Very Dental: Rethinking Decay Removal with Dr. Melissa Seibert

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

[00:00:17] Welcome to the Very Dental Podcast, where you'll find entertaining and relevant conversations with visionaries, clinicians, and your friends in the dental space.

[00:00:26] Now, here's your host, Dr. Alan Mead. Very Dental people, welcome to another episode of the Very Dental Podcast.

[00:00:33] I'm your host, Dr. Alan Mead, joining me as co-host. She's been on the show multiple times before.

[00:00:38] We've got Dr. Melissa Seibert. Melissa, how are you doing?

[00:00:41] Hey, thank you so much for having me. It is such a pleasure to get to be back with you, Alan.

[00:00:45] You know what is a pleasure? It's a pleasure to podcast with a podcaster because you have like serious gear and you sound really good and there's no dinking around with gear or anything like that.

[00:00:56] Not that I don't love other guests, but it doesn't sound like a bad cell phone call. So it's kind of great. I kind of love that.

[00:01:03] So, Melissa is a podcaster also. She has the Dental Digest podcast. You know, I've just been going on for five years or something like that.

[00:01:12] Yeah. Good memory. Coming up on five years. Crazy. I need to do something special to commemorate it.

[00:01:17] Yeah. Yeah. Like a birthday cake or something like that.

[00:01:20] Something.

[00:01:21] Firework show. I don't know. I mean, what do you do? Probably an extra episode. That's what you do as a podcaster, right?

[00:01:27] You do some kind of like some retrospective episode, like one of the episodes of the Brady Bunch where they do flashbacks to other things.

[00:01:34] I feel like that would be appropriate. I don't know.

[00:01:36] Something like that.

[00:01:37] Five years worth. So that's awesome. And then the other thing that is kind of interesting, Melissa, she likes to be spread thin.

[00:01:46] Let's just say this. So she's got a podcast. She's a full-time dentist.

[00:01:50] I mean, you're wearing your fatigue. So you're still Air Force. And she's busy. She's a busy person. Much busier than I am.

[00:01:59] She's got a lot going on. But she also has started a journal club. And it's actually now called Elevated GP.

[00:02:05] I want to know a little bit about what started the journal club and what has it become? What has this monster become?

[00:02:12] Yeah, you're way too kind. So this kind of grew just based on demand. So started as journal club. This is a once monthly study club kind of talking about hot topics in dentistry.

[00:02:24] And the reason for this is basically, you know, I don't know. We all know those kind of those GPs that they basically just heavily relied on their training.

[00:02:32] And then, you know, decades out of dental school, they don't really know what's going on anymore.

[00:02:36] I hate that phenomenon. And it's almost to prevent against us. Like, hey, these are all the things that are going on in dentistry.

[00:02:43] And then that kind of grew based on demand where there was a request for because I just have like a lot of these lectures.

[00:02:50] I don't know, like go to a meeting. Someone will ask me to do a presentation on this. I'll put my heart into it.

[00:02:56] And then I won't use the presentation again. So basically, I put it all up.

[00:03:01] I saw what you put out there for Voice of Dentistry a couple of years ago. You definitely do. And your photography is great and everything.

[00:03:06] I cannot imagine doing a lecture like that and not really using it a bunch. So yeah, you got to repurpose it. You got to find this is great. I love this.

[00:03:14] Yeah, you're too kind. You are too kind. Yeah. So basically, it's now ElevatedGP at theelevatedgp.com.

[00:03:22] It doesn't have a lot of SEO yet. So yeah, you got to be careful. But so basically, it's membership. It's like on demand content.

[00:03:31] And I mean, it's really a support GPs. Like the big tagline is power to the GP. And we still have journal clubs still have months monthly meetings, but you know, hopefully a little something in there for everybody.

[00:03:42] Oh, it's really cool. It's good. We'll make sure that it's in the show notes. You guys check this out. She's got a lot of stuff. That's really cool. Because not only that, then like you're able to the, the stuff you've put your heart into, you get to use. That's really great idea. Actually, it's a really good idea. That's cool.

[00:03:57] To be honest with you, honestly, honestly, I have many weaknesses, but I have a few strengths. And web building, like I built this puppy myself.

[00:04:07] Did you really?

[00:04:08] It is a really sexy website. Like I am proud of this.

[00:04:12] Really good. And it's, but the other thing is it's not overdone either. That's the, the, the, the danger for, for dentists doing that kind of thing. They, they make it a little bit much. Yours is not a little bit much. Yours is just about.

[00:04:23] And that's like, those are all my own photos.

[00:04:24] Yeah, they are. Yeah. Well, that's one of the things too, that you've, you've, the strength of, the strength of photography. That's the serious clinicians are the ones to take all the pictures. I'm sorry. And the other thing is I'm, I'm so lazy.

[00:04:38] The camera is literally like a step away and I'm still so lazy.

[00:04:42] No, I don't think it's laziness at all. I think it's hard. I think like I have spent so much time doing it, you know? So I don't think it is not a laziness thing.

[00:04:52] Like the story is like, if you're just trying to crank this stuff out and see a regular patient base, that sort of thing, pulling out the SLR in the midst is it definitely, I mean, I've talked to Jason Smithson about it too. It's like, if you're, if you're going to really document a case, you need to plan time-wise for that. And the patient needs to know what they're getting. And there's a lot, there's a lot to that, but that, I mean, your photography is spectacular. Everyone should go check out the website for sure. This is very cool. So it's a subscription website. Obviously you're going to see E and all kinds of information, all that stuff.

[00:05:22] So here's the thing. Last time we talked, I really wanted to get to a couple of topics that we didn't get to. So enough chit chat, girlfriend.

[00:05:32] So I have a strong, strong feelings about a topic that they call selective carries removal or, or some people say that, you know, leaving decay. Don't say leaving decay. Doesn't sound, it's a leaving decay. Sounds like it's a mistake. Selective carries removal. And I have to say that my training with Dr. Clark over at the BioClear place, several people have talked about this kind of thing.

[00:05:57] And, and there's, I got to tell you, for me, it's a part of my day-to-day, it's a part of my day-to-day dentistry. And it's exactly what we didn't learn in dental school.

[00:06:08] I mean, in dental school, you probably remember this, you leave, you leave no decay ever. You need, you remove everything. And if that means you're into the pulp, it just means you're into the pulp. That's that onward. Am I right? I mean, is that, is that what we kind of learned?

[00:06:22] And you're younger than I am. I definitely, I was in the mid nineties for sure. That's what we learned in the mid nineties, but, but tell me, tell me your thoughts on all this.

[00:06:29] Okay. A hundred percent. It's funny that you said you had strong feelings toward this because I didn't realize that you were pro selective carries. I thought you were anti-selective carries.

[00:06:40] Yeah. So, okay. Let's talk about this. First of all, this is well substantiated by the literature. This isn't really your or my opinion. This isn't really a hot trend.

[00:06:49] And big organizations like the American Dental Association and organizations such as the British General Journal, a subsidiary of the Nature Journal, they have come out. It's very pro selective carries removal. This is well substantiated. It's been around actually for quite a while, but you're right. It's, it's interesting because you look at exams like the big dental state boards. If you leave carries behind, I mean, at least as of six or seven years ago, you would fail.

[00:07:15] Yeah. Yeah. And what's funny too, is like at that point, I remember that too. I remember, I remember that. And, and, and when you're taking boards, you don't even really know what carries is. You don't know. Like, like, like I think of the fact that like when I was in dental school, no one really used magnification. The light we had was whatever the overhead light in your operatory happened to be like, you know, and carries die was just not really a thing. None of it. And so like, so any judgment that was being made on carries removal was, was some completely

[00:07:44] subjective by you, by the instructor, by everything. And, and so you just did the best you could. And you probably drilled a little more than you thought you needed to just to make sure and that sort of thing. So I'm curious, like what your thoughts are in the history. Cause, cause I mean, there's, I do agree. I feel like the literature has been pretty clear about this for a while.

[00:08:06] And, but yet you talk to people and they still feel really like you can't, you can't leave decay. You have to remove all the decay. There's tons of decay. And, and even people who probably even know quote unquote better, it's, it's sort of ingrained in us. You know what I'm saying? On some level as clinicians, you're just like, eh. So I'm, I'm curious, like what your thoughts are and how you approach these sorts of things.

[00:08:31] Okay. So yeah, let's first start by talking about what it is when it comes to any carries removal process, there's sort of different approaches one could take. And the first approach that we talked about that everybody's accustomed with is the total carries removal. This is again, the whole notion that the tooth has to be absolutely, uh, what would you say? Bone dry, if you will, totally spotless, any sort of discoloration, even if it's not carries, even if it's just oxidized tooth structure, that all has to be removed.

[00:08:59] Um, and the problem with that is that first of all, that can really lead to excessive removal of healthy tooth structure. Um, but here's the biggest consideration is that, you know, and this is kind of talked about in really the big publications. We even talked about this in journal club. We ask clinicians are, um, very poor judges, believe it or not, of being able to delineate between affected versus infected dentin versus even healthy dentin. Like the composition of the dentins changes as you get close to the pulp.

[00:09:28] Tubules get wider. Tubules get wider. You have more tubules. And so this can make you think that, um, you still have disease dentin effectively that needs to be removed. Um, but so, and forgive me, I'm a little bit tired today, but so yeah, the first thing is we talked about the total carries removal. Another carries removal approach is the stepwise carries removal. This is something that's, um, kind of a bit more popularized in Japan.

[00:09:52] Something you don't necessarily see in North America because this does require multiple appointments. Um, and you know, I think the lesion can continue to get larger if you do a stepwise removal approach. Uh, it takes place over the course of several months.

[00:10:05] Just something, I mean, you, Alan, you own a private practice. I don't really think you can talk to patients.

[00:10:10] I'm not even sure what that is to tell you the truth. Tell me what stepwise, like multiple appointments. This is novel, but it's also multiple anesthesia, multiple isolation. I'm just curious. Like what, what's the story?

[00:10:21] Yeah. Well, um, I think very respectable clinicians like Junji Tagami, they are proponents of this approach and effectively, um, one of the approaches, not all of it, but one of the approaches is you could take a grossly carious lesion and you just sort of remove the gross debris. What you can easily remove perhaps with a spoon or just a, um, sort of a slow speed type of burr and a round burr. And they would even advocate that you don't even have to do this with anesthetic. It's a relatively painless procedure.

[00:10:49] Okay.

[00:10:49] And then you put material such as glass ionomer over the lesion, give the, uh, lesion underneath time to sort of remineralize, repair itself. Then you go back in and resect way more of the tissue. Um, there, there really is, there is virtue to this approach.

[00:11:06] Yeah.

[00:11:06] I just don't necessarily think it's always practical here in North America, but it's not a bad approach. I just, there's a few other things I don't care for about it. It's just, I really believe like every time you go into a lesion, just the preparation.

[00:11:18] Invariably is going to get wider and there's the conceivable possibility of traumatizing the pulp.

[00:11:23] Assault to the pulp every time you're in there. Exactly.

[00:11:26] Right. But I think, I do think that the stepwise approach, that is another minimally invasive approach to carries removal that we can't necessarily forget.

[00:11:33] But then, so the, uh, selective approach to carries removal, it's really critical. I think a very meticulous protocol needs to be followed. What we're not talking about with selective carries removal is you just, um, unscrupulously leave a bunch of carries behind. That's not at all what we're talking about.

[00:11:51] And so I'm going to kind of tell you my approach and then I want to hear the approach you're using. Um, and again, it's technique sensitive, but so effectively what you are doing is you are removing the carries in such a way that you get clean margins.

[00:12:06] It's critical that you have clean, all of your enamel margins need to be clean. And then I like to also have clean dentin margins, but then now you are leaving behind some of the carries.

[00:12:17] Part of the purpose of it is to avoid a pulpal exposure. Now, again, if you have a very small lesion, I think that in some regards, it just makes the most sense to remove everything.

[00:12:27] I'm even going to make the argument that if the lesion is that small, where really we have a D1 lesion, it's just initially into the dentin. I don't necessarily even prepare those teeth. I actually wait because like if we looked at the classic pits and rimmer study with those small D1 lesions, only 40% of them are cavitated.

[00:12:45] Uh, 40 to 50 or so, depending on what numbers you're kind of consulting. So that means, um, I, I kind of wait and I look at historical bitewings, look at if it's progressing. It's possible that it's, um, arrested, but we think I'm going to stop you. Classic thing.

[00:12:59] Yeah. Patients that don't want to have, they're like, I don't want, I don't want radiographs. I mean, and one of the things that I will tell them is here's the thing.

[00:13:08] One of the reasons that we do take these, these x-rays on a pretty regular basis is because that's one of the best ways for us to not drill on your teeth. Right?

[00:13:18] Right.

[00:13:18] Like what you just said, uh, how often is it a new patient? You see a, uh, an early dentinal caries lesion. And there's a part of you that goes, if I had, if this was a patient of record that I had been seeing for a long time, I have a much better idea of whether that is something that may have been stable like that for years.

[00:13:38] And I don't need to touch or I need to go right in there. And patients think you're, I do think that it's so funny because patients think we're just taking x-rays because we love to make money off of them.

[00:13:47] They're like, no, no, no, no. I actually want to take these on a regular basis so that I don't drill on your teeth as much. Patients don't, you, I will say this.

[00:13:55] It's a good trick for the patient that's really hesitant about radiographs. Like, look, one of the reasons we do this is because I'm sitting and keeping an eye on this. How do I keep an eye on this?

[00:14:04] Well, I use a microscope when I do your exams and I take these x-rays for comparison's sake. And this is one of the reasons I know I can leave this safely without it getting bigger. It's a huge deal. It's a huge deal what you just said. And I just feel like we need to remember that sometimes we like to complain about patients that, that make these choices. And the reality is we can explain that actually, especially with digital radiography, it's very minimally invasive the whole way to do it and, and keeps us maybe from drilling on their teeth that much. Patients like to hear that.

[00:14:33] Just, you know.

[00:14:35] So did I hear that you do your exams with a microscope?

[00:14:38] Oh yeah. Oh yeah. I have, I have microscopes in every operatory. And so I, when I do hygiene exams, I've been doing hygiene exams on the microscope on video for, I don't know, five, six years now, something like that. So I have, I have video that I can go back and look at too.

[00:14:51] And I'm going to tell you that the video is not always, not always, I've gotten better with video with better cameras, that sort of thing. But so, but I tend to think that in the same way that, you know, keeping a radiographic surveys over a period of time, high magnification, high light is a really, I mean, people don't,

[00:15:08] karyology is, that's a lot of it, right? Like, I don't know, there's a lot, I got more to say about that, but yeah. So I do my exams with the scope. I have a scope in the hygiene exams.

[00:15:19] Yeah. That's amazing. I love that.

[00:15:21] I won't lie, it's overkill, but I, I've gotten used to it. It's just become part of my protocol now.

[00:15:25] Let me ask, are you doing this perhaps to prevent neck or back injury or?

[00:15:31] Yes, but I just have been a microscope guy. I just, I'm just fascinated by the whole technology and stuff. So I, I, I've got them in all my operatories. I don't use them as much as I probably should, but I really do like them.

[00:15:42] Yeah. Wow. You're really giving me a things to think about with my future practice someday.

[00:15:45] Okay. So I really appreciate what you just said though, about the virtues of magnification and light, especially with Kary's diagnosis. You know, I had a mentor and I'm not even sure if this was his expression or perhaps it came from somebody else, but this whole saying of, you know, when we're trying to detect Kary's, we want to have sharp eyes and a dull explorer.

[00:16:05] Yeah. Yeah. I, the explorer thing always pissed me off, honestly, because like, uh, I, I literally heard on, oh man, I, I'm going to do a podcast on it at some point. Cause, uh, there's the VPZD podcast, which is Vinay Prasad, who's a very smart guy in a Z dog. He's like an internet, they're, they're physicians and they do. And they were ripping on dentists just a couple, like last month, month and a half ago.

[00:16:30] They were bitching about how you're taking the explorer and you're poking. I'm like, that's not how, that's not how I do exams. The explorer is next to the explorers like next to nothing. I remember it was, I want a sharp explorer. I'm like, no, you don't. You don't know. You want sharp eyes. I love what you just said. Sharp eyes and a dull explorer. The explorer is helpful, but it doesn't, it doesn't diagnose Kary's. And honestly, if you're finding a groove that'll catch an Explorer, that is an anatomic finding. That's not that you found Kary's. That's insane.

[00:16:58] Kary's. The best way to see Kary's is, is a change in color and texture with magnification light as far as I'm concerned, but that's the.

[00:17:06] Right. And the optical properties when you dry it. Yeah. When you dry it, do the optical properties change? Like, is it very porous? But I think, I think we just really need to foot stump this.

[00:17:19] Because, like, we as a profession, as a whole, are very unreliable at detecting pit and fissure Kary's.

[00:17:24] Yeah. Yeah. Yeah.

[00:17:25] It's not, and let me say this, not as if that is a personal shortcoming, more so that they're very difficult to diagnose.

[00:17:33] Yeah. Yeah. They're difficult to diagnose. And also, as a profession, we're sort of like, let's just do it. Let's just do it.

[00:17:42] I'd rather, I'd rather have a pit and fissure that's been filled in with something than, than a scary pit and fissure that I don't know what's going on in there.

[00:17:49] And the problem is that's not, that's not a very, it's not a great way to, it's not a great way to do it.

[00:17:53] I'm going to tell you that the magnification for pit and fissure is, is a huge deal. Dry, like if you get really dry air in a, in a good mirror, oh, that's the other thing, a good mirror.

[00:18:02] Or you go in there and you got a mirror that looks like it's been dragged behind a truck and you're just like, how you can't, you can't, you have to have all the, all the right tools to be able to see everything.

[00:18:09] Well, you know, it's, it's, it is a funny thing. Like the, some of the things, particularly when you use a microscope a lot, a mirror with any kind of a splotch on it will drive you bananas. It'll drive you crazy.

[00:18:20] I mean, even with high magnification and light, it just, yeah. So I'm, my team knows that I throw out a lot more mirror heads than the average dentist, because if there's, if it's scratched or splotched, I lose my cool.

[00:18:31] So I just, it's, it's one of those things and it is, it's everything about, you gotta be able to see all that stuff. So anyhow.

[00:18:36] Right. But you know, I mean, let's just also take a moment and talk about that idea where a lot of times people will default to, you know, I'm not quite sure if there's carries there. So let's go ahead and open that up.

[00:18:45] I think there's a few flaws to that approach and I understand the logic and I really appreciate, I think people are taking the approach of let's go ahead and restore it or do a PRR.

[00:18:55] Because I think they're, they're trying to protect their patients, right? They're thinking that this might be something there. So let's go ahead and be preemptive.

[00:19:02] But I actually think that there's more problems with being preemptive. I think, first of all, I think this is perhaps something we don't always necessarily appreciate here in North America, but teeth are really these incredible structures.

[00:19:14] I mean, really underneath these fissures are all these sort of interwovens that help to just keep the tooth together itself.

[00:19:22] And I'm not really doing this concept a lot of justice, but really like as soon as we bury into the tooth, yes, we are resecting tooth structure, which I view as a body part, but even more, I sound like a tree hugger now.

[00:19:34] But even more importantly, it's this really kind of vital anatomical structure that really, as soon as we start to take away from the structure, the whole structure itself is compromised.

[00:19:45] It's all, none of it is superfluous, but then the other thing.

[00:19:49] You know, you know, you know, Tim Rainey, how, how.

[00:19:51] Yes. Okay. That's it. Exactly. The Rainey Ridges. No, those aren't the Rainey Ridges, are they?

[00:19:54] Yeah. I mean, basically he, he liked to show all these, first off, he's crazy. He's nuts.

[00:19:59] All the best people are. In a great way. He's, he's sort of a crazy mad scientist. I met him in 2005 at the World Congress of Minimally Invasive Dentistry.

[00:20:09] And he's got all these different structures. And what it is, it's the occlusal structures.

[00:20:14] Why are these amazing occlusal structures and all that anatomy that Smithson adds back and composite and all these guys, why, why are they all that?

[00:20:21] Why, why did teeth have those things? And it's because like engineering wise, it's pretty smart.

[00:20:26] All those different cross structures that are all, you know, you've got these, you know, molars are cranking on, you know, they need the strength and they need to be, they, you know, they need to have perpendicular forces come on.

[00:20:37] I mean, these, when you look at how the enamel and dentin are put together and all that, it's kind of amazing.

[00:20:43] So every time you drop a burr into that and all of a sudden you've started to break down that thing, God help you.

[00:20:47] If you're into a marginal ridge, then, then you're, then it's a whole other story.

[00:20:51] But I mean, like, so every time you're undoing that, you're sort of going, and you hate to be, like you said, tree hugger, but it's like teeth develop that way.

[00:20:58] Yeah. I don't even know why, why I said that.

[00:21:00] Like, no, no, no.

[00:21:01] I stand by what I say.

[00:21:02] Like, I think exactly if we view a tooth as none of these structures are superfluous.

[00:21:08] These all have a very vital structure.

[00:21:10] Exactly.

[00:21:11] Right. And we are now undermining the structural integrity.

[00:21:15] And yes, of course there are times where restoration is vital by all means.

[00:21:19] That's not what I'm saying, but I think we have to approach it with that view.

[00:21:23] So if we have that view in mind, what are some more conservative options?

[00:21:26] I think something that is underutilized is SDF and adults.

[00:21:30] Like we have evidence to show that SDF functions just as well as like a glass on them or type of sealant.

[00:21:39] So I think if there's a question, I think SDF is a great option.

[00:21:42] Do you like to do SDF in grooves?

[00:21:44] Oh, yeah.

[00:21:46] Or are you asking if I put it in grooves?

[00:21:47] No, I'm afraid to because it stains everything so bad.

[00:21:51] So you got these...

[00:21:51] Oh, I put SDF on my teeth.

[00:21:54] I have like a very small buckle pit and I have deep fissure.

[00:21:58] So I put SDF on my teeth probably more than I should.

[00:22:02] Probably about every three months.

[00:22:03] Like if you're really trying to do this, you should be doing this about every six months, twice a year.

[00:22:07] Yeah, but no, if they're...

[00:22:10] It really...

[00:22:10] SDF only stains like hypomineralized tooth structure or defective tooth structure.

[00:22:15] So it is not going to stain the fissure any worse than it's already stained.

[00:22:20] It's already stained.

[00:22:21] Yeah.

[00:22:22] Yeah.

[00:22:22] Yeah.

[00:22:23] That's wild.

[00:22:24] Okay.

[00:22:24] Because I won't lie to you because a lot of times when I'm getting the SDF out, it's typically...

[00:22:30] It's gerontology kind of stuff.

[00:22:32] It's stuff where patients that are old, they have root caries.

[00:22:35] It's probably already kind of dark anyhow.

[00:22:36] Like you said, it's sort of broken down.

[00:22:38] And yeah.

[00:22:38] So I get it.

[00:22:39] That's interesting.

[00:22:40] That's very interesting.

[00:22:40] Oh, yeah.

[00:22:41] I didn't expect it to go this way.

[00:22:42] And look at these pearly whites.

[00:22:45] Yeah.

[00:22:45] No, I don't see any.

[00:22:46] I don't see any.

[00:22:47] But...

[00:22:48] And also, who cares in a groove, right?

[00:22:50] You like it.

[00:22:51] You know, the only...

[00:22:51] I know some people look at that and they're all bummed out about it.

[00:22:54] But for the most part, people don't pay that close of attention to it.

[00:22:57] So...

[00:22:57] And I mean, it beats drilling on them.

[00:22:59] So, yeah.

[00:22:59] Oh, yeah.

[00:23:00] And I think actually the bigger consideration just to forewarn patients of is more so that it

[00:23:06] might stain calculus.

[00:23:07] So over the course of the next probably two, three days, you might begin to notice a little

[00:23:11] bit of discoloration.

[00:23:12] That can easily be scaled off.

[00:23:14] But the bigger consideration too, just from a patient satisfaction standpoint is it'll stain

[00:23:20] skin for a little while.

[00:23:22] So again, the stain will show up after a course of a few days.

[00:23:25] You just have to be careful with the material.

[00:23:27] But no, I mean, I'm a big, big proponent of using SDF.

[00:23:31] But I will say this too.

[00:23:33] Alternatively, if you don't want to do that, you know, it's a little controversial, but there

[00:23:38] is evidence out there that you can seal over the fissure, over the deep fissure, even if

[00:23:43] it is curious because you're effectively cutting off the food supply to the bacteria.

[00:23:47] Now, again, some will say, oh, well, isn't this going to give the anaerobic bacteria an

[00:23:51] opportunity to thrive?

[00:23:52] But you're really entirely cutting off the food source, provided you place a very well-sealed

[00:23:58] restoration.

[00:23:59] And that's the problem is that sealants are, in a lot of cases, overused and probably not

[00:24:05] isolated the way that they should be done at dry.

[00:24:07] Exactly.

[00:24:08] Honestly, I've gotten to the point where, I mean, okay, God love the hygienist, but that's

[00:24:14] not the place to place a sealant as far as I'm concerned.

[00:24:17] Unless they're placing a rubber dam.

[00:24:18] If they're placing a rubber dam, I guess I'm fine with that.

[00:24:20] They're not placing a rubber dam.

[00:24:22] They're not.

[00:24:23] In the hygiene operatory, they're trying to crank out the production.

[00:24:28] And understand, I think sealants have a place, but I've been very anti-sealant the way that

[00:24:33] they're prescribed in a lot of cases.

[00:24:35] Because yeah, I'm not doing a sealant unless I know that I've isolated well enough and I've

[00:24:40] sealed that thing up well enough.

[00:24:42] Do you remember, okay, I don't know if, do you remember a material by GC called triage?

[00:24:48] I use triage all the time, actually.

[00:24:51] By the way, I think triage is a great material for sealants.

[00:24:54] I don't think patients will ever go for that.

[00:24:56] But I will say this.

[00:24:58] On little kids, it's the freaking best.

[00:25:00] The classic is when you got a little kid with a second molar that's half in, half out, and

[00:25:06] you can just see that it's already starting to, you know, if you don't get on something,

[00:25:09] then it's going to be decayed before it ever even comes completely into the mouth.

[00:25:13] And that triage is pretty forgiving as far as placement stuff.

[00:25:17] I mean, isn't it like pink or something like that?

[00:25:19] I haven't used it for a while, but it doesn't look very nice, but it works great.

[00:25:23] It was actually developed for the military, believe it or not.

[00:25:27] It wasn't everything.

[00:25:27] Let's be perfectly honest.

[00:25:29] It wasn't everything that's good.

[00:25:30] Yeah, something like that.

[00:25:31] Yeah.

[00:25:32] But it's this neon orange type material.

[00:25:34] It's glass ionomer.

[00:25:36] It's great for sealing because there's no-

[00:25:37] But it's runny glass ionomer.

[00:25:38] It doesn't have much body, if I remember correctly.

[00:25:40] And it kind of, like compared to like a Fuji 9 or Equia Forte or something like that,

[00:25:44] it's a little bit runnier.

[00:25:45] It goes into grooves more easily.

[00:25:47] Yeah.

[00:25:47] Yeah.

[00:25:48] Like it has good wettability.

[00:25:49] Yeah.

[00:25:50] But I think it is such a great material.

[00:25:52] Like patients come in, let's say you have a walk-in, quote unquote emergency, patient

[00:25:56] breaks off a cusp, can't get him in for two weeks, Fuji triage.

[00:25:59] Like I use Fuji triage for a lot of things as an orifice barrier after endo.

[00:26:04] I mean, I think this is a material that there's a lot of indications, but kind of the big takeaway

[00:26:09] from this is if you do have like a hygienist in your practice that want to play sealants

[00:26:13] or you really want to play sealants, I really think it should be a glass ionomer material.

[00:26:18] I'm here for it.

[00:26:19] Yeah.

[00:26:19] Yeah.

[00:26:20] Like sealants should, resin-based sealant should never, ever be placed without a rubber dam.

[00:26:25] It is still resin.

[00:26:26] I haven't placed resin-based sealant in, I'll bet, 15 years.

[00:26:29] I haven't placed resin-based sealant, I think in like five years.

[00:26:32] Yeah.

[00:26:32] Because I got no time for them.

[00:26:34] I got no time for them.

[00:26:35] Like everything about it was, they were designed to be fast and placed.

[00:26:39] I'm not going to lie.

[00:26:40] I think they were designed to be placed kind of poorly.

[00:26:42] That was, they were taken out of the dentist's hands and they're like, this is something the

[00:26:45] hygienist can be doing.

[00:26:46] And I just don't think, I mean, unless the hygienist is a restorative hygienist, that's

[00:26:50] what they're doing all the time.

[00:26:51] It's, I feel like it makes more sense to do that in the dentist's office.

[00:26:55] I know people are saying it's not very productive, but I'm like, yeah, but you know

[00:26:58] what, you're doing some amazing stuff for those teeth, particularly if you're doing a

[00:27:01] glass ionomer sealant of some sort.

[00:27:03] I just, I'm all here for that.

[00:27:04] Yeah.

[00:27:05] I mean, but I, you know, I don't, I think it's still polymer chemistry.

[00:27:08] I think it's therefore still technique sensitive.

[00:27:10] I think you still need to be meticulous.

[00:27:12] Yeah.

[00:27:13] I think, yes, we all know how you and I feel about resin-based sealants.

[00:27:18] Yep.

[00:27:18] I mean, and we've talked about it on the show before, but I, a lot of people disagree with

[00:27:22] me, but they're just wrong.

[00:27:22] So that's, that's just, so, okay.

[00:27:25] So let's, let's get back to, this is so good.

[00:27:28] Selective carries removal.

[00:27:29] Selective carries removal.

[00:27:30] Now, okay.

[00:27:32] Let's just assume that your normal, your normal lesion, your normal primary lesion, first time

[00:27:39] you've restored it, it's not huge, but it's worth restoring.

[00:27:43] You get in there.

[00:27:44] I got to say that bite wings are usually not a great indicator of depth of decay in a lot of

[00:27:49] cases.

[00:27:52] So I think visual is probably better, but a lot of times it's a good indicator of should

[00:27:55] you restore it, but you're not, not necessarily sure what you're going to get into.

[00:27:58] So one of the things that I, when I am confident about selective carries removal, I want to know

[00:28:06] symptoms if the patient has symptoms or not.

[00:28:09] Because if you have a tooth that's symptomatic, it's sensitive already, I'm already a little

[00:28:13] skeptical about, about selective carries removal.

[00:28:15] What are your thoughts on that?

[00:28:17] Okay.

[00:28:17] So that's a great consideration and I'm really glad that you brought this up.

[00:28:21] So if I have a larger lesion and I'm doing selective carries removal, I, I get a PA.

[00:28:28] It'll be kind of amazing.

[00:28:29] Like what you will find, I would say probably one in 15, one or 20 cases, you will see some

[00:28:34] sort of lesion in which case the whole course of treatment is very different, right?

[00:28:37] We're going to proceed with endo, but you want to rule that out because of course we don't

[00:28:42] want to be doing selective carries on a case that's necrotic.

[00:28:44] Um, but then the other thing is I will do vitality testing.

[00:28:48] I will, um, you know, cold sensitivity testing.

[00:28:51] Do they have a sort of lingering response, which that in itself is even controversial because

[00:28:56] now the AAE has come out saying that, you know, symptoms rarely actually correlate with

[00:29:00] the histology of the tooth.

[00:29:02] That's fair.

[00:29:02] But along the lines, I want to bring this up as well, if I will, if you would allow me

[00:29:06] to, um, you know, it is also kind of, we're talking about selective carries here.

[00:29:10] I feel like the restorative community, we have really embraced this.

[00:29:13] I think we are very much in favor of this, but we need to also note that the endodontic

[00:29:17] community, um, not everybody in the endodontic community is as pro selective carries removal.

[00:29:23] Yeah.

[00:29:24] In fact, um, someone I really respect, Domenico Ricucci.

[00:29:27] I mean, really like one of the most respectable authorities in endo, he is not pro selective

[00:29:32] carries removal.

[00:29:33] So I think we just need to know as with just about anything in sort of evidence-based dentistry,

[00:29:39] evidence-based medicine, there's nuance, there's, um, differing opinions.

[00:29:43] And I think we still need information, more information.

[00:29:47] Absolutely.

[00:29:47] Absolutely.

[00:29:48] And, uh, okay.

[00:29:49] So that's, that's the thing.

[00:29:51] I think that as much as the evidence you can go on, I do think it, uh, experience with

[00:29:59] it is also helpful too, like, like the fact that I've been able to, to start using it.

[00:30:03] Like, like you say, you want to have clean enamel margins.

[00:30:06] That's, that's on uncontroversial.

[00:30:09] And honestly, clean dentin margins.

[00:30:11] I like how you said that too, because the, you know, you, you want to do this intentionally.

[00:30:17] You don't want to say, well, let's just see how far I can go before it's a, but you want

[00:30:20] to do this intentionally.

[00:30:21] Um, and like I said, isolation's everything on this, but visualization is, is everything as

[00:30:27] well in, uh, documentation is important too.

[00:30:32] Not only do you want to know, okay, this is a tooth that we did selective carries removal

[00:30:35] on in the past.

[00:30:36] How will you check for symptoms?

[00:30:37] Check for, but also, you know, like God only knows dentists would love to throw other dentists

[00:30:42] under the bus because they didn't remove all the decay, you know, on the, or the classic

[00:30:46] thing where I, I, I can see decay on the x-ray.

[00:30:48] I'm like, eh, I don't know that you can actually see decay on the x-ray.

[00:30:51] It depends on the materials used and that sort of thing.

[00:30:53] There's a, there's a lot of nuance to this whole thing.

[00:30:55] Thoughts on thoughts on that?

[00:30:56] Well, like, it sounds to me like you're using this on a regular, like regular basis.

[00:31:02] This is not like, oh, this is a case I can do selective carries removal on.

[00:31:06] Whereas you're looking at this and it's, it's a bit of a continuum on just day-to-day

[00:31:10] restorative dentistry for you.

[00:31:11] I feel like that's how I am with it too, to be perfectly honest.

[00:31:14] Yeah.

[00:31:14] And I think there's a few considerations here too.

[00:31:17] Again, going back to the idea of, uh, in dentistry, we as clinicians, it's just very

[00:31:21] difficult, first of all, to just be able to delineate between sort of healthy dentin

[00:31:25] versus affected versus infected dentin.

[00:31:28] There's one way to do it.

[00:31:28] There is one rule.

[00:31:29] It's histology.

[00:31:31] Extract the tooth.

[00:31:31] Yeah, sure.

[00:31:33] Exactly.

[00:31:33] And then you know, for sure that you did or you didn't.

[00:31:35] That's exactly right.

[00:31:36] Exactly.

[00:31:36] And then, you know, someone could come back and say, oh, well, what about caries detector

[00:31:39] dye?

[00:31:40] We need to know caries detector dye, AK propylene glycol.

[00:31:43] This is not staining for bacteria.

[00:31:45] This is really more so staining just to kind of, as a commentary about like the health of

[00:31:50] the collagen in the tooth.

[00:31:51] And so that can also have false positives.

[00:31:54] So you need to be careful with that.

[00:31:56] The lesion, it's going to stain more just because it's deeper in the lesion because the

[00:32:01] tubules are wider open.

[00:32:02] Right.

[00:32:02] There's, there's, uh, I actually, I, I used to swear by it.

[00:32:07] I liked, uh, ultra dense sable seat cause it was green instead of pink.

[00:32:11] Yeah.

[00:32:11] I don't do ink when you're getting close to the pulp, I say that's a, but, but I, I don't

[00:32:15] use it anymore because I feel like, I feel like, uh, well, cause I'm using high magnification

[00:32:19] in a bright light.

[00:32:20] I feel like I, I get enough information that way.

[00:32:22] And I just feel like particularly on a lesion where it's already, I'm already a little nervous,

[00:32:27] a little deep.

[00:32:28] If I've got a deep lesion without, without periapical, uh, lucencies and if, and if

[00:32:33] I don't have symptoms, I'm down to do this, but I do not want to be using caries dye

[00:32:38] because it's, it's going to stain as I get deeper into that lesion.

[00:32:41] Even if, even if it's not an exposure, I, I get, I'm not real confident about it.

[00:32:44] I don't like to use very often.

[00:32:46] Yeah.

[00:32:46] I think there's virtues to it.

[00:32:48] I just think that you need to know the limitations to it.

[00:32:52] And so for example, it'll also stain the den and enamel junction, AKA den and enamel complex,

[00:32:56] depending on who you ask.

[00:32:57] I mean, you just need to know the limitations there.

[00:33:00] But, um, you know, the other question then becomes is like, well, why do we need these

[00:33:04] clean margins?

[00:33:05] You know, other than just because I'm told to do this, why do we need to have these clean

[00:33:09] margins?

[00:33:10] And the biggest thing is for the bonding.

[00:33:12] So you can bond to infected dentin, for example, but the bond strength's only as little as like

[00:33:17] about 10 megapascals.

[00:33:19] And so if we're talking about getting a good hermetic seal, we need a really good, like

[00:33:24] reliable substrate to bond to.

[00:33:26] You'd much rather, I mean, let's be honest.

[00:33:28] If you get to choose where your bond strength is the best, you want it on the outside.

[00:33:33] The inside, right?

[00:33:35] Like, I mean, on some level, that's one of the reasons that the, that you're, um, the,

[00:33:39] what did you call it when the Japanese, where they come back and do the, uh, the stepwise,

[00:33:44] the stepwise approach.

[00:33:45] Stepwise.

[00:33:46] The story is like, that's, I just, I'm just very interested in that.

[00:33:50] And it's like, that's the whole concept.

[00:33:52] You're covering it over and, you know, take out just the big stuff, cover it over, see

[00:33:55] what's left.

[00:33:56] So you really, you, this is, you want the edges to be the best bond you can possibly

[00:34:01] get.

[00:34:02] And in that way, that way you're closing, as you said, you know, you're, if there's

[00:34:06] bacteria left in there, you're sealing that in with no chance for substrate.

[00:34:10] You're not feeding it.

[00:34:11] And that's, so your best bet is to have the best bonding you can have on, on the outsides

[00:34:15] as much as you can.

[00:34:16] Right.

[00:34:16] And there's also another important consideration that once you start doing this, you might

[00:34:21] begin to see.

[00:34:26] Bond strength to the infected dentin sort of at the middle, uh, most aspects of the

[00:34:31] preparation that you have not excavated because the bond strength is so poor.

[00:34:34] What might happen is as you're carrying the material, as it's polymerizing, it's going

[00:34:39] to begin to shrink and then it's going to pull away.

[00:34:41] So now there's this sort of microscopic void between the substrate and the restorative material.

[00:34:46] So now when the patient goes to bite down, they might have a little bit of sensitivity

[00:34:51] almost because now the composite is flexing a little bit.

[00:34:55] It's not actually bonded to that infected dentin.

[00:34:58] So for that reason, you do want to keep this area.

[00:35:01] You don't want it to necessarily be too large.

[00:35:04] That's really good.

[00:35:06] It's all very good stuff.

[00:35:07] And what's funny about it though, is I got to go back to the fact that this is probably

[00:35:11] for a lot of practicing dentists.

[00:35:13] This is just not even a consideration.

[00:35:15] They don't even think about it because the simplicity is remove everything.

[00:35:20] And because we, I don't know.

[00:35:22] I feel like, I feel like there's a fair amount of, this is, there's a fair amount.

[00:35:25] You're not going to say this, but I don't mind saying I'm old and cranky.

[00:35:27] There's a lot of hubris with, with dentists that believe we know more than maybe we do and

[00:35:32] that we have the ability to do things that maybe we can't.

[00:35:35] But like I said, I mean, if you had someone remove, I've removed all the decay.

[00:35:40] Okay.

[00:35:42] Maybe.

[00:35:42] Like I said, there's one way to check that.

[00:35:44] We don't know.

[00:35:45] We don't know.

[00:35:46] Exactly.

[00:35:46] Thank you very much.

[00:35:47] Right?

[00:35:47] Like you don't know.

[00:35:48] I don't know.

[00:35:49] We do the best we can in situationally.

[00:35:52] That's why I think it's really important.

[00:35:53] Isolation.

[00:35:53] Excellent.

[00:35:54] Isolation makes a big difference on that because you don't really know.

[00:35:57] Yeah.

[00:35:57] I think it's not as hard.

[00:35:58] I don't know.

[00:35:59] I feel like it's harder to tell or it's easier to tell on your margins that it's clean as

[00:36:04] a whistle than, than in Denton like that.

[00:36:06] I feel like, I feel like that's better.

[00:36:07] I don't, I don't have any evidence of that, but it just seems like it.

[00:36:10] So we do the best that we can.

[00:36:12] But I also think that it's not easy to know that you've removed all the decay.

[00:36:15] And I think that we need to, we, if that's your goal, I don't even know that we know that.

[00:36:21] And here's, here's the other big consideration.

[00:36:24] We have no idea if we've removed all the bacteria.

[00:36:27] I think we assume that if we remove all of what we think is the decay, then therefore

[00:36:32] all the bacteria is removed.

[00:36:34] We have no way of knowing that.

[00:36:36] Yeah.

[00:36:37] Yeah.

[00:36:37] God, that's funny because it's almost, it's almost a given that you say, of course I have.

[00:36:42] I ran the burr in there.

[00:36:44] It has to be gone.

[00:36:45] No, not really.

[00:36:45] It's, I mean like the, it's, yeah, it's, it's hard to know.

[00:36:48] I mean, it's the, they can live in the tubules.

[00:36:50] There's the anatomically, it's very, you know, and they don't, they don't give up very

[00:36:54] easily bacteria.

[00:36:56] So yeah, no, that's really interesting.

[00:36:57] So you do the best that you can in all these things.

[00:37:00] I think, I think that as a profession, we like to believe that we know more than we do.

[00:37:05] I know I just said that, but it's, it's worth saying again, because I think sometimes we need

[00:37:08] to take a deep breath and just understand that it's amazing that any of it works at all.

[00:37:13] Let's just be perfectly honest because, but we also, we also do the best that we can and,

[00:37:17] and we try and understand the best that we can too.

[00:37:19] And that's, that's a hard, that's a hard thing to do.

[00:37:21] Would you permit me to throw out another consideration as well?

[00:37:25] Let's do it.

[00:37:25] So something people also advocate for is perhaps putting silver diamine fluoride down in the

[00:37:30] preparation, you know, cause we're talking about, Hey, these are the challenges we face

[00:37:35] with carries excavation.

[00:37:36] It's unpredictable.

[00:37:37] So people will put silver diamine fluoride in the virtue of silver diamine fluoride is

[00:37:41] that the silver component, this is antimicrobial, the fluoride component, this facilitates

[00:37:45] remineralization.

[00:37:46] So this concept sounds very well and good, but there's a few shortcomings with this and

[00:37:50] I would not advise using this approach.

[00:37:53] So first of all, like this can kill the pulp.

[00:37:56] So if you are doing a large, uh, lesion excavation, really, if you're within half a millimeter to

[00:38:02] a millimeter within the pulp, because the silver diamine fluoride can diffuse through the den,

[00:38:06] this can kill the pulp.

[00:38:08] And I've seen a really well-meaning people inadvertently.

[00:38:10] A patient will have a really large lesion, can't get the patient in for a little while.

[00:38:14] They'll want to arrest the carries.

[00:38:15] So they'll place SDF and this kills the pulp.

[00:38:19] So that's kind of reason number one for why I would not use it.

[00:38:22] Uh, the other reason is that we don't necessarily really have good evidence about what this does,

[00:38:27] the bond strength.

[00:38:28] Some evidence says that this decreases the bond strength.

[00:38:30] Some will say it has no effect.

[00:38:32] Um, but we don't have good long-term clinical evidence.

[00:38:35] And then the other thing is that as the SDF, as it oxidizes, that's really when it begins

[00:38:40] to darken.

[00:38:41] And so, um, that restoration that you put that might become darkened.

[00:38:46] And then let's say the patient leaves your practice and then one of your colleagues sees

[00:38:50] it and they see this very discolored composite.

[00:38:52] Now they want to remove it.

[00:38:54] I just, I wouldn't necessarily advise incorporating that into your adhesive protocol.

[00:38:59] Yeah.

[00:38:59] Yeah.

[00:38:59] It's interesting too.

[00:39:00] Cause you know, you wonder in a few years when we have better information and maybe better,

[00:39:03] better delivery, delivery systems of it becomes more commonplace.

[00:39:08] That's an interesting point.

[00:39:09] It's like, I mean, God, back in the day, uh, a lot of people were talking about the,

[00:39:14] those glass open sandwich and closed sandwich glass ionomer and composite and all that stuff.

[00:39:18] Like, I mean, it's cool.

[00:39:20] Um, it's complicated.

[00:39:22] It's complicated.

[00:39:23] I mean, like, it's like, it's not technique sensitive enough already than adding, you know,

[00:39:27] these two different materials.

[00:39:28] But I also understand why they would do it too.

[00:39:32] I understand.

[00:39:32] I made sense.

[00:39:33] And I, I just never really got into that.

[00:39:35] Not to say that there isn't something to talk about there though.

[00:39:38] It's a complication.

[00:39:40] Did you, did you learn any of the sandwich techniques or not really?

[00:39:43] You know, I felt like my dental school kind of grazed over it.

[00:39:49] Um, and I, I never quite was following it.

[00:39:51] I never quite completely understood it.

[00:39:53] And then it wasn't until a bit later, I realized like, this is perhaps, um, an older, like an

[00:39:59] outmoded technique that's not necessarily used.

[00:40:01] It's not necessarily something I do.

[00:40:03] Um, I think though, one consideration and one advantage perhaps with the sandwich technique

[00:40:08] or just the idea of you basically putting glass ionomer down in the box is just really

[00:40:14] this whole idea of, you know, uh, light diffusion, like the led light really truly does become

[00:40:21] considerably less effective the deeper you get into the box.

[00:40:24] So if I have a pretty deep box, I will use a bulk fill for perhaps that first millimeter

[00:40:29] or two, um, just to help better facilitate light transmission.

[00:40:33] Bulk fills tend to be more translucent and they have more photo initiators and different

[00:40:37] types of photo initiators.

[00:40:39] So they're not as aesthetic for that reason.

[00:40:41] They're more translucent, but I think it's a great adjunct to put down in your box.

[00:40:45] Yeah, sure.

[00:40:46] There's, I would, I, I wouldn't try, uh, a glass ion or sandwich technique myself just

[00:40:51] cause I don't feel like I'm, I'm, but, but if I needed something like that, there's a

[00:40:55] guy, have you ever heard of Graham Milicich?

[00:40:56] He's from, uh,

[00:40:57] Milicich and Rainey.

[00:40:59] Yep, exactly.

[00:41:00] I'd let him do one.

[00:41:01] I mean, he, I, he showed some amazing stuff, but I, it's, it's all interesting.

[00:41:04] I mean, it's all interesting.

[00:41:05] These guys are, are some of the smartest and most interesting people to, to, to listen to

[00:41:10] sweetest guy you ever met too.

[00:41:11] I mean, oh my gosh, Graham's a great guy.

[00:41:13] Yeah.

[00:41:13] But it's just like, I, I guess you kind of have to find, it is funny because we're

[00:41:18] talking a lot about evidence base and, and a lot of maybe, you know, certain size.

[00:41:22] And then you gotta be able to deliver on a regular basis in like a regular situation.

[00:41:27] And that's, that's where, that's where we lean on people like you who can kind of tell

[00:41:31] us where it's at.

[00:41:32] And then we just do the best we can with it, knowing that, knowing where it is.

[00:41:35] It's, it's, it's, it's a very interesting concept.

[00:41:37] I really like, I like that we're talking about it because it doesn't get talked about all

[00:41:41] that much, to be honest.

[00:41:42] I think it's, I think it's a really important concept for restorative dentists.

[00:41:45] I think it's super interesting.

[00:41:46] And I will say, I don't know, in my heart of hearts, I think I have a little bit of a

[00:41:50] rebellious spirit.

[00:41:51] So for example, I got really excited about ceramic onlays and overlays because it was

[00:41:56] different.

[00:41:56] It wasn't a crown.

[00:41:58] Same idea with this.

[00:41:59] I kind of, if a small part of me feels like I'm sticking it to the man, you know, like,

[00:42:03] oh, this is going against the dental state boards.

[00:42:05] I do like that.

[00:42:06] That's exactly right.

[00:42:07] And bring it on.

[00:42:08] I, I, whenever I talk about it, like you go online and talk about, oh, but what, what

[00:42:12] if someone sees it and says you didn't remove the decay?

[00:42:14] I'm like, okay, first off, they weren't there.

[00:42:17] Second off, tell me more about removing all the decay.

[00:42:20] Cause really?

[00:42:22] Like, like, really?

[00:42:23] I love that.

[00:42:23] I agree.

[00:42:24] I'm with you.

[00:42:24] I have the rebellious streak about, particularly about this too.

[00:42:27] Cause I'm like, you're so sure.

[00:42:29] I remember when I first got out of dental school and I was working with my dad and, and I'm

[00:42:34] like, God, you know, I think I got all of it.

[00:42:36] I don't know.

[00:42:37] I'm not sure.

[00:42:38] And, and he didn't sweat it too much.

[00:42:40] He was, you know, he, he was a dentist for 40 some years and he, he did a nice job.

[00:42:44] And I think on some level, part of it might be the fact that you see, you've seen it for

[00:42:49] a while.

[00:42:49] You've seen teeth survive amazing things that you did to them, all this sort of stuff.

[00:42:53] So I, I agree.

[00:42:55] Like I'm less sure about things than I ever was, but I'm also, I'm more sure that we're

[00:43:00] doing the right thing by not being overconfident about it.

[00:43:04] You know what I'm saying?

[00:43:05] Right.

[00:43:05] Exactly.

[00:43:06] I think that this is, I think this is what makes the profession fun.

[00:43:10] Uh, I love just kind of the concept of the more I learn, the more I realize I don't

[00:43:14] know anything.

[00:43:14] I love, I don't know.

[00:43:16] There's always just so much more to explore.

[00:43:18] There is for sure.

[00:43:19] There is for sure.

[00:43:19] And with that, I think we will explore vital, uh, vital pulp therapy another time.

[00:43:25] Cause we went for, I'm not surprised this happens.

[00:43:29] It's very fun.

[00:43:30] So Melissa, I'm going to, I'm going to wrap us up on, on selective carriers.

[00:43:33] And we'll give, give us the website of the, of, of your elevated GP one more time.

[00:43:38] Yeah.

[00:43:38] Just go to the elevated GP.com.

[00:43:42] Yeah.

[00:43:42] This is, this is great stuff.

[00:43:44] I love it.

[00:43:44] And, uh, so we'll do vital pulp therapy another time.

[00:43:47] What do you think?

[00:43:48] I really appreciate it.

[00:43:49] Thank you so much for having me on and sorry that I was such a pita to get ahold of here.

[00:43:55] No worries.

[00:43:56] No worries.

[00:43:56] We'll do it again very soon.

[00:43:57] Thanks, Melissa.

[00:43:58] You're my dude.

[00:43:58] Thank you.