Howard: It is just a huge honour for me today to be podcast interviewing a legend in dentistry. Lee Ann Brady from leeannbrady.com, restorativenation.com or pankey.org.
She is a privately practicing dentist and nationally recognized educator, lecturer and author with an extensive history in leadership. She is currently Director of Education of the Pankey Institute. Dr. Brady has also developed a vast library of online instruction at leeannbrady.com and restorativenation.com . She practices in Glendale, Arizona, is a member of the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and Dentaltown Magazine.
And seriously, I mean, I’ve been trying to get you on this show for 2 years. Thank you so much for coming on today. You talk a lot about occlusion, materials, restorative continued education. I just want to start with this one question. It seems like if you talk to a hundred endodontists, they don’t really disagree on much. If you talk to a hundred paediatric dentists, they don’t really disagree on much. Man, when you go into occlusion, it’s like 10 different major world religions. Do you agree with that assessment or not really?
Lee Ann Brady: Well I admit it, yeah experientially I do agree with that. That for years, historically, occlusion has sort of fallen into camps and people look at occlusion, think about it, diagnose it, and treat it based on how they were trained, which particular philosophy they were trained in, so yeah, I would agree that’s been my experience in 29 years of practicing dentistry.
Howard: So, these kids coming out of school, this is July 10th, so, last month we had 6,000 new kids join our profession. How are they supposed to pick a camp? Because one of the common questions is, "Should I do neuromuscular? Should I do CR?” Podcasters are young, I mean, people our age read textbooks. They jam out on their iPhone to Podcasts so help talk to these young kids on how they should pick a camp or what they should be thinking about.
Lee Ann Brady: Well, one of the things that’s interesting about it Howard is, if you look at the different occlusal philosophies, we actually agree about a whole lot more stuff than we disagree about. So that’s the good news…. Is that, if you actually said where are the areas we agree, it’s going to be the lion’s share of what everybody is teaching no matter where you go get that education. There are some pieces of that puzzle that we don’t agree on and so one of those for instance is kind of where the condyle-disc assemblies when you make all the teeth touch. Right, so the three biggies are intercuspal position which the truth of it is most dentists, most dentistry gets done by just saying to the patient "bite".
So that’s maximum intercuspal position and we don’t actually know where the condyle-disc assemblies are. And the reality of it is, does it work? Of course, it works! That’s why, if I took a guess, 85% of all the dentistry in this country gets done at maximum intercuspal position. Of course, the risk is it doesn’t always work so there are those patients on whom that’s not going to be a predictable, reproducible, comfortable position. Then you have the folks that want to seat the condyles and people refer to that as centric relation. Does it work? Absolutely, it works! Does it ever not work? Yeah, for some patients that’s not an appropriate approach, and then the third big approach would be neuromuscular and finding something called myocentric. Does it work? Yes, it works! Does it ever not work? Absolutely, it’s not for every patient. So, for me, one of the things I’ve done over a lot of years is I actually got education and got continuing education from a variety of different approaches. So that I can look at, you know, here are the things across the border that are consistent: make all the teeth touch evenly; make the front teeth, make the back teeth come apart; and I could also then interpret the things that are different and realize that it’s actually the same as everything else we do in dentistry. It’s about diagnosis; understanding your patient’s risk factors and what they present with. Health of their joints, muscles and their teeth; what’s your restorative treatment plan; and then you’re going to use your professional judgment and figure out what’s the best approach for that individual patient. So, I don’t know that I would make a strong, you know, here's a camp to start in from a standpoint of your education. You already have, you did that in dental school. You were taught an approach in dental school.
When it comes to occlusion, my feeling about it is just remember, it is a part of what we do, so it's not necessarily wise to think you can ignore it and that if you don’t pay attention to it, it won’t pay attention to you. It is going to come up in your practice. Keep learning, learn as much about it as you can and simply remember it’s a risk factor your patients present with. Just like some people have high Caries risk and some people have low. Some people have high Perrier risk and others low. Some patients have high occlusion or functional risk and others have very low risk and identifying that risk factor and knowing how to manage it when they show up with it is the key to success when you think about occlusion.
Howard: You know, you put 4 courses on Dentaltown and seen you lecture many times. You’re so gifted at teaching. I mean, you just make the most complex things so easy. I love it when you start making yourself a tooth. Are you aware that you do that? You actually turn into a tooth you’re so good at that stuff! Back to just another one occlusion question... What advice would you give to keep them out of trouble so they don’t get into trouble taking on one of these? What are the risk factors of someone who's a couple of years out of school where like with orthodontics, you wouldn’t want to start with the long face!? You wouldn’t want a class 3. How would you keep them out of trouble until they get really grounded?
Lee Ann: You know, honestly it really is about diagnosis, Howard. It's like anything in dentistry. If you start working outside your comfort zone the odds of you getting into trouble are higher, you know, so it’s amazing to me truthfully, given how much we have to do in dentistry, how much more there is to learn than when you and I went to dental school! That for young people it’s daunting compared to what we had to do, you know. I could talk about restoratative materials. I had to learn 2 in dental school, gold and PFM. Today there’s so many, your labs look like an 8 1/2 x 11 sheet of paper or a legal-size sheet of paper. So, for me the peace of it is if you stay within what you know and you feel confident and then you continue to go to education and you start to increase the boundaries of how big that is, that’s really the key to not getting into trouble, whether it’s occlusion or restorative dentistry or implants. With occlusion, I will tell you, probably one of the newest things that I love that’s come up in the last couple of years is actually a protocol called the JAMS protocol which stands for Joint and Muscles,Sprain and Strain. Really fancy name! I just call it JAMS. And what the JAMS protocol did is it looked at all the different things that we do on a functional exam and it said, "Can we come up with a really simple approach for people to assess a patient who has a high risk of developing an occlusal issue and acute TMD” and they did that. And what they honestly came up with is if you can ask a few simple questions and then you can do one thing which is range of motion on maximum opening, you can identify the patients who are your highest risk patients and those patients do need a more complete functional exam. So, whether I was just newly out of school or I have been out of school 15-20 years but I really don’t integrate a lot of occlusal diagnosis in my practice, one of the first things I would want to do is learn how to ask these 5 or 6 simple questions. Take a range of motion on max opening and I can at least sort out the high-risk patients before I actually start treating them.
Howard: Nice! I don’t want to turn this into a TMJ lecture but I would say that if someone comes in and they’re complaining about TMJ, grinding or whatever, probably 90% of the time the dentist is just going to an upper impression, send it to the lab and make an arch splint for that. Do you agree that's the majority treatment?
Lee Ann: Oh absolutely! I would say that that’s what most people are comfortable with is we're just going to make a night guard right? So, we're going to take upper-lower alginate impressions and send to the lab and say make me a full arch appliance. That’s what most of us were taught in dental school, absolutely!
Howard: And what do you think of that approach?
Lee Ann: You know what, there is one benefit which is if you put anything in between the teeth, especially at a new vertical dimension, for about 90 days you are going to reduce the muscle activities. So, you have the chance of a lot of those people feeling more comfortable. The challenge with doing that is if the patient continues to wear it or needs to wear it more than that, once they accommodate, if you haven’t determined where the condyle-disk assembly is when they’re on that appliance, how have you designed the occlusion on that appliance. You have just as good a chance of them now getting worse again or even getting worse than they were before they started than if you’d left them on their teeth. So as an acute, just put something between the teeth….. It'll work on a lot of patients which is why we've taught it for years. I will tell you much quicker than that, I make a patient like that a quick splint. Right, and we have tons of those kinds of temporary for some bite ridge or VPS material inside the appliance and that can manage that same huge percentage of those acute situations. And if they get better and they don’t need to wear it long term, then great. You haven’t left them with something that could potentially be harmful and if they do need to wear something long term, now you have the time to go back and actually figure out what’s the best appliance for them to wear based on their joints, muscles and occlusion.
Howard: And what would be the best way, fastest way, easiest way for people to learn that?
Lee Ann: Oh, you know what!? Honestly, on the internet! Which is where everything is, right? So, you know, I can obviously refer people back to the Dentaltown programmes that I did for you on occlusal diagnosis and so go on in there and getting some information in an hour online on doing a joint, muscle and occlusal exam will be powerful and, you know, I know that you guys have programmes on there also about some occlusal appliances. You could just google “quick splint”. There’s others like “best bite” or obviously folks on Dentaltown are super familiar with NTI. They’re all just prefabricated answer discluder shells that you can just customize to the patient.
Howard: Is that.. Jim Boyd was that? NTI?
Lee Ann: Yeah.
Howard: Yeah, I always used to see him lecturing. I don’t see him out much anymore. Did he retire?
Lee Ann: I do not know! I would agree, I don’t see his name as much as I used to but I do not have any of those details.
Howard: Yeah. So, what's the difference between these dentists going onto leeannbrady.com vs. restorativenation.com ? Which one of those websites do they go to for what?
Lee Ann: You know what, they are actually both designed to just supply folks with readily available information on the internet. My Lee Ann Brady site is a blog. It's been up for 6 and a half - 7 years and it’s all in written format. So, there’s tons and tons of information, 200 - 500 words so that you can get it in like 2 -3 minutes. Easiest way to use it is the search bar because there’s about 600 articles on there now. So, just type in what you’re looking for in the search bar and it’ll find you an article. restorativenation.com is a new website I just launched this year and it’s all video based so everything on that website is in a video format. From 2-3-minute-long video blogs or vlogs, all the way up to an hour - hour and a half long, more informative content driven videos. So, they can go to either, depends whether they have a preference of reading or watching.
Howard: My homies are driving, so I always retweet my guest’s last tweet so they can find it there. So I am retweeting ‘The Pankey Institute,get your infusion of occlusion at our next essential too.’ I’m going to retweet that. Again, I mean, you are an amazing legend. How did you write 650 articles? You are the most prolific content creator! I seek out your lecturing every week, I mean, do you ever sleep?
Lee Ann: Actually I do sleep! But I tell people all the time, I only have 2 states of being, on and off. I don’t sit on my couch and do nothing much. If I’m awake I need to be doing something. So, you know, writing blogs and doing that stuff keeps me out of trouble. If I wasn’t doing that Lord knows what trouble I’d get into!
Howard: So I’m on your .restorativenation.com . Do you have a separate twitter for that?
Lee Ann: You know what, restorativenation.com is a membership site so to get in past that front you actually have to go in where there's that “join” button or “members” button up in the upper right-hand corner?
Howard: Ok. It’s true, I mean, what we learnt 30 years ago... I don’t think we use any of that stuff. That was a long time ago. There is so many materials. What's your advice on all these materials. They go to the Chicago mid-winter meeting and there’s 174 different dental implant companies. It’s just so overwhelming! How could you simplify materials for dentists?
Lee Ann: Simplifying it for me honestly, when I think about it is, I want to kind of know what are the active ingredients in the material and if I know what those do then somebody comes out with a new dental adhesive or new this or new that. I can figure it out for myself! Does it do something different than the one I had before? Or nope, it’s the same old stuff just with a different label or different marketing or different packaging. I basically have my philosophy about materials is, I only really look at and consider new materials if what I’m using currently isn’t working. So, if I’m not getting the clinical outcomes I want from my material, I obviously need something new. If what I’m using is working, and someone brings me a new material I want to know, does it do as well as what I’m currently using? Like is it equally as good, and if so, it better be easier or less expensive before I'll consider it. Or, it better be better than what I’m doing now. So, tell me that it’s actually going to improve my clinical outcomes. So, I have manufacturers all the time who bring me new materials and say, "we have this hot new this or that", and I ask them those questions! I’m like "is it as good as what I’m doing now and it’s faster or less expensive, or is it better than what I’m doing now and if so, tell me how? Otherwise there’s really not a reason for me to move things around clinically and as you know, in a fast-paced clinical practice, you switch a material and have to learn one new set of directions. That can throw your whole dang day off. Right, so there has to be some really good validity to making that decision. And then I will tell you that I will go and get information. So, I will go to Dentaltown and I'll read what people are saying about those materials. They already tried it in the mouth... What were their experiences? I'll go to Dental Advisor, I’ll go to CR and I’ll actually not only read the scientific report, but I want to read the comparing contrast by the clinicians who have been using it. And find out how it’s actually working for other people in clinical practice.
Howard: Its funny when you said CR. I’m so old I still think of it as CRA! I can’t believe that they were the biggest brand name in dentistry. "Coca-Cola" and then they changed their name. Another thing, sometimes I fault the dentist for this... Sometimes they’re doing a filling and the best bonding agent, might be acid, rinse, adhesive whatever but they want it in one step. Remember when they came out with Promptopop?
Lee Ann: Yes.
Howard: Because they just wanted to get rid of a couple of steps and they’re trying
to do with endo files. Well let’s just get it down to one file you know? It's like, come on dude, you’re doing a root canal! I wouldn’t want to be getting a bypass and some cardiovascular surgeon says, "I found this new stuff that can eliminate 3 steps because I’m just lazy." So, do you think some of that stuff is getting too simplified? For instance, like what bonding agent do you use?
Lee Ann: So I actually use several different bonding agents in my office because I use different ones depending upon the clinical situation. So, if you said to me what bonding agent do I use for my day in and day out direct composites, direct restorative, I use a bonding agent called Ibond Universal, which is a Kulzer product. If you said to me what bonding agent do I use when I bond in indirect ceramics, I use Adhese Universal from Ivoclar Vivadent because I’m a strong believer for indirect segmentation that you buy a system and use the entire system from one manufacturer. Because I don’t think most of us in clinical practice are smart enough to understand how materials from different manufacturers interact with one another and are there contraindications or places where they’re chemically incompatible. So, I use lots of them! I do Total Etch, I'm still a Blue Gel person because that's how I grew up in dentistry. But that's one of the things that I like about the new Universal adhesives, is that you can do Total Etch, you can do Selective Etch, you can do Self Etch, you can do Hybrid Etch, you know we have all these etching techniques. So, you can buy one thing so you have good inventory control and you can etch with or without the gel depending on the clinical situation, without having to have a different product for that. But yeah, I do like Blue Gel and I've got a system where that's never caused me to have excessive sensitivity or problems in my practice so I'll continue to use that. You know, I'm a big believer in efficiency because the truth of it is, in dentistry time is money. I know we all like to yack about time because we think it's impolite to talk about money but time is money in a dental office and figuring out if there is a way that I can do something and I can not compromise my clinical outcomes, but I can be more efficient, I think about that every day in my dental practice. For me where I sort of draw the line is, I’m not willing to save time if it’s going to compromise my clinical outcomes and that’s the hard part as a clinician, is to figure out when we have newer materials with fewer steps... Is it as good? It just takes less time and fewer steps or no, is there a compromise in there somewhere that maybe we're not clear about. Self-etching adhesives have gotten so much better over the years we've been using them, decades we've been using them, you know, that when we look at dentin bonding and bonding to cut enamel, they’re pretty equivalent to Blue Gel. We start talking about bonding to uncut enamel, Blue Gel is still superior. So, if you said to me "I’m doing a really conservative veneer case. Everything is going to be bonded to enamel", I'd be like "Howard, pick up phosphoric acid and use an adhesive that uses phosphoric acid”. Because why not? Why not optimize the outcomes? If you said to me "Hey, for my routine class 1 and class 2 direct composite” I'd be like “Use a Self Etcher if you prefer to use a Self Etcher and you get better clinical results. So, again for me it’s about information and about understanding what you’re using and if you can say to me here's why I’m using it, because I believe its best in this clinical situation, you can answer that question. You have enough information.
Howard: So to be clear, you’re saying the bonding agent, you like the company to go from A-Z. So, if you’re going to use that bonding agent you want to use their composite.
Lee Ann: Well, not in direct composites.
Howard: Pardon?
Lee Ann: Not when it comes to direct composites but when it comes to indirect bonding. So, if you’re talking about like a light cured resin cement, a dual cured resin cement, I’m putting in a veneer or an inlay or an onlay, and I’m actually bonding it in. I’m a big believer in buying the whole kit so make sure that the dentin adhesive that you’re using came in the kit with the resin cement because of compatibility.
Howard: Ok. I want to ask you another question. Sometimes I almost think that, you know, I just celebrated my dental office 30 years. I graduated in 1987, and it seems like in a lot of respects, dentistry is worse today than it was 30 years ago. Like all my fillings are gold and it was all gold and amalgams and they just lasted longer than all this white stuff. And a lot of dentists on Dentaltown, you tell them that amalgams last longer than composits they say, "well maybe yours do, but mine lasts longer." So, I want to ask you what would last longer. Your direct composite or a direct amalgam you did in dental school 30 years ago? What do you think last longer?
Lee Ann: An amalgam. But you and I are compatriots, we're peers. I graduated one year after you from dental school. I guess it depends when you say things are worse, you’re obviously referring to the longevity of what we can do. And there's no question that when we moved from gold to other restorative materials, one of the changes was how long our restorations will stay in the oral environment. When you compare amalgams to composites, there's no question. I think clinical experience, I could find you research articles that say they last the same amount of time. Clinical experience, dentists will tell you their amalgams lasted longer. Composites are much more technique sensitive material. You know, and we’ve just got done talking about time in a dental practice. To do a composite at that level where it is going to competitively stay in the mouth as long as an amalgam, it's going to take you probably 2 or 3 times as much chair time. And so, because of that, they’re not done that way routinely and so routinely our experience is they don’t last as long, ok? But then of course if you’re going to say worse or better, we can have the same conversation about using metals vs. plastics and people with metal allergies and the mercury. We could talk about just the aesthetics, of the fact that as a society, we are way more focused on how things look today than we ever were and our patients, most of the time, would not want the dentistry that we did. Before you and I, Howard, we could go back to pin retained gold restorations on anterior teeth and I’m pretty sure that disappeared from dentistry because patients didn’t want gold class 4 angles on their teeth! That the dentists of that generation are like "oh my God, these young people are doing materials that are worse". So, a part of it is being driven by the demands of our patients and meeting people based on what they want. I will tell you that I still do a whole lot of faux gold crowns in my practice.
Howard: I bet they're all on men?
Lee Ann: You know what, and even some women but here is one of the demographics. You know where I live. I live in Glendale, Arizona. My patient population is all baby boomers. Most of my practice is people my age or older and so they grew up with a different level of aesthetics in dentistry and a lot of my patients, because of their age and their life experience, they don’t mind a gold crown on a second molar or a first molar. And because of where they are in their lives, they are also if I say to them "I could do it out of gold and it might be the last time you need a crown on this tooth in your life, or I could do a tooth coloured restoration and I need you to understand that you’re probably going to replace it every 10 - 15 years, maybe 20 if I’m really hitting it out of the park that day", a lot of my older patients are like "nah, I only want to do it once". But literally today I put in a gold second molar on a female patient and I put in a ceramic full coverage crown on a lady patient. They were both second molars, they are probably similar in age. Had those conversations and one said, "I’ll do gold" and one said "nah, I want tooth colour. I'll deal with the risks.”
Howard: That is the one thing I never….. I grew up with 5 sisters. I can’t believe that women decorate every body part they have with gold. Nose rings, ears, belly buttons, ankles, wedding rings and then you say molar and then they look at you like you’re crazy. You know we were talking about do some of these products, are they catering to too much shortcuts like you'll never meet an endodontist who says I’m going to do a molar root canal with one file, you know! You’re just not going to find that person. But what do you think about the bulk fill on getting rid of the steps? Does that shortcut keep the same quality, or do you think that the shortcut is a compromise?
Lee Ann: Well, you know what, the interesting thing about that is in some ways bulk fill composites are an evolution on our traditional composites. So, in order to make them bulk fill, the manufacturers have come up with a way to manage the shrinkage stress of the material. They've altered the photo initiators and the direction that the polymerization pulls in, so they're actually superior materials in some way. So, the generation of composites that came before them, in other ways it’s a compromise so most of our bulk fill composites, in order to get 4-6mm of depth of cure are less aesthetic. You know, so they’re more translucent, they don’t look like tooth structure. And so now you have a balance of if you’re doing an occlusal on a second molar, does your patient really care if its more translucent and lower in value vs. if you were using that material some place where it was more aesthetically visible. So yeah, I’m of the generation, first of all... when I went from amalgam to composite I was like "Woah, what are y'all doing!? We need to use amalgams". And now when I’ve finally converted to doing posterior composites in my practice, they have to be done in 1mm layers and I lived through the generations of ramp cure, art cure, angled layers, C factor, you know... All this stuff we don’t talk about anymore, and so it was like literally you never would bulk fill and all of a sudden they come out with bulk fill and the manufacturers are sending it to me and saying, "I want you to test these products", and I’m like "no way, we don’t bulk fill! Bulk fill is a bad thing!" But when I finally looked at the science and realized the manufacturers figured out how to make the science better so that bulk filling works. They’re actually great products and you need to know how to use them. Again, it adds confusion. Most of them can’t be used as the layer that's in occlusion. They have to have a cap layer because the rates of wear and longevity in the oral environment of those materials isn’t going to be as good, so you need to put a Nano category composite, Nano fill, Nano hybrid or Nano cluster on top of it as a cap layer. But there are a couple of bulk fillers on the market that don’t need a cap layer, you know, there are some that are flowable. There are some that still need to be condensed either with traditional instruments or a special handpiece. So, when you say bulk fill, you kind of almost have to step back and say what kind of bulk fill are you talking about because then we can kind of compare and contrast. But there are a lot of things about that category composites that are actually improvements over some of the other stuff we've been using.
Howard: Are you using one?
Lee Ann: I do use a bulk fill composite.
Howard: Well which one?
Lee Ann: I actually use Ivoclar Tetric Bulk Flow composite to do the boxes or the deepest portion of some of my class 2 or class 1 deposits.
Howard: And you’re liking that?
Lee Ann: I do like it. I like it a lot for 2 reasons... I love the radio-opacity. So, one of the places I think we've gotten ourselves in trouble in the last decade in dentistry is resin based materials that are radiolucent. Because I don't think we can evaluate our own restorations on follow up radiographs and certainly when our patients end up in somebody else's practice. They have no way to determine is that a void, an open margin, like what the heck's going on. So their material has really phenomenal radio-opacity. It's self-levelling so it's a flowable and you can put it in a class 2 box with a base of a restoration. And if your patient for 15, 20 seconds, it will actually self-level so you don't get any voids and you get a nice dense fill. And it does this weird color shifting thing that I don't understand. But it starts out totally translucent so the light will go through it. And then it becomes more opaque as it light cures. So if you do want to use it some place where aesthetics is more important you're not trying to cover up the translucents. But I don't use it as a cap layer. So it has to have something on top of it.
Howard: Back to, you know at our age we reminisce that you know that we always think that… I still think 99% of all the good songs were written in the 70's. I don't think I've heard one new song since the year 2000 that's even worthy of finishing and I'm sure that's wrong because I remember as little kid, mom always yelling down to the basement, “turn that crap off”. You know, “turn that music down” and it was like the Rolling Stones but somethings... I still think we’re going in the wrong way. For instance, in 1900 there were no specialities. By 2000 there were 58 specialities and dentistry has 9. And these kids are coming out of school and they're saying they want to learn invisalign, sleep apnoea and do their endos and pulpotomies and it's like are we really going back in time where one dentist is going to do everything? And what would you say to like when a young kid says to me I'm going to learn sleep apnoea, I'm like that's a lot of information. That's a lot of knowledge, what are you going to give up? And they never are going to give up anything. They just want to learn everything. What advice would you give to some 25 year old kid that just walked out of dental school? That thinks he's going to master: implants and bone grafting and sinus lifts and root canals, invisalign and sleep apnoea and I mean…. Can you really be a super dentist and do it all?
Lee Ann Brady: You know I guess you can. It depends how many hours of your day you want to devote to continuing education and studying and science and research. You know, I mean my personal philosophy about it is anything that I do, I want to do as well as anybody else can do it. And so, you know, I've gone and taken classes to learn how to place implants. I don't place them in my practice because I can't keep up with the information at the same level that my oral surgeon and my periodontist can. But I went into free education because I want to be able to help my patients understand what's going to happen. It helps me figure out who are the right surgeons to work with. I can talk with them. We can have that communication level. I'm a better referral source the more knowledgeable I am. But I don't want to have to maintain the level of information to be an expert at it all the time as it evolves. You know, and it's constantly evolving. But you know what, in the space of restorative dentistry materials, occlusion, the things I love that I really enjoy, I do dedicate the time to stay at the top of my craft. Now can you stay at the top of your craft in a real wide array in dentistry wider than mine? My guess is yes. If you have the time and the energy and the inclination to stay on top of all of that information. And you know what new materials are coming out, what new techniques are people doing. You know, are you going to the implant meetings and the sleep apnoea meetings and the occlusion meeting and the restorative meetings and you know. So I… That's my piece of the puzzle is, you know if you're going to do it, do it really well. And to do it really well you have to keep yourself continuously educated in this business. It's changing so fast. It is mind blowing, how fast it is changing. I don't know if you feel this way but.
Howard: Yeah!
Lee Ann Brady: Change curve is accelerating. The longer I'm in dentistry the faster the rate of change is getting which makes me feel like, okay, it's that much tougher to stay on top of it, you know. And part of it too, I think has to do with your resources. I know dentists who practice in really rural areas, small towns where they don't have an endodontist, they don't have a periodontist. You know, to try to take care of their patients, they have to get that skill and that level of expertise in all of those areas. And certainly, in Phoenix, Arizona we have lots and lots and lots of access and resources to specialists. And the other thing I would flip on there, Howard, is after 29 years of being a dentist, I'm really clear there are things in my clinical practice I love to do. And there are things in my clinical practice I do not enjoy. And if I don't enjoy them, I'm not as good at them arbitrarily and I don't spend as much time learning and staying ahead of the curve. And I also after 29 years I don't want to spend my day doing stuff I don't enjoy, you know. I want to come to work every day and be ready to jump out of my car and walk in to my practice. And not sitting the parking lot having to like do like yoga meditation to get out of the car. Hope right? So, you know and………
Howard Farran: Yeah!
Lee Ann Brady: And so part of that is realizing …. Like I realized a really time ago. I don't like endo. I don't enjoy it. It is just I don't enjoy it. I don't enjoy the process, I don't enjoy the fact that often the folks are in pain and uncomfortable before you start. I don't enjoy managing it at the post op level. So the truth is I have no idea how they do endo today. You could tell me they do it with one file and I would believe you. Because I have zero idea because I haven't done a root canal in 15 or 20 years but I happen to love occlusion and TMD so I do a lot of that in my practice, right? I know other GP's who it's the reverse. They are like, I wouldn't treat a TMD patient no matter how much money they were going to pay me. But endo…. I love sitting down and doing endo, right? Or how many dentists do you know in the middle. They'll do endo on a central, a really easy premolar, like you get more than one canal- they are out, right? Time to go see the specialist. So, you know, I think that's a blessing and a curse of our profession, right? On the one hand, the blessing is we have tons of choice. We have more choice around how we express our profession than any other profession I can think of. And the other side of that is that sometimes we feel some weird obligation that we have to do all of that. Or that we have to be good at all of that or, you know, our patients expect it or something. So, I've learned over a lot of years, no I actually get to say, and I can still be really successful in my practice even without doing endo and referring it all to the endodontist. It just makes a whole lot more space in my schedule to the stuff that I love.
Howard : Oh my God! I don't know how the paediatric dentists do it, that is the craziest. I mean, my God that I'm….
Lee Ann Brady: That you…. God bless them.
Howard: Yeah. And you know, you said that you went and took the implant surgical courses so you'd be a better referrer and you’d see what surgeon on that side….. You know the orthodontists get that the least. When I see the biggest rocking hot orthodontic practice, they set up study clubs. They're like okay my…. these guys are going to get in Invisalign, they going to do braces or whatever. But 80% of them will do it for couple of years and realize that they'd rather get, you know. They'd rather do a root canal or billable crown and get 2000 right now than drag it out over 2 years. And all those…. the fatigue rate of the …..so they educate, they make friends with all these guys and then within 1 or 2 years they all quit doing it. You know the orthodontist is flipping their chairs every 15 minutes and you start doing ortho and you schedule a half hour for that same appointment, now you have twice the overhead. So now, if the orthodontist has 60% overhead and you're scheduling 30 minute chair time. I mean it just does even make…. they all learned that but then they become really great referral people.
Lee Ann Brady: Right.
Howard: You know the luckiest thing about you also is you get to live by the Arizona Cardinals so you only have like a 5 minute drive to the game. I have like an hour drive to the game. But I want to get back to the millennials on this show. The under 30's.
Lee Ann Brady: Okay.
Howard : You know, if the Cardinals….. you know they'll tell you that you know when….. what they want you to do. They say the games are won by fancy plays, it's 4 things, did they block, that they tackle, that they passed, that they catch the pass, that's the 4 basics. When you look at crown and bridge the thing that's confusing …the biggest complaints about these millennials when they go these conventions, is that all the crown and bridge courses they are always full mouth rehab. But when you go to the labs 95% of all the crowns are sent in one at a time. So, go over one single unit crown on a 6 year molar. What's the block, tackle, pass, reception that these kids should kind of focus on. And they are probably also wondering do you do this new…... I mean are you using a Zirconium, are you using Empress, are…… you know there's so many new materials so go…. Just review a simple 6 year molar crown.
Lee Ann Brady: You know for me I guess the first piece of the puzzle is you do need to know what material are you planning on using for that. Because your prep design is going to be driven by your material. I will tell you in my practice, I told you, I still do all gold. I do do full contour zirconia. I do a full contour lithium disilicate or Emax. And every once in a blue moon I still do a PFM. I would tell you if it's a first molar odds are…. I'm going to be doing lithium disilicate or Emax or I use zirconia and full gold classically on second molars or patients with high occlusal risk. But you need to know what material you're using and in the worlds specifically of Emax you need to know whether you're planning to bond or cement because that's going to drive your prep. So, the first rule is prep the tooth appropriately for the clinical procedure, the material and the segmentation process. Then prepping a tooth for me is about be efficient, know what burs you want to use and create a bur system so that you can really go….. and go okay here's my bur for my occlusal depth cuts, here's my bur from my occlusal reduction, here's my bur to do all my axial walls and my margins so that you can cut the same prep consistently all the time and you're not dinking around wasting time trying to find the right bur. Third piece of that puzzle is impressions. Probably one of the things we do the worst in dentistry is take a really good quality impression. We blame it all the time on the impression material or the tray. It's about tissue management. I'm personally still a 2 cord dentist. So, I prep equigingivally if I'm planning to go sub G. Place the size zero cord. Drop my margin then place a size 1 cord. And I'm a huge fan of retraction paste, not for retraction but for vasoconstriction. But you need a really good quality impression with flash. So, 1 millimeter of material that goes past the margin. And then honestly after that it's your home free. You know what, if you’ve prepped the tooth appropriately with enough reduction for the material and the segmentation technique, if your margins are appropriate for that material, you've taken a good quality impression, you're going to get something back from the lab where your seat appointment is easy and doesn't take a lot of time. And your contacts are good and I guess the last piece of that, Howard, is I think 97% of us let our assistants do our provisionals or temporaries. Make sure that your assistant knows that a temporary has got to have interproximal contact otherwise you're going to spend a ton of time adjusting the crown when it comes back. And your temporaries have got to have occlusal contacts. Or you're going to spend a ton of time adjusting when the crown comes back and they’ve got to seal the margins or the patient’s going to call and complain about sensitivity. So, I don't do mine either, my assistant does them. But my assistant knows what the expectations are for how a provisional fits that supports us having an easy crown seat appointment.
Howard: If you make the temporary with your assistant you can make it so much faster but that… you'll never have a reduction coping because you figured out all those things when you’re making the temporary. You got to adjust the temporary. You know, I just adjust and clear through my temporary.
Lee Ann Brady: Yeah. And using depth cutters too. That's one of the things. I think a lot of dentists come out of a dental school and they think dropping depth cuts was something they just made us do in dental school. They do it to torture us. It actually really is important that you know that you get the right reduction. And that's a measurement's device is to use a depth cutting bur.
Howard: Yeah. So what impression material do you use?
Lee Ann Brady: I use Flexitime Xtreme from Kulzer.
Howard: Flexitime Xtreme from Kulzer.
Lee Ann Brady: Yeah. And…..
Howard: This is Dentistry Uncensored so I want to ask you some controversial questions.
Lee Ann Brady: Okay.
Howard Farran: A lot of these kids walk out of school 350,000. The two schools in our state are both private schools. They're very expensive. These kids are coming out 350…. 500 thousand debt. And there's so much pressure on them that to really be a good dentist they got to drop a 150 on a cad/cam, a 100,000 on laser, a $100,000 on a CBCT and they’re saying “man I keep …… come out of school, make three purchases and double my student loan debt. So if somebody, a 25 year old kid's at you….. if I want to be a good/great dentist like Lee Ann Brady do I need a CAD/CAM machine?
Lee Ann Brady: Well I guess the answer to that would be no, since I don't own one currently in my dental practice.
Howard: I guess that kind of sums it up.
Lee Ann Brady: Yeah. You know I mean. You know honestly, I love the technology and I taught the technology for years as many people know. And I don't own one in my clinical practice because I just bought my practice 5 years ago. I was an associate for 1 year before that. And I have a really large six figure note on my dental practice. And investing another large six figure number to buy in office milling technology, doesn’t make any fiscal sense in my practice right now. Five years from now if you ask me that question, it’s possible I will own CAD/CAM technology and milling technology. Because the numbers will work.
You know, I learned a lot of years ago that practicing dentistry always has to be fifty-one percent healthcare and forty-nine percent business. And those numbers can get skewed. But they do have to be forty-nine percent business. And those numbers can get skewed. But they do have to be forty-nine percent business. I have to be a good steward of my business decisions which always means my financial decisions. If you put yourself in fiscal hot water and you owe a ton of money, and you’re stressed about how you’re going to pay it back, it is going to influence your clinical decisions, whether you think it is or not.
Howard: And your stomach lining, and your stress.
Lee Ann: Yes.
Howard: Which can lead to drinking and fighting with your spouse and…
Lee Ann: All sorts of things, exactly. So be a good steward of your finances, because it makes every other part of your professional life, and your personal life, easier. And maybe this is… maybe this is part of the wisdom of doing this a long time and getting a little older. I’m clear that I will have the opportunity to buy that cool stuff in a few years, in a way that it will be less stressful. So, I’m not in a super big rush to do that.
Howard: Okay. Same question about an oral scanner for an impression. You told us your impression material. What about oral scanning?
Lee Ann: I do not have an oral scanner in my office. And part of that is I keep waiting for the technology to get even more mobile. So, I think the technology, as far as the quality of the image and the scanners is good. I don’t necessarily like the size of the camera you have to hold in your hand. And especially this is maybe… maybe a gender discrimination piece but if you have small hands, holding some of those cameras can be really challenging. But the other piece of it is just the device and the computer.
I’m waiting for somebody to come out with one that literally you just throw the software on your computers in your office, and all you have to do is move it from room to room. Plug it in with a USB, you don’t have this big thing you have to wheel around or move around. But I love the technology. And probably my favourite thing about the technology is it makes us better dentists. You cannot look at your preps on that computer screen and not be motivated to do better.
Howard: Absolutely. Same question. Lasers.
Lee Ann: I do have a laser in my office. So, I have a CO2 laser in my office. I grew up on Electrosurge. And so… Right.
Howard: I can still smell it.
Lee Ann: Exactly. And I would not use that technology today. And when I started to do some research into lasers, for me personally, moving to a laser and going diode which is in some ways a glorified Electrosurge Because you’re not, most of the time, cutting with laser energy you’re still cutting with heat. I said I might as well just go all the way to really using the laser, where I’m going to have less patient post op discomfort, faster healing times. I’ve got the advantages of actually using a laser. So I do use that in my office as an adjunct for my restorative dentistry. I don’t do a lot of surgery for it’s own sake.
Howard: And which laser… which brand did you get?
Lee Ann: I actually have a DEKA laser, a CO2. I’m not even sure, honestly Howard, what their position is in selling in the States anymore these days.
Howard: Yeah. That’s true. So, a lot of… some of these kids they come out with three hundred and fifty, five hundred thousand dollars in debt. And they want to be an associate for a long time. What would you say to a kid who’s thinking, “I want to start my own practice like you” versus being an associate. What do you think they should wrap their mind around?
Lee Ann: Well I would tell you that I do think there’s some advantages, when you first get out of dental school, to find an opportunity that lets you just be a dentist for a while. I hear lots of phrases that refer to that. But you, honestly, just need to be some place where you don’t have somebody looking over your shoulder. You need to learn how to do an MO in less than four hours. Right?
You need to actually get used to being a dentist out in real clinical practice, not in a dental school setting. I know people who do that in one year residency programs, they get their speed up a little bit, and their independence. Others who go into practices to just be associates, where they know somebody else is worrying about the business, somebody else is driving them patients. And they get to just be a dentist for a year or two, or whatever it takes them. And, depending upon the associateship you get into, it’s also an opportunity to learn to be a business owner.
I have yet to meet a person who comes out of dental school who knows how to run a business. We’re not taught that. We get the bare, bare minimum from that perspective. And so being in somebody else’s practice, be curious, ask questions. How do they hire and fire? How do they handle their payroll? What percentage of the overhead or clinical supplies and rent? It’s an opportunity to learn those things without learning them where you actually have to learn them and make it work at the same time. So, I think those are important pieces of the puzzle.
And then you will also figure out for yourself what’s the best fit for you. And lots and lots of the dentists that I know could not work in any other way, than owning their own private practice. They need control. They need autonomy. And on the other token I know lots of dentists who want to just be able to show up for work in the morning, be with their patients, treat the clinical situations, and go home at five o’clock. And not worry about, there’s a leak in the supply room closet where the compressor connects, and they’re raising my rent next year and all of those pieces.
So, part of it is figuring out what you want. But the other piece of that is recognizing that in a well-run dental practice you should be being paid not only as the dentist who produces dentistry, but you should be being paid or compensated for the management and the leadership. So that… yes, you are spending more time than the person who doesn’t own the practice, but you’re also getting compensated for that investment of time. And figuring that out is… it takes a couple of years for most people.
Howard: I want to ask you another… I’ve only got you for another… you’re on your lunch break. I’ve only got you for six more minutes. I’ve got to squeeze in a bunch of questions. Since you’re a woman that… they’re always saying that since it went from mostly all men to now half the graduating class women. You always hear a bunch of men saying how that’s going to change everything. Maybe they won’t work as long, or they’re going to stay home and have kids, blah, blah, blah, blah.
Do you think the half the class that are women are going to be any different than the half the class that’s men? As far as like… a lot of them say things like, “well the women they just want a job they’re going to… that’s what’s going to feel corporate”. But then when I look at corporate their number one problem is employee turnover. I mean some of these chains can’t keep their average dentists a year. And if they can keep a dentist two years it’s considered a miracle. So, are women dentists more likely to do anything different than their male colleagues?
Lee Ann: The truth is my gut answer is going to be no I don’t think so. I just spent the weekend with twelve other women dentists at our women’s program down at the Pankey Institute. And every woman in that room was a practice owner or a future practice owner because that’s their goal. Because I think we all… the things that bring us to dentistry are the same regardless of our gender. We love people. We’re half science and half art. We want to be in the healthcare profession and we want to be autonomous.
We like that environment of being in control of our own world, regardless of whether we’re men or women. And so that’s going to lead the majority of dentists to being private practice owners, or at least in a position of controller leadership in the practice they work for. And I just think it’s so funny how I hear lots of people say, “well we’re going to need a whole lot more dentists because women are only going to want to work three days a week”. Most of the men dentists I know have always aspired to only work three days a week. That’s a measure of success is to only be able to work three days a week.
So honestly when I talk to dentists all over the country, I don’t hear differences. I think there’s different logistics to work out. And I think that we may come up with a whole bunch of new practice models and paradigms, that are still private practice based. But that maybe fit differently for this whole new generation. A whole new generation, men and women. They see their worlds differently than we did, Howard. They see how work fits with their family differently than we did twenty-nine and thirty years ago. But I don’t think it’s as much of a gender issue, as it is just a generational issue.
Howard: Yeah. I mean all my memories of my dad… if I want to see my dad I had to go to Sonic Drive-in.
Lee Ann: Yeah.
Howard: I mean he was there from morning to night and I thought nothing wrong with it. Because that was just all we knew. And you got to see your dad and eat a cheeseburger at the same time. How cool is that? Last question. Last question because I know you’re on a lunch break and you’re so amazing to come on the show. How can these young kids… I mean when I think of you I think of leadership. I mean you’ve been a leader in dentistry for thirty years. How can they speed up, fast forward, learn to be a leader?
Lee Ann: You know what? Honestly, I think you put yourself in the path of leadership. Be active in our profession. Be active in continuing education. Be active in your local dental society. Be active on Dentaltown. Pick a community in dentistry. And there’s lots of communities, there are real ones and virtual ones. And put yourself in that path, speak your mind, share your opinions. And get to know our profession.
I think one of the saddest things about our profession is, how many people go into their little practice all by themselves every day. And they don’t interact with the rest of the profession. And dentistry is darn hard work, Howard. I know nobody else outside of being a dentist understands that. But it’s darn hard work. And one of the most important things you can do is sit with another dentist, so that you could celebrate that veneer case. And somebody else is going to get it and not think you’re a weird geek. But you could also talk about the five really stressful things that happened in my practice today. And nobody’s sitting there going “oh woe is me, you poor dentist you”. Right. But they actually get it. So be involved would be my two cents.
Howard: But one last thing that’s so different about you versus the other ninety-nine percenters. They’re afraid to say anything. I mean they go to these meetings, they don’t talk. They get on Dentaltown, they don’t want to post. I mean the lurkers are off the charts compared to the posters.
Lee Ann: Right.
Howard: They’re all afraid to say anything. Like when you give them a lecture, they couldn’t do it because someone might raise their hand and say, “hey, I disagree with that. I think that this should be in the other room next to the refrigerator”. They’re just… how did you not have that fear?
Lee Ann: Oh, I did have that fear. And I think all of us have that fear and yet one of the things I embraced a long time ago about dentistry is there is no one way to do it. And there’s no one right material. And there’s no one right technique. And there’s no one right practice model. That there’s as many different possibilities. And they’re all excellent choices. They’re just different choices.
And it’s funny for me that in a profession full of people who want to be individuals, that you’re right, that we all get together and then we don’t want to be that individual. Right. We don’t want to have that individual voice. For me it’s like, “hey, okay. You know what? I take physical impressions, I use goo”. Is that for everybody? Nope. Not for everybody. Does it work for me right now? It works for me right now. Is it possible that it won’t work for me in a year, or two years, or five years? Possible it won’t work for me. You use a scanner. Awesome, I think that’s phenomenal. Right?
So as a profession if we could embrace the fact that there’s a lot of different ways to do it, that all come out of our commitment to our patients. That I have yet to ever meet a dentist, ever, who sat in the parking lot before he got out of his car to go into work, and said, “you know, let me see how many people I can screw up today”. Right. We don’t do it. We all go in with the best intention to be the best we can be, and to help our patients. And our expression of what that looks like is as individual as we are, that patient is, and our offices are. And so, if we can all give each other a little space, that we all have the best intentions, and we can be different. Then I think those younger folks would feel more comfortable speaking up.
Howard: Last question, you’ve had a really big year. You’ve launched restorativenation.com , which is huge and amazing. But you also took over the… you’ve got a… you’re now back at Pankey. I was wondering is that because you went to University of Florida and is that your way of just hanging out… spending more time in Florida, or what. Tell us your Pankey move.
Lee Ann: Yeah. I was missing the beach, Howard. No actually. You know what, I love Arizona and I’m not leaving Arizona, I’m not selling my practice. This has been a big year with lots of changes. And there’s a way for me… this is about going home. I actually didn’t go down to Pankey as a student. And until I’d been out of dental school about thirteen or fourteen years. So even though I went to Florida, I didn’t realize I had that resource right in my own state. I went to the Pankey Institute after actually giving up practicing dentistry. Because I got burnt out and I hated it. And I quit for three years. And got forced back in because I had to earn a living. And I happened to end up meeting a dentist who’d been down there. And it changed my life. It really is the place that taught me I can love practicing dentistry, that I get to choose. You know all the things we talked about today, I wouldn’t be who I am as a dentist, as a spouse, as a parent, or as an educator if it hadn’t been for the Pankey Institute. They also gave me my opportunity to teach for the very first time in my career. And so, they approached me this year and asked me if I would consider stepping back in, because I was a full time employee there as you know for four years in the early 2000’s and take over being director of education. And for me to be able to help them grow and move powerfully into the future, and be there for other dentists so they can get what I got, and give back for the gifts they’ve given me, it kind of was a no brainer but to say yes.
Howard: You are an amazing person. An amazing leader. You leave dentistry better than you found it. You’re truly one of dentistry’s thousand points of light. I want to thank you so much for coming on and spending an hour with my homies today. This has just been an amazing, amazing podcast.
Lee Ann: Well thank you. I’m super honoured to be on the podcast. And sorry it took me so long to make it happen.
Howard: Well, hey, I would’ve waited twenty years to get you on the show. Alright have a rocking hot day Lee Ann. Thank you so much for all that you’ve done for dentistry.
Lee Ann: Thank you, Howard. Thanks for having me.