:09:17] Let's talk about an ideal pedo exam in the general dentist office. And let me say this. I know we bag on kids a lot and, you know, a lot of people don't like to do it, but it can be fun. And I'm going to say this right off the top. I do feel that when I have a, I still see some, you know, like for recalls and stuff. I do feel like that's when I can be most myself because I just joke around with the kids and say things I wouldn't normally say to an adult.

[00:09:45] Not, you know, just I joke around with them the whole time. And I, I, I do like that aspect of pedo that I can just sort of clown around. But that's usually for recall exams and that sort of thing. But let's talk about our ideal pedo exam. So under five year old, five or okay. Five and under, you know, I think that the first question is what's my relationship with mom and dad, you know, who's coming in the, who's coming in the room.

[00:10:13] If I've got a mom that, you know, cause it's almost always mom that brings, brings the kid in, you know, mom comes in every six months has never had a cavity or it's like had a very few cavities of her lifetime. You know, generally I'm pretty much like, okay, let's do a little toothbrush trophy. Um, for a kid that's like under three that just can't sit in the chair because every now and then you'll get a child who just, you try to lay them back and it's clearly just not happening.

[00:10:39] And then we do a lap to lap exam, which is a really easy exam to do that. I feel like a lot of general dentists just don't know how to do. And it's hard to demonstrate on a podcast, how to do a lap to lap exam. So up here in the North, we call that a knee to knee exam. Okay. Same thing. I mean, I've heard it go both ways. Like I was taught lap to lap back in, uh, 2011, 2010 by Janice Townsend and LSU dental

[00:11:07] school, but we go a little slower down here in the South. So, you know, like call it knee to knee, whatever you want to call it. But it's pretty much where the mom or the parent or the guardian is restraining the child in their lap or in their knees and pushing the kid back into your knees so that you can do a full exam on them. Yep. And then when the child's screaming, it's even better. You just say, oh yeah, this is fantastic. The child's screaming. I could see all the teeth right now. I love when that happens. The mom always wants to shut that down. And I'm like, no, let it go.

[00:11:37] Oh, cause I can see everything really easily here. Well, I think also the mom kind of feels embarrassed and you just say, well, this is normal behavior for a three-year-old, you know? Absolutely. If you're doing it to an eight-year-old, yeah, you say, yeah, this isn't normal at all. But like a two, three-year-old, you're like, yeah, the toddlers scream. They don't want like a big, weird guy in their mouth. That's normal, you know? And I find that to be pretty, I find that to be kind of useful to kind of break the tension because they feel like a, they just don't feel good about it when that happens.

[00:12:07] Now, like a, I guess like a- Are you a fan of the knee-to-knee exam? Oh, for any kid that won't lay back immediately and you know them, like when they're clinging to mom the whole time, I'll do the knee-to-knee without a question about it, you know? I find they're kind of hard to do for non-insurance patients because a non-insurance patient be like, wait, you just charged me how much money to like just have me hold my kid back and you brush their teeth? So I, it's kind of a hard one there just for the value-added perspective.

[00:12:36] But I think that for like insurance patients, it's so easy. Mom brings the kid in when they, when the mom has a recall and it just, it's easy to do for like that little age right there. And generally, it's just- What are you, what are you looking, what are you looking for? What are the like quick things you're looking for other than like gross decay? I mean, what's, what are you going for? So really my biggest question isn't even like, just like checking in the mouth.

[00:13:04] It's really asking mom, how many cups of juice does this child get a day? Three or more is an automatic. Something's weird. Like a child can have like one cup of sweet drinks per day and I don't even call it juice. That's called a sweet drink, you know? And actually the second thing I'm looking for is snoring. I asked the mom, does your child snore? And like, cause I've kind of enjoyed ever since taking Aaron Elliott's class with T-bone on sleep apnea, I've kind of gotten to saying, hey, snoring is not normal at all.

[00:13:31] You know, and trying to say, okay, if your child snores, let's get them to ENT for an evaluation to look at tonsils. So that's kind of the two things. It's not so much the, the exam itself is kind of, it's, it's useful, but it's not as useful as like just talking to mom or dad saying, hey, is the kid who's brushing the kid's teeth? You know, who, how much sugar is the kid drinking? Hey, it's Kate, the assistant. And it's time to get very clinical in this episode's very clinical corner. Are you ready, Dr. Mead? I'm ready, Kate. Let's hear it.

[00:14:01] Dr. Mead, have you ever given your assistant the death stare when they leave the room mid procedure? Definitely. It totally disrupts the flow. They're probably off finding something that we need. I've been there and it's usually because we're in a mad panic to find something that wasn't restocked or somebody forgot to move it from one room to another. My assistant tries to keep up with inventory, but it's tough. Exactly right. You can simplify material management with procedure tubs and central backstock location so we can

[00:14:30] avoid the mid procedure escapes, which means no more death stares. That sounds perfect. How do we make this happen? Well, you'll evaluate your clinical workflows. If your assistants are constantly leaving to grab materials, it's time for an upgrade. Check the show notes for links to upscale for your team. I really view this as a counseling session for mom and dad. Mom, usually mom. Yeah. In terms of diet, nutrition, home care, all that sort of stuff.

[00:14:55] And I really, I really feel in, in a former life, I, my partner was a pediatric dentist. So I really got a huge dose of what happens, what should happen with children in the pediatric office. And I learned a lot through that. And I really, I do have a heart for kids.

[00:15:14] And I do, I do think that our number one goal at that age is to create a safe dental home for these kids so that they aren't afraid of the dentist, that they have a positive experience, that we don't push them beyond what their emotional age can handle. And, you know, that we, we counsel the parents in terms of creating, you know, good dental health for the rest of their lives. And I take that real seriously.

[00:15:41] I know we joke around a lot on this podcast, but that is something that I take really seriously in our practice. Yes. I completely agree with you. And I, to go back to Zach's question, like what am I really looking for outside of gross decay? I'm looking for like just that little cervical demineralization that you'll see around the anterior teeth that pretty much like tell me that the teeth are just baking in sugar all day long.

[00:16:06] And I think that's the most important one because I'll literally tell mom or dad, I'll say, hey, do you see this like white stain right here? This is a cavity getting ready to form. And the way we fix it is with a silver tooth. And I'm sorry, little Susie, little Johnny is just too darn cute for a silver tooth. You know, we don't want that. And no parent really, well, you know, says, oh yeah, I really want my kids to have silver teeth.

[00:16:30] And I find that to be like a really useful way of like kind of like getting everyone on the same page where I'm not necessarily blaming the parent for what's going on. I'm just saying, hey, this is what's going on. How do we stop this? Well, we stop the sugary drinks and maybe we would just say like no better brushing habits by having the parents do it. Anyway. And then I think that, you know, from like the three to four year old, from there we get to like the five, six year old. And by that point, I kind of expect to be able to take a couple of bite wings on them.

[00:16:59] Like I really like the two by two, like two PAs, two bite wings just to kind of see everything. And if a kid by the age of five or six can't take two bite wings, two PAs, that kind of was automatically a, hey, something's not right here right now. Like most kids I feel should be able to tolerate like a DEXA sensor, pedo size, a DEXA pedo size sensor by the time they're six. That's just how I kind of feel.

[00:17:25] And if a kid can't tolerate that, it gets kind of iffy only because like if they got closed interproximals and I know mom has decay in her. Well, I get kind of worried not taking x-rays on that age group because I have to see so much interproximal decay. And that that's that's always my that's my toughest area to find. And I know, Zach, when we're talking earlier, you say use phosphor plates, but you don't have a lot of luck using phosphor plates on those little eight, those little ones. It's not easy. Yeah.

[00:17:56] No, it's it's it's not. And, you know, sometimes I've defaulted to taking a pano sometimes even earlier than those six year molars coming in just that way. I can pick. Obviously, that's not going to pick up your your board lesions, but it'll it'll pick up something that's on the verge of a pulpotomy. Yeah. Yeah. I agree with that. So let's say we've we've got someone in that age range. We take some bite wings. We see some interproximal decay. Let's really get down and dirty here. How are we going to treat those?

[00:18:26] So let's say we have a quadrant of primary interproximal decay. Let's go around the horn here and see how we're going to treat that. Go ahead, Russell. You can go first. So I'm pretty darn aggressive with interproximal decay. You know, like I think that whenever you take a step back, I think doing treatment planning.

[00:18:51] Because there's a there's many there's a, you know, do be conservative or be aggressive with pediatric decay is really like an individual decision for the practitioner. I am personally am pretty aggressive. If my child. I don't have any children, but if my child had interproximal decay that that's getting a stainless steel crown on it. Just no questions asked. I know some other, some very smart, very talented, much better pediatric dentists who I would send my kid to in a heartbeat would disagree with that.

[00:19:20] But I love my SSCs, you know, SSCs and amalgams are kind of my go to for for kids teeth. Outside of anterior, I'm not going to do like an SSC on E or F. But I feel like you don't really see you don't do, you know, I don't do many fillings on anterior teeth for little ones. But interproximal decay on our primary molar gets an SSC every single time. Like, Zach, what's your go to for some interproximal?

[00:19:50] Okay, so, well, first of all, you said multiple interproximal lesions. Okay, first of all, once we hit the point where it's going to take me more than probably three visits to fix something, we're off to the pitid on us at that point. So if it's like A, E, I, J, K, L, S, T, that's too much at that point. I'm not, I'm probably not going to do that. But if you're just saying like, okay, this person's got A, B, M, O, D, O, that combo.

[00:20:17] Okay, so I really, I didn't do a single SSC in school. And, and I, so I never got that comfort level. And I didn't see the kind of patient population that was like very rampant in decay. And so I, I, lifetime wise, I bet Russell does more stainless steel crowns in a month than I've done in my entire 18 year career. And so I've just never achieved that, that comfort with them. Do I know how to do them? Yes.

[00:20:47] Do I do them? Yes. But for what you're describing, I, I would use resin all, all day, every day on those. And I, I would use like a Comprimer style resin. I'd use like a Beautifil too from Shofu. So that's what I would do. So if we're talking about small interproximal decay, I'm right with you there, Zach. I'm not going to pull out the stainless steel crowns for that. However, I agree a hundred percent with the concept. I did part of my training at Ohio state.

[00:21:16] We went to another community where there was no fluoride and all we did was see kids there that had rampant decay. So you really had a good idea of what that looks like in the population. And, you know, what you don't want to have happen and what we're alluding to with the stainless steel crown is to do, you know, one interproximal surface and then see them back in six months and the other surface is now decayed. So just get rid of that obviously is, is the way to go.

[00:21:43] However, I sort of do draw the line at that now, even more now where that's going to go off to the pediatric dentist when we have that sort of situation. But, you know, the situation where it's just one quadrant and a good kid, I'll probably end up doing a composite or composites there and be fine with it. And I do want to take a step back for behavior management for those kids.

[00:22:07] I know there's a lot we can talk about, but I really feel like there's behavior management that has to go on with the parents or whoever the caregiver is. So this scenario happens a lot in our office. So, you know, little Johnny has a cavity and you can see in the parent's face that they're starting to flip out about it. And I'll usually ask you, well, how are you going to fill it? And I'll look at them. I want to say, well, how did we fill yours? Because, you know, we're going to have to do sort of the same thing. Right.

[00:22:35] But what I really like to do is to take the parent alone in the hallway or go down the hall somewhere and tell them, please don't say anything to little Johnny at all. Nothing. Don't just say that we have to go back to Dr. Fryer's office. He's going to fix your tooth. Yes. How? Amen. And you don't know. That's Dr. Fryer's job. He'll explain it when you get there.

[00:22:59] And I explained to them about good natured or really evil Uncle Joe or Cousin Johnny that's going to scare your little boy or girl to death and that the dentist is evil. No one walks in that door expecting us to be, you know, expecting to have a bad time. It's all planted in their heads by some, you know, other adults or some other cousin or kid down the street.

[00:23:27] Just I want I want the kid in there as a blank slate and nine point five times out of ten. I can get through that appointment and the kid doesn't even know they had an injection. They don't need and they, you know, they leave laughing and the parent thinks we've turned a miracle when really all we've done is manage the mental aspect of it. Huge fan. No prep. I also still do that. You don't have to prep your kid for this. Don't tell them. Just tell them they're coming back. They're getting a tooth fixed. That's it. You know, done.

[00:23:56] So how about you, Russell? Oh, no, it's kind of funny, Kevin. Like, like literally what you do is I will take the parents out the room. Yep. And especially if I can see the parents afraid, I say, I see that you're scared right now and that's normal, you know, and then I'll say I'll say something like, you know, I want your child to have the best experience possible. And I'm actually kind of fortunate by doing dentures. I will say, you know, it's really important to me that your child has a good experience.

[00:24:22] I do a lot of dentures and I'll say something like, you know, I'd be willing to bet you that probably one quarter to a half or maybe more of my denture patients had bad experiences when they were a child. You know, and I don't want your child having dentures. I don't want that. And I'll say, look, this is what you need to do. Bring them in. I will take good care of them. And I just say that, say like, don't scare them. Don't tell them what's going to happen. Just say, I'll take good care of them. You know, they're going to, they're just going to fix the cavity and you leave it at that.

[00:24:49] And I, I, I think that, you know, getting the parent on the same page. Now the parents are on the same page. Yeah. They, they get punted to pedo in a heartbeat because I don't want to say to the child. Like I, I am not confident enough to state a child under the age of 16, like 16, even heck 18 and younger. I don't want to date them. Like just anything more than laughing gas. No, they go to someone who's smarter than I am with that sort of stuff. But, but you really got to get kids.

[00:25:16] You got to get the parents on the board saying, Hey, this is normal. We'll take good care of them. But you're a team member here. I need you to work with me. So back to that. Are you using nitrous a lot for the pediatric patients in your practice? Oh, I will. I will fight tooth and nail that every single child gets nitrous. Like I know Zach loves nitrous and I fully agree with him. Like I do. Yeah. Yeah. Like, so what I do is I charge a hundred dollars for nitrous in my office, you know, it's a flat fee, no matter whether it's five minutes or two hours.

[00:25:46] Um, but if like I have a kid, I'll say, you know, mom, I give this half off for kids. Cause this makes everything just so much easier. And you know, $50 for nitrous that, that pays it pretty much. That's a, you know, it's, it makes it easy. But with nitrous on a four-year-old, I can crank out four SSCs with no problem at all that the kid just doesn't care. Give them two IAs and I can just rock and roll within 15, 30 minutes or so. They leave with a couple of what I call Superman crowns, you know, just stainless steel crowns.

[00:26:14] They love that term or princess Elsa crowns. Cause that's the other one too. You know, what percent do you rock them at? Usually Russell. Um, what do you mean? Wait, so the, oh, 50% like rank it up to 50. Usually don't like when you see, you'll see that child, you see the kid, like their right hand will just go limp on the chair. And that means they've kicked on the laughing gas and it's phenomenal. But I also think the laughing gas is really good too. Cause you'll very quickly know whether the appointment is going to go well or not.

[00:26:43] The kid that fights you on laughing gas. I abandoned very quickly, you know? Oh, you're going to, you're taking the nose off. Yep. This is, we're done. You know, like if mom wants to, if mom wants to fight it, I'll give mom like 15. Meds or so just walk out the room. But if they're fighting the nitrous nose, yeah, we're you're, you're going to, uh, you're going to my pediatric dentist down the street who will knock your kid out in a safe setting and we'll all leave happy. Right. Russell, what kind of anesthetic are you using?

[00:27:13] Like, let's say you're doing like the AB SSC case. What, how much anesthetic are you to give? What, and what flavor of anesthetic? Um, I like, so I like lidocaine just because that's what I was kind of raised about, you know? And I know that you can, I know that a lot of pediatricians use septicane as well. I don't have a good answer for that other than saying like, so if I'm giving like AB, I'll go in there and give, you know, uh, put laughing gas on, use some lidocaine jelly on the, uh, buccal mucosa.

[00:27:43] Give a very, very, very gentle injection by as gentle as I could possibly give a lot of shaking and a lot of just like saying, all right, you know, like I'll do something like saying like shaking. It's like, Oh, it's an earthquake. Like, just, I find you got to kind of find your one act play with kids, like see what feels normal to you. Shake the heck out of their jaw. And then there's like, give a very light injection of lidocaine. And then with A and B, I will actually go in there and I'll give a link.

[00:28:10] I'll give a palatals like run on the palette of those teeth. And I'll say, Oh, sorry about that. Oh yeah. It's a lot of cold water. And I find that if you just reframe the injection to being cold water, and I know a lot of pediatric dentists use that. Um, in fact, everything I learned is pretty much from dental town, like pediatric forums, but like just call cold water that reframes in the kid's mind of saying, Oh, this isn't a shot. This isn't an injection. This is cold water. And that just kind of makes more sense to the kids.

[00:28:38] But, um, and then I guess, I think also like if I was doing K and L at the lower left, I give IAs all day long. Like I don't mess around with infiltration. I want to literally what I like to do is I like to give them an IA, walk out the room, come back in five minutes and take my Explorer and I just dig it right into that lingual. And mom can literally, I want mom in the room seeing that like I'm digging my Explorer into the lingual of that tooth and saying, okay, my kid's numb.

[00:29:08] You know, that way mom has more confidence that if any, if the kid starts freaking out for wherever they freak out, then like mom could say, okay, it's not, it's not Dr. Shaver's hurting my child. It's the child's just having, just freaking out about it. Anyway. All right. Let's move on to something more aggressive. So the decays into the pulp, we need to do a pulpotomy. Let's, let's go around the horn on our pulpotomy technique. Um, Russell, you can go first and then we'll, we'll go around the horn here.

[00:29:38] So honestly, I like former creosol. Like it just seems to work really well. Um, you just like the smell, right? I love the smell of it. Like right now I'm actually doing a whole bunch of Valplast at my office, which would be another episode. And Valplast needs former creosol apparently. But anyway, um, no formula just kind of works in my hands. I see the, um, what's the other one? Um, ferric sulfate. I see so much resorption from it. Like those, those cases come back looking hideous within a couple of years.

[00:30:06] And I say, you might as well take it and out and just give them a space container. Um, I know some people that have, are more fancy than I am love the MTA or love some other combinations. Um, I like form hooks. It works, but I can respect someone who says, I want to form all my office because it's, it's a nasty material to have. You know, I can't argue with that at all. So formal, formal creosol, then IRM. Yeah. Form of creosol IRM.

[00:30:36] And then, uh, sink, uh, SSC on it afterwards. With Durlan? Um, with, uh, I know I think I SSCs with a Fuji too. I mean, Fuji, um, well, let me, sorry. Uh, Fuji sim or Reliax, uh, looting. So. Well, I mean, I do a grand total of about two pulp autobies a year. Again, I, I just don't see a huge aggressive, uh, population. Um, I am a, I have a diode laser in each of my rooms.

[00:31:03] I'm a, I'm a laser to cauterize, uh, MTA over the top of it and cement the chrome steel crown with, uh, a glass ionomer, like a Fuji sim type of cement. So yeah, a few seconds with the laser after I do the round burr. Um, and then I use a retro MTA from a company called bio MTA. It's the fastest setting MTA I've ever run into. Uh, so you can get it, get it, uh, decently set within a couple of minutes and then it's ready to cement on top of. So that's, that's my, that's my go-to.

[00:31:33] I have a good, I have a good friend that, uh, is a pediatric GP and that he told me if you've got a laser, this is what you should do. This has the, this has the highest, uh, success rate. And ironically, he does the ferric sulfate and since he doesn't have the laser, which he acknowledges has the worst success rate. Uh, so that doesn't, I don't know. I don't get it. But, uh, anyway, he told me to do the laser thing. So I'm doing the laser thing. How about you, Kevin? Yeah. So back in the day, I would, I'm a former creasol guy.

[00:32:04] Um, currently we don't even have any former creasol in the office, but former creasol, um, IRM and then cemented on with Duralon and, you know, hope for the best. And, you know, usually that, that worked out fine. So, and that, that's pretty much old school pediatric industry and, you know, it works. All right. Before we leave this real quick, I know we're up against it, but Russell, what happens if you, uh, get into that tooth and it's necrotic? You take it out.

[00:32:34] Honestly, like I am. So anytime a child comes in saying, you know, well, any, I, whenever a kid, mom, I don't have to do pulpotomies. If a child says this tooth hurts, that's the only time I'm, I love the, uh, I love SSCs, but I don't actually do it. I don't have to do it. I don't have to do it. So my thought is like saying, okay, if a kid, if it, if a tooth hurts, what's going on with that tooth? If I see a periapical radiolusancy, that tooth comes out. No questions asked. We're not doing a pulpactomy.

[00:33:04] Those don't, those are just really too darn difficult to do. And you don't get the time to do them. Well, if that kid says to me, or his mom says, this child has woken me up in the middle of the night with a toothache, that tooth comes out. Just it's, it's clearly irreversible pitis. It's got to come on out. I feel that like if a kid says, or mom says he, he or she only complains about this tooth when I'm chewing on it. Well, that's probably reversible pulpitis.

[00:33:33] And in all honesty, I really think that we're doing pulpotomies, not so much for therapy, but more just for diagnosis. That's how one pediatrician has explained to me saying, you know, you could supposedly just do an SSC on it. Don't remove, don't, don't hit the nerve. Just like do an SSC on a tooth reversible pulpitis on it. And it should be able to heal on its own if it's not irreversible pitis or necrotic. And so my mind is we're going in there just to make sure that the pulp's not hyperemic or not necrotic.

[00:34:02] So I, I'm probably like you, Zach, I don't do a lot of pulpotomies just because I don't think they work. We're doing it for diagnosis, not for actual therapy, if that makes sense. Kevin, can I, can I extend the episode like three more minutes? Can I, can I get, can I get three more minutes on this with Russell? I'll allow it. You'll allow it. All right, Russell. All right. I need two of the things from you.

[00:34:25] Um, one, uh, obviously if you're working in a pediatric practice, um, I'm sure there's a little bit of pressure to do a bunch of sealants. I don't know if you listened to our sealants episode, but we, uh, Kevin and I are firm anti-sealantists. Uh, I want to know what your take. I agree. Honestly, I don't think they actually work that way. Yes. Like, I feel like, guess what I did yesterday. Roundhouse sealants? Took out some sealants. It had a bunch of decay underneath them.

[00:34:55] And, uh, yeah, it happens a lot. Go ahead, Russell. No, I, I completely agree with y'all. Outside the Frank Clayton method of roundhouse sealants, honestly. I, so I feel like sealants have been over-prescribed or they're just done so, um, crappy that, you know, just, well, they're used to make production for so many practices. And I see this all the time and I love sealants.

[00:35:24] Like a well-done sealant. I love, you know, but in my mind, a well-done sealant is as difficult as our well-done resin. You know, I think it's more so. Back, back in the day, if I could get a rubber dam clamp on, let's say number 19 and we were treating, you know, the primary molars on that side and I've got everything dry and I see that those grooves are clean. I'll seal that tooth. Yeah. Because I have control over it, but that's such a rarity.

[00:35:51] And I feel like, honestly, like I would like to just take a, if I've got a kid numb, let's say I've got like 19 and 30 or there and I've got both quads numb. I would rather go in there and just kind of like, just remove the groove with my handpiece. Keep it all on enamel, but like etch bond and put a, put a good feeling in there rather than like etch and then put a sealant that you're kind of hoping bonds, but you don't really quite know if it's going to bond or not. But I, I guess I.

[00:36:20] Occlusal composites have a pretty strong track record. They have a. Occlusal composites done well have a very strong track record. Yes, I should say that. Yes. You know, and like, I love my isolate or. But even like if you've got like me working with an assistant and no like isolation. If I can see the tooth the entire time and like control everything, I can still probably do a pretty darn good occlusal amalgam on it. Or I may start an occlusal.

[00:36:48] I do a lot of occlusal amalgams, but anyway, I can do an occlusal composite on it pretty darn well. But I completely agree with you, Kevin. Like if it's so like oftentimes if I'm seeing like a family that's fee for service and I'm doing like a. A pack of SSCs, which doesn't happen very often. In the pack. I love that. Yeah. Nice. Crack it open. Yeah, exactly. Like a. A B I J K L S T. Like every night that does happen.

[00:37:14] And the kids like doing well and I'm able to like isolate night, the six year old molars. I'll throw a couple of sealants in there for no charge because it takes me no extra time. And I feel like I hate charging a parent 50 bucks for something like that when they're already paying me a lot of money to do other stuff. It's kind of like just, it's that little bit of a lanyard as we Louisianians like to say. I getcha. Yeah. So. And then finally, Russell, SDF and Pito. Oh yeah. Love it. Well, so this is.

[00:37:43] How are you using it? I guess. I think we, I think universally it's loved. I would just want to know how, when SDF versus when resto. SDF. Well, so first of all, I will do SDF on everybody that lets me SDF on them. Like I love the material. I think it's a fantastic option. You take a shot in the morning. You just, you just shoot a shot out of SDF to get warmed up. You know, like I do that after I do my bourbon in the morning. So I'm from New Orleans. Yep.

[00:38:11] But I guess my thought is saying for kids, SDF is buying time. That's, I mean, SDF in my mind is just buying time for everybody. For our nine year old patients that are, you know, trying to hold on to their teeth. SDF is like buying time until they meet St. Peter. You know, SDF and my patients that are Pito are buying time until those teeth are out the mouth. And so when do you use it? Well, tell me when you use it. When do you use SDF on a kid? I don't, I will be honest right now.

[00:38:40] I've actually never had the opportunity to use SDF on a child right as of now. Usually most of those kids are kind of coming to me. Well, so in my private practice, I don't see a lot of rampant carries on one or two year olds. And my mind is that SDF and little ones, when I say little ones, I mean anyone under the age of six. It's when you're trying to avoid general anesthesia on a child. You know, you don't want to do general anesthesia on a one year old.

[00:39:07] And not many pediatric anesthesiologists really are looking forward to seeing a one year old on their schedule. And my thought is like, if you can do SDF on a kid and keep him to like four years old, like happy, you know, and then you can restore everything more definitively.

[00:39:25] Um, that's what I would like to do it for, honestly, is like, so if I had like a two year old in my practice or actually a three year old in my practice and I saw some, some Frank decay on the molars, I would say, you know what, let's place a little SDF on these teeth. And next year, come back when they're four, because there's a big difference between a three and a four year old. You know, a four year old can tolerate two visits and I can do two quads per visit. The three year old can give me one visit. Um, but I'd like to use the SDF on a three year old just to kind of get them through six months to a year.

[00:39:55] And then we can do some definitive restorations on them. And that's how I'd use it. Honestly, Kevin has lost his microphone. So I'm going to kind of wrap up the, uh, the show here for us and we'll, uh, we'll pick him, we'll pick him back up later. So, um, Russell, thank you for talking, uh, uh, pedo with us. Uh, we really appreciate it. We will, uh, we're going to spoiler alert. We're going to have Russell on next week to go back to removable. So if you, uh, saw, you saw that we were talking to Russell and you were hoping that we were going to talk removable, uh, tune in next week.

[00:40:24] So, uh, for Russell Schaefer, for Kevin Fryer, this is Zach Miners. And we thank you for listening. See ya. See ya.