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VIDEO - DUwHF #932 - Edward McLaren
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AUDIO - DUwHF #932 - Edward McLaren
Dr. Edward A. McLaren DDS, MDC
Graduated from UOP in 1983
Graduated from UCLA in Graduate Prosthodontics 1990
Former director of UCLA graduate esthetics
Founder and director of UCLA advanced esthetics and restorative dentistry full time graduate program
Founder and director of UCLA master ceramist program
Former Professor UCLA school of dentistry
Professor at UAB school of dentistry
Founder and director of UAB advanced esthetics, restorative dentistry and masters of material science residency program
Founder and director of UCLA master ceramist program
Founder and director of UAB master ceramist program
Author of the textbook “The Art of Passion”: teeth, ceramics, faces and places
Author of over 80 articles
www.edmclaren.com
Howard: [00:00:07] It is just a huge, huge, unbelievable honor to be podcast interviewing Dr. Edward A. McLaren, DDS, MDC. He graduated from the University of the Pacific in 1983; he graduated from UCLA in Graduate Prosthodontics in 1990; he's the former director of UCLA Graduate Esthetics, founder and director of UCLA Advanced Esthetics and Restorative Dentistry, full-time Graduate Program, founder and director of UCLA Master Ceramist Program, former professor at UCLA School of Dentistry, professor now at the University of Alabama School of Dentistry, founder and Director of University Alabama Advanced Esthetics, Restorative Dentistry and Master's of Materials Science Residency Program, founder and director of UCLA Master Ceramist Program, founder and director of University Alabama Master Ceramist Program, author of the textbook "The Art of Passion: Teeth, Ceramics, Faces, Places", author of over eighty articles. How the hell did I get you to come on my show today, Ed? Thank you so much for coming on the show. You are amazing.
[00:01:14] When you and I got out of school, the new hot thing, we were going from amalgams and full gold crowns to PFMs and composites. Did you ever think you would live long enough that, now the PFM is gone the way of the full gold crown and now there's all these new materials. It's so overwhelming. What is a young kid supposed to think about when it comes to ceramics, adhesion, esthetics?
Edward: [00:01:41] Well, good point. I mean, gosh, I haven't done a gold crown in fifteen or twenty years. And not that I'm against gold and it's a wonderful material, but you know and I know that our patients really want minimalistic dentistry. They want to look youthful today, they want to stay youthful and with the materials and adhesion today, we have the ability to do that. That's what's really exciting. And it's almost overwhelming, the choices that young dentists have today. I'm personally excited, but I also feel overwhelmed with all of my knowledge today. So, I would recommend any young dentist, if they're into studying dentistry, to focus on two things: understanding new ceramics and understand adhesion and become a master at adhesion. I try to break it down very simply for young dentists. There's really three choices today, if you really break it down, there's three choices in ceramics. If we talk about composites, it's feldspathic ceramics, if the restorations are minimalistic, it's something like E-Max, if you're bonding the dentin, and if you have to do a conventional crown, it's zirconia today. There's various forms, that's pretty much as simple as that. But yes, you're right, I never thought we would see the day that we would eliminate metal, that would be possible to eliminate metal today. It's certainly a viable option, a PFM.
Howard: [00:03:06] Well, Ed, here's what I want to do. You're overqualified to teach the most elite fifty-year-old cosmetic dentists around the planet. You're overqualified to teach them. I want you to bring it all the way back home, because you're talking to a young crowd, 25% are in dental school, the rest are under thirty, they got out of school. So, I want you to just go into detail, detail, detail of two things. When you look at a hundred million insurance claim's form, you just see four spikes and they're all on the six-year molars, tooth number three, fourteen, nineteen, thirty. The tooth most likely to get a MOD - first molar, most likely to get a root canal - first molar, most likely to get a crown - first molar, most likely to get extracted, it's all first molar. So, she's twenty-five, she's trying to build up her speed in a MOD on a first molar and a full crown or a crown on a first molar. Can you dive deep into an MOD on a first molar and then go into a crown on a first molar, what materials, what products? Because it's so overwhelming, there's so many companies, there's so many different bonding materials. I mean, what generation bonding agent are we on right now, 327?
Edward: [00:04:28] 401.
Howard: 401.
Edward: We’re up to 401. Well, the good news the last two or three years, the universals... I'll get real simple with the bonding agent, I'll come back to the crown. Trying to make it real simple. The bonding to enamel, you still should etch, you still should etch, but the good news is the universals are working with the dentin. So, we can keep it real simple. You could have a universal, just in your practice today, and if you want to attach the dentin, you don't need to etch, you just don't need to etch, that universals are working. And if you want a good, stable, long-term bond to enamel, you should selectively etch the enamel and it looks like you're going to be very safe long-term with that.
Howard: [00:05:12] Name brands.
Edward: [00:05:15] So, you've got Scotchbond Universal and you've got All-Bond Universal, those have been the two on the market the longest period of time and I would recommend those two, OK?
Howard: [00:05:25] And Scotchbond...
Edward: [00:05:25] Yeah, those are one - bottle materials.
Howard: [00:05:28] Scotchbond is 3M and All-Bond?
Edward: [00:05:32] It is Bisco. And the Kerr product, it's a two-bottle material, so you got to use two bottles, is OptiBond XTR. So, to sort of give you three right there.
Howard: [00:05:43] OptiBond X?
Edward: [00:05:47] XTR from Kerr, but it's a two-bottle material. So, if you want a one-bottle material, it's the other two products. And 3M has been on the market the longest and has the best research, OK? But I would etch the enamel, if you want to play it safe, the research shows to at least etch the enamel and you're pretty safe there.
[00:06:07] Bulk-fill today, I have no problem with the bulk-fill for a dentin replacement. I would still use a micro hybrid for the enamel replacement, if you're going to use it on an occlusive surface. So, names come to mind. I kind of hate to give product names, but I would just use a good bulk-fill, if you want to, for a dentin replacement and whatever micro hybrid you would like for enamel replacement.
Howard: [00:06:43] I know you guys hate giving names, but give a couple of names.
Edward: [00:06:47] Jeez, 3M's material, it just escapes my memory right now, because I just have a little bit of an aversion for that. I like Ultradent's material, Vit-l-escence is the main material I use for occlusal surfaces, OK? And jeez, I'm brain-dead right now.
Howard: [00:07:12] What was the one, what did you say, L-escence?
Edward: [00:07:13] Vit-l-escence from Ultradent. Yeah, that's the material I use the most, OK? And I use it on my patients.
Howard: [00:07:23] OK.
Edward: [00:07:25] And then, for ceramics today, if I'm doing a full crown, I'm using the STML from Noritake.
Howard: [00:07:32] Say that again.
Edward: [00:07:34] That's a cubic zirconia. I use STML from Noritake for a full crown. That's the cubic zirconia.
Howard: [00:07:42] Can you find that, STML from Noritake, cubic zirconia?
Edward: [00:07:46] The new cubic zirconia is much more translucent than the original zirconia. You can use it in a monolithic format, a monolithic format. Meaning it's a very simple material to use and it looks very good. Other materials to use that work very well too, that we have some experience with, the Lava Esthetic - to give you three brands that look very good, I like to give two or three brands - the Oregon Anterior from Oregon, Oregon Anterior. So, those are the three brands.
Howard: [00:08:22] Oregon Anterior. And who makes Lava Esthetic?
Edward: [00:08:23] 3M.
Howard: [00:08:26] 3M?
Edward: [00:08:27] 3M, yeah.
Howard: [00:08:28] You know what I like about 3M the most?
Edward: [00:08:31] Yeah.
Howard: [00:08:32] You know?
Edward: [00:08:32] What? No.
Howard: [00:08:33] Well, my older sister's a cloistered Carmelite nun and it's in Lake Elmo. So, when I go visit her, to make it a business expense, I fly in, I go spend four hours and one minute at either 3M or Patterson headquarters, make it a tax deduction, then I go spend all afternoon with my sister and then fly home, all pre-tax. How cool is that?
Edward: [00:08:53] Might not want to say that so live. I'm sorry, it popped in my head - Filtek Supreme Ultra is my favorite posterior composite, that's from 3M, Filtek Supreme Ultra, and Vit-l-escence and the Anterior from Ultradent.
Howard: [00:09:12] OK, so, here's the belief... What's that?
Edward: [00:09:19] Well, I just try and keep that very simple. I use a universal, like I said, for a bonding agent and then I'll etch the enamel, I'll use a bulk-fill for dentin replacement, for a build-up, and then if I do a full crown, I use a cubic zirconia. You can keep it pretty simple without too high of an expense. Like you said, to treat that molar before it turns into an endo, for a young struggling dentist.
Howard: [00:09:46] A lot of people mix and match, like they'll use a bonding agent from Kerr and a composite from Ivoclar and a crown from Oregon. Do you think that, when those organic chemists with PHDs are making the product, that you should stay within one system, like use the Scotchbond from 3M and the 3M bulk-fill and the 3M Lava Esthetic? Do you think it's a better product when the PhDs designed a closed system from A to B, as opposed to mixing and matching different chemistry sets and different composites and materials?
Edward: [00:10:25] There are very, very few product lines that you can't mix and match. There are very few. In fact, the only ones that I haven't seen match is the 3M with their special chemistry with their resin cement, with their veneer cement. The 3M's veneer cement doesn't set with some other people's bonding agents. That usually is not a problem with resin cements, I have not seen that to be a big problem. So, for instance, you happen to like Scotchbond Universal, because it's a very good universal and you're using somebody else's veneer cement and I have never seen a problem with that. I realize companies will tell you to use their whole line of products and you obviously know the reason for that, that's marketing and sales, but we have not seen a problem with that. They will copolymerize.
Howard: [00:11:21] A lot of people believe that zirconium is for second bicuspid and back, and E-Max is for anterior, because of esthetics. Do you draw a line like that or do you not see a line like that?
Edward: [00:11:37] I would have agreed with that with the original zirconia. It was all tetragonal-phase zirconia, which was much more opaque than this newer version of zirconia that has some cubic phase. Cubic-phase zirconia is more translucent. They give a fake diamond. It was a 100% cubic-phase zirconia, more like glass. These newer materials have up to 30%, 40% or 50% cubic-phase zirconia, which make them significantly more translucent. And they're very similar now to the MT or medium-translucent E-Max. They're not quite as translucent, but they're getting very similar. So, here's where I break it down for me today. Where I need increased strength, maybe in a crown environment or a (inaudible), I can't do adhesion, where I can't bond. Then I'm going to use the zirconia. In more minimalistic situations where I can't use feldspathic porcelain, I'm still using E-Max. I think E-Max is one of the better materials that's ever been invented in dentistry and I can use it in an adhesive environment. Zirconia we can only bond chemically, we can't etch the internal surface. So, the stability of a bond with E-Max isn't that good. E-Max, we can etch it like porcelain. So, I can use it with a non-retentive preparation. So, the direct answer to your question is - zirconia is not as esthetic as E-Max, but it's getting close.
Howard: [00:13:11] OK. A lot of the young kids will say, "Well, what's going wrong with your composite or crown?" Back to the kids at school, when they come out of school, they don't need to learn how to place implants and full-mouth rehab. They need to practice their filling, their crown, their cleaning. It's like when you start playing football in high school, you need to practice your block, your tackle, your pass, your catch. So, they need to get out of school and work on their basics. And I say, "Well what's your main problem with your basics?" The first thing they always say is sensitivity.
Edward: [00:13:44] OK, great I'll tell you, one of the best things that ever happened to me about sensitivity was meeting Ray Bertolotti. And I don't know if that name means a bell to you, but he was the head of...
Howard: [00:13:57] His wife used to be in the same Catholic nunnery as my oldest sister.
Edward: [00:14:04] Great.
Howard: [00:14:06] I've known them for thirty years. Great guy, just a great guy.
Edward: [00:14:11] I can tell you that whether you etch or don't etch the tooth, if the dentist is willing to put a 5% glutaraldehyde product for thirty seconds on a tooth, prior to doing any adhesive procedure, it will eliminate sensitivity and it will increase bond strength. I'm sure you know Rella Christensen, she loves the stuff, she wants you to put it on for two minutes to kill all the bugs. It does not decrease bond strength, it increases bond strength with self-etch or total-etch and it decreases sensitivity. And you do need to be careful, because it will burn soft tissue. You don't want to get it in anybody's eye or on their gingiva. So, what I do is, I put it on a little micro-brush, whether I'm doing etch or no etch, non-etch, and I rub a little bit on the dentin and then I'll do my adhesive technique. So, if you were doing total-etch, you would etch first, then you'd put a little on a micro-brush and rub it on the dentin for thirty seconds, suction off the excess, being very careful not to get it on the gingiva, then go to your adhesive technique. If you're doing non-etch, obviously you're not etching, you put a little on a micro-brush, rub it on the dentin, just a little bit, slap it on, suction off the excess and then do your adhesive technique. Young dentists out there, please try that and sensitivity will disappear.
[00:15:37] So, the products to try - the original product was GLUMA that had the original patent, it's 5% glutaraldehyde, 35% HEMA, 60% percent water. The product of choice today was a product that actually re-developed, it's called Micro Prime G, Micro Prime G from Danville Materials, it has the exact same formula - 5% glutaraldehyde, 35% HEMA, 60% water. The patent's run out and basically they copied it. Other things on the market - Systemp desensitizer, Herschel, similar type products. There are some people that are against the use of the product just because glutaraldehyde is toxic. You just have to be careful in its use. Again don't get it on soft tissue, it will burn, but if you try that, I can guarantee you 99% of your sensitivity will disappear.
Howard: [00:16:32] Ed, in the market today there's 211,000 Americans who have a license to practice dentistry - 150,000 are general dentists, thirty-two hours a week or more, 30,000 are specialists, thirty-two hours a week or more, of those 150,000 general dentists doing thirty-two hours a week or more, what percent of them do you think use a rubber dam when doing an MOD composite on a first-year molar, six-year molar?
Edward: [00:16:57] I would guess less than 15%, maybe less than 10%.
Howard: [00:17:03] I love that you're so real. You're so real. That's so obvious. What are your thoughts on that? Do you think they're still getting it done with 3-inch cotton rolls or do you think they're just really doing secondary dentistry?
Edward: [00:17:20] Well, it's very interesting and in point that you mentioned that. There is a gentleman here that has, at UAB, not hear right now, but at University of Alabama, his name is Gregg Gilbert and he is the chairman of the Biomaterials department or the whole department that I'm in, and he has the largest grant in history from the NIH (National Institutes of Health), it's a practice-based study grant, and actually he is studying exactly that, he's looking in practices that use rubber dam and don't use rubber dam, and following success and failure, exactly what you're asking me. And pretty much he has not seen too much difference between using rubber dam and not using rubber dam. Now, I'm not saying that's a license not to use rubber dam, OK? "Oh, Dr. Ed just said or Gregg just said (Gilbert) - don't use rubber dam." So, it really comes down to, the real obvious answer is your ability to control moisture, it's not whether the rubber dam's on or not, it's whether you can keep moisture, saliva and crud off of the tooth. So, if you can keep it with cotton rolls, if you can keep it with something like an Isolite or Isodry system, some way to keep a contaminal... Isolite or Isodry, that's what I use. If I can't keep moisture off the tooth, then I'll put a rubber dam on. I don't like putting them on, I don't like working with them, but if it's absolutely necessary, I will use it. But that's the key. The key is clean and dry, right? And if you put somebody's head in a bag, you know... But that is the point. The point is clean and dry. I've seen some very good dentistry with rubber dams and I've seen it without. So, anyway, I think you get the point.
Howard: [00:19:05] Another thing that she's confused on, she's twenty-five. They hear so many different things, especially on Dentaltown, that you shouldn't get a pulp exposure because you remove too much decay. There's affected dentin, infected dentine, you don't have to remove all the decay, you don't want a pulp cap, other people say you remove all of decay, you need a pulp cap or a root canal, other say to get a pulp exposure, use a MTA or whatever. Talk about those things, those issues.
Edward: [00:19:35] So, that's an interesting point today. I was taught in school, and I think the prevalence still today is, if you get a pulp exposure, it's almost a root canal. And that's pretty much what I used to do. Then I had the benefit of listening to John Kanca a number of years ago and then I kind of followed up with Ray Bertolotti's, the gentleman I've mentioned, that if you had a pulp exposure, and then Charlie Cox and Jon Suzuki, some names you might remember, Howard, that if the pulp was still vital and hadn't given any symptoms and you could seal that, you could wall that off and keep bacteria from going in there, that you give the pulp a chance to heal. And John Kanca published a work on this, that if you could seal the pulp, that the body would heal itself. And my strong recommendation to you out there is maybe either take a look at that. And I started doing that. If it was a small pulp exposure and I can control and get some seal, I would then just do a big composite build-up, let's say, and I would see if the tooth would heal. If the tooth became non-symptomatic in six months later that I saw a dentin bridge in there, which would happen most of the time, I have to tell you, if the tooth was asymptomatic before and asymptomatic after, then I just go ahead and do an onlay or a crown. And the material that I'm using today is TheraCal, TheraCal Dual-Cure. It's a calcium silicate material that stimulates secondary dentin. You can use something like MTA, use essentially a bioactive restorative material. If the tooth is super symptomatic or you think it's an irreversible pulpitis, that's a different story. And we are assuming that the tooth is going to die and the body has amazing reparative capabilities. I'd give the tooth a chance to heal.
Howard: [00:21:26] You talked about using GLUMA before your protocol. Some people are really big believers in chlorhexidine gluconate, they want to scrub their prep out with chlorhexidine gluconate to kill all bugs. What is your thoughts on chlorhexidine gluconate?
Edward: [00:21:40] All right. So, the use of chlorhexidine is one of those more controversial things. I haven't seen any negative on it. It's somewhat equivocal, people talk about it. It definitely kills bugs. There's a group out there that believes it inhibits this group of enzymes called MMPs that potentially causes long-term bond failure. I added it to my protocol of adding thirty seconds after etching. But in reality, it probably actually does nothing. So, if you want to add one thing, I realize there's a lot of young dentists out there, add the glutaraldehyde, add the glutaraldehyde.
Howard: [00:22:24] OK. I'm just going to run over four or five other issues. Curing lights - there's some people that think the number one variable to failing composites is they were undercured, because the curing light wasn't strong enough, it doesn't work anymore, it's broken. What's your thoughts on curing lights?
Edward: [00:22:43] Not the biggest expert there, but I would agree that that is a problem and I got to tell you, when I'm teaching courses, I'll tell you what I see a lot of dentists do, is they're not even paying attention to where they're putting the light, to tell you the truth. If you double the distance of a light from where you're curing, it's one fourth the power. So, if you just move the light away a little bit, you lose an amazing amount of power. So, I'm wondering and in fact I'm sure that a lot of the lost energy is just poor placement of the light. And then you add on top of that the poor quality of light. Yes, I would agree that that is a big issue. I would agree that that's a big issue.
Howard: [00:23:26] And there are also some people talk about pulse curing. Some people don't know what pulse curing is. Rant about pulse curing.
Edward: [00:23:33] Well, OK. Where the theories are today on that, and if anybody wants to read Fred Ruggenberg is the expert in that, is that pulse curing doesn't seem to matter where you're going when the light stays on and sort of ramps up. There is a little bit of credible research that if you turn the lamp on, the light on, and then turn it off, that the stresses will relax. So, if you want to do that, that's kind of what I would do, I would cure it for a few seconds and just turn the light away for a few seconds, if you want to take advantage of that. So, I wouldn't essentially nuke it for the whole time, because you can create stresses that might create a little bit of a problem. So, I don't worry about a light that has all those abilities. I'll just kind of tack here for a few seconds, turn the light off or turn it away for three seconds and then do my final cure, so I don't have to pay for a super expensive light with a lot of bells and whistles.
Howard: [00:24:29] What do you say his name was, Fred what?
Edward: [00:24:31] Fred Ruggenberg, Ruggenberg.
Howard: [00:24:32] How do you spell that?
Edward: [00:24:33] R-U-G-G-E-N-B-E-R-G.
Howard: [00:24:38] Is he German or German?
[00:24:44] Another thing, we talked about the market, 150,000 general dentists, a lot of people they just don't... If you were born and raised thirty years ago, like I was, where you put a small increment cure, a small increment cure, a small increment cure, they just don't buy in the bulk-fill. What would you say to some old guy who did for two decades increments and cures, who's now supposed to fill up the bottom half with one increment cure and then the second half two four-millimeter increments. What do you say to that guy about bulk-fill?
Edward: [00:25:19] OK, I guess I'm not sure, to use a bulk-fill, maybe clarify a little more from the (inaudible).
Howard: [00:25:25] Yeah, they still think doing increments and curing in increments is just a Mercedes-Benz and a bulk-fill might be like a Chevy. Do you think it's a higher quality to do increments and cure, as opposed to a bulk-fill?
Edward: [00:25:39] Well, certainly you're going to get a higher quality esthetic result, because you can then control how it looks in the three dimensions of color, but I don't think that you're going to get actually a better functional or long-term result. I don't think there's any science that shows that. And the reality is, the young dentist is not going to be able to put an hour or two or three hours into getting that beautiful result that you show in magazines, and they're going to have to get a good, decent, long-term, functional result. You can't do it in one increment, but you could do it in three.
Howard: [00:26:15] And I know you have no way of answering this question, but what percent of those magazine articles do you think are Photoshopped?
Edward: [00:26:22] Well, I wish it wasn't true, but I would say well over half.
Howard: [00:26:29] Oh, yeah. When you're on my side of the equation, I own a media company. Oh, trust me, all the editors all know each other, I'd say it's like 80% come in.
Edward: [00:26:43] You pulled the number out of the air. I was going to say 80% to 90%, but I was being kind in "well over half".
Howard: [00:26:48] So, some people, when they look at their final restoration bonding, they just think it looks better if they put flow on the floor, especially in the boxes. What do you think of someone who puts flow on the floor just for that radiopacity seal, a really radiopaque flowable, for a kind of radiographic esthetics?
Edward: [00:27:11] Well, from a functional and seal point of view, I actually kind of like that. So, I use a functional flowable. I'll put a little thin liner down, but I don't cure that, I know people actually cure it, and then I'll put my first layer on top of that and that's pushing it into any little microscopic areas that the viscous material won't go into them. So, I actually think that's a good technique.
Howard: [00:27:37] And what flow do you use?
Edward: [00:27:39] I actually had Bisco make me a special material that I use for a long-term mock-up, called Reveal, but any functional flowable. 3M makes one, Filtek Supreme Ultra flowable, almost everybody makes one now, Boyko makes one, Shofu makes one called Beautiful, the functional flowable that has some radiopacity.
Howard: [00:28:03] Everybody claims that the trend is going towards minimally invasive dentistry. You see it with surgeries all the time. You see patients come in, an old grandpa pull up his shirt and show you where they removed his gallbladder and he's just got two or three little dots. Whereas thirty years ago it was a Frankenstein flap with staples in it. Are you really a minimally invasive dentistry if you switch from direct MODs to indirect CAD/CAM milled restorations? What is more minimally invasive, a direct MOD or a CAD/CAM chairside milling machine?
Edward: [00:28:39] Well, I think they both can be minimally invasive, right? They theoretically both could be minimally invasive. To me, I think there's nothing more minimally invasive than a well done direct restoration. It's interesting, Howard, you've been at this a long time, just like me. I think people kind of misunderstand the benefit of a minimalistic direct restoration. They cut all of these perfect, perfect, perfect preps. Yeah, we want to cut, there are some guidelines to preparations that we need to cut, young dentists out there. We need to have clean margins and not unsupported enamel, but you don't need to cut like a G.V. Black prep for a composite, because composite doesn't have to have smooth internal finish lines. We want to save tooth structure, that's the concept of minimalistic dentistry or minimalistic anything, to save healthy tooth structure. So, we don't have to cut all that away, we just need a clean finish line. So, it saves time to do a minimalistic direct restoration. For an indirect, you do have to cut all that stuff away and smooth walls and do all that internal. So, I actually think direct is more minimalistic.
Howard: [00:29:57] If it was your daughter, your wife, your mom, your sister, and she wanted a smile makeover on her upper incisors, a smile makeover, canine to canine, upper six, eight, ten, would you do direct composite veneers or would you prep them and do indirect veneers?
Edward: [00:30:18] Well, I'm also a Master Ceramist. So, if it's kind of one or two teeth, like a Class four or something like that, and I've got a finish line, I would do direct. But if it's multiple teeth, it's faster for me honestly, cause I can do porcelain and I'm really good at it, I'm going to do feldspathic veneers and I can do it with, theoretically I could do it with no prep, but usually I'm going to do a micro-prep and it would be the same for me, whether I did composite... The same amount of tooth structure for me, for a veneer, really is, it would be for composite or porcelain. For me personally.
Howard: [00:30:56] By the way, you just mentioned G.V. Black and Chicago now has a monument to him. Have you seen that?
Edward: [00:31:04] I have not.
Howard: [00:31:05] Next time you go to Chicago, to the Chicago (inaudible), you've got to take an Uber to the G.V. Black monument and take a selfie. I think it's just cooler than cooler than cooler than cooler.
Howard: [00:31:17] But I want to ask you another question. You're a Master Ceramist. You're probably the most highly qualified esthetic dentist ceramist I've ever had on the show, I was so excited that you decided to come on. But they're coming out of school, they're $250,000 in student loans and they think, in order to be a high-tech dentist, they need to spend 150 on a CAD/CAM machine. Do you think to be a high-tech cosmetic exquisite dentist you need to invest in a $150,000 chair side milling machine or not?
Edward: [00:31:46] No, they don't, OK? They absolutely don't. Chair side, CAD/CAM, it's very good today, there's no doubt about it, OK? And that needs to be really a business marketing decision. You know, you're a business guy. We have to be business people too. If the business decision, if it can pay for itself by increased patient flow and increased turnaround, they can generate dollars and pay for itself, then it makes sense. But that doesn't make them a better dentist, it doesn't make them a better cosmetic dentist. I read a great book of a guy that was an economist, "The Theory and Practice of Economic Wealth" or something like this, and the guy talked about technology, he said you should pay for technology if it increases your business, the cost of technology, and you can pay for it in one year. So, if that machine cost 150, as an example, you should generate a minimum of a $150,000 new business in one year. So, if in the dentist's assessment they will get $150,000 of new business, it's worth it, according to this guy. Oh, "The Theory and Practice of Economic Alchemy" was the name of the book, Paul Zane Pilzer.
Howard: [00:33:13] Theory and practice?
Edward: [00:33:16] Of economic alchemy.
Howard: [00:33:18] Of economic...
Edward: [00:33:20] Economic alchemy, Paul Zane Pilzer.
Howard: [00:33:24] OK, almost done. Paul Zane Philzer?
Edward: [00:33:27] Pilzer, P-I-L-Z-E-R, Paul Zane Pilzer.
Howard: [00:33:33] P-I-L-Z-E-R?
Edward: [00:33:33] Yeah. They should have a scanner to upload to the lab. They should have something like a Trios.
Howard: [00:33:42] I'm going to stop you right there. Back to CAD/CAM, what percent of the... The numbers I hear that are most real is that 12% of dentists have CAD/CAM and to me that's a red flag, because practice management software came out and that's in over 80% of practices, digital X-rays came out, that's in over 80% of practices. But when you say, "Do I need a laser?" It's like, man, lasers didn't even penetrate. It's the same as CAD/CAM, it's about 12% of the dental office bought a CAD/CAM or a laser. If it was a must-have technology and all of your colleagues have eight to twelve years of college and got As in calculus, physics and geometry, to me, what percent of the market has to buy it to where it's a must-have technology? I think when only 12% buy a CAD/CAM or a laser, that doesn't mean it's a must-have, if 88% of dentists don't have to do it, whereas if 80% have digital X-rays and practice management computers, then it's a must-have. Do you agree with that type of theory?
Edward: [00:34:41] Well, yeah, that's kind of what I was saying. It really isn't a must-have, OK? And if they want to enter the digital world, then they probably should have a scanner only, and the scanners are getting pretty good.
Howard: [00:34:52] OK, now I want to stop you at the scanner too, because here's my thought. So, I'm old school, I got out in '87. I've been using 3M's Impregum back when it used to be owned in Germany by ESPE, and then Minneapolis-Saint Paul bought the ESPE, so now it's 3M Impregum. So, it cost me about $14 an impression in a triple tray. We're talking about dental kindergarten in dental school, single-unit crown. I think a $14 Impregum, send it to my lab and they make their zirconia crown, but 3M wants me to buy a $14,000 True Definition scanner and trade it by a $14 Impregum. So, talk to me. And then it's not just the $14,000 oral scanner, I have a maintenance, I have a yearly maintenance fee for that. What is that, $200 a month? What's 200 times 12? $2,400 a year. I don't even buy $2,400 a year of Impregum. So, talk to me off the cliff, talk me down from the balcony. Why should I switch from a $14 dollar Impregum to a $14,000 oral scanner with a $200 dollar amount, $2,400 a year licensing agreement?
Edward: [00:36:02] Well, where I was going to go in the next... OK, here we go. Where I was going to go with it, instead of you having a milling machine and you having to be a lab and doing all those kind of things, the next thing that we're on the cusp of and where we should be with this, in my opinion, and I coined the term "digital dental team" and I wrote a couple of articles about it, digital dental team.
Howard: [00:36:24] When are you going to write one for Dentaltown magazine?
Edward: [00:36:26] Yeah, I'd be happy to write one for you.
Howard: [00:36:27] You know what I would kill for? I swear to God, I'd fly all the way down to Alabama and buy you a beer if you did it. These millennials love the online CE. We put up 401 online CE courses, just an hour long. They've been viewed over half a million times. They just love it, man. You would give so much credibility to our online CE if you'd graciously give us an online CE course.
Edward: [00:36:51] Yeah, I'm kind of at that point now where I am tired of writing for scientific magazines, because only scientists read that. I want people to read it and do it, you know? And see it and do it, kind of thing. Yeah, so let's definitely talk, I'll interface with Ryan on that. But the digital dental team concept was... Here's what I believe, dentists, the reason why CAD/CAM hasn't penetrated chair side to the big numbers that they would hope is, dentists find out they're having to be dental technicians way more than they want to be. You know this. And then it's just spending too much time not being dentists. And the concept that I have, and we're on the cusp of this, where a dentist just basically scans in their mouth and the speed with which I'm actually working, with the ability to turn zirconia around and we can turn some of these things around in two or three hours. So, imagine this, you prep a couple of onlays, you upload it to a lab close by, from your Trios, so another type of scanner, and within two or three hours they deliver those restorations to you. So, you now have the ability to do same day dentistry, but you don't have to play technician. You don't have to adjust contacts, you don't have to stay in and glaze, you don't have to sit there and design. This is where we should be, Howard. And we are right there, we are just right there.
Howard: [00:38:13] I agree. When you go to all the seminars, they sit there and tell you that all these chair side things are done in an hour. A patient presented with broken teeth, you numb, you prep, you scan, you mill, they're out in an hour. Then you go in the field and it's two to three hours. And then people are calling up saying, people are calling up with an emergency saying, "I broke my teeth, can I come in now?" No, I'm sorry, that chair is tied up for three hours, because the dentist just demoted himself to a lab tech and it takes him three hours to get this done.
[00:38:40] I want to add just some more. This is Dentistry Uncensored, I just like to randomly fly through what they're all asking on the message boards. You know, a lot of people don't... It seems like the most people that lecture are from Beverly Hills or Key Biscayne or Manhattan, but all the dentists taking their courses are from Parsons, Kansas and Roanoke, Oklahoma and they're treating middle class and poor. And grandma's got this big 6-unit bridge and a big old chunk of porcelain broke off and she ain't got the money for a new 6-unit bridge. Can you successfully really repair that broken porcelain on a crown with a chairside composite?
Edward: [00:39:19] OK.
Howard: [00:39:20] And they just moved their headquarters from Tokyo to Switzerland. Do you think that was about their tax rate, their tax rate or their tax rate?
Edward: [00:39:28] Or maybe the tax rate.
Howard: [00:39:32] I want, another thing... You talked about... Both of us admire Ray Bertolotti, he was with Danville, engineering out there in... Where is that in San Fran? It was in Silicon Valley? It was in Danville, California, yeah. But anyway, he was also famous for selling a sandblaster. Some old school guys always want to sandblast out their zirconia crown before they cement it, some of them want to sandblast, like you're talked about porcelain repair, they don't want to take that Danville microetcher with aluminum oxide and sandblast that. Some say it increases bond strength, others say it doesn't. What's your thought about the Danville microetcher?
Edward: [00:40:12] The absolute science is, if you are going to adhesively bond zirconia, you have to sandblast it. Now, here's the thing. The original zirconia tetragonal, the old stuff that we had that was opaque, that we all knew from before like the original Lava, it does not weaken. The new cubic zirconia, it weakens about 50%, but it's not a problem if you bond. So, dentists, this is really so important. I've done some research on this, it's coming out. If you're going to conventionally cement zirconia, the new zirconia, the cubic, don't sandblast it. If you're going to use like glass ionomer, don't sandblast it, use glass beads. If you're going to resin cement it and you want to bond it, you do want to sandblast it with two bars of pressure, that's thirty PSI. So, you sandblast with aluminum oxide, two bars of pressure, that will weaken it, but the weakening is not a problem because the resin cement will compensate for that. So, two simple answers - conventional cements like glass ionomer, glass beads to clean the inside, resin cement aluminum oxide to increase the bond strength. So, the answer, Howard, is that absolute science shows it does increase the bond strength.
Howard: [00:41:23] Now, with the Internet... You know, when we were little, we talked to dentists in the same city and county. Now, on Facebook and Dentaltown you're talking to dentists from every corner of the Earth. Why do you think places like Australia and New Zealand use so much more glass ionomer than America? It doesn't seem like they could both be right. It seems like in America there's almost little use of glass ionomer, then you go to Australia or New Zealand and so many of them just love the stuff and use it every day. Why the disparity? Why the difference?
Edward: [00:42:00] Well, simple answer was, the Sandwich Technique was developed there. A lot of the science was done there and the Sandwich Technique by definition was underneath composites, that you put a layer of glass ionomer and then put composite on top, and that seems to work. And they haven't had a real big problem with it. Different techniques developed here that also work if done correctly. So, that basically shows you that there are more than one technique that work. So, that's working in Australia and New Zealand, and until they see a wholesale failure rate... It kind of shows you that basically it comes down to good seal, right? Good seal, some of the things that we know that are absolute, and a good peripheral seal, that several things could work.
Howard: [00:42:50] So, are you talking about Graham Milosic out of New Zealand? Do you kind of credit him with that technique?
Edward: [00:42:55] Yeah, he's one of the guys that was a major contributor, yeah. His name comes to that.
Howard: [00:43:00] Yeah. A couple more questions.
Edward: [00:43:04] Yeah.
Howard: [00:43:05] Back to burs. When you go into... You know, the people that are promoting independent private dentistry are actually the ones killing it, because they're saying you need to upgrade your $20,000 panto to a $100,000 CBCT, you need a $145,000 CAD/CAM, you need a $135,000 LANAP laser, you need to buy all this stuff. That's what happened to health care, as the physicians started buying all these MRIs and ultrasounds, the solo practitioner needs to be in a group practice. So, group practice is growing fast and in a group practice what kills the dental assistants and almost drives them to drinking is that, if you're working with three dentists, they all need fifteen different burs to do a damn filling or a single-unit crown. And then when they go to the dentist and ask them, "Can we just agree on five burs for a filling and five burs for a crown?" they look at her like she's a demon from the Exorcist. How do you get a group practice to agree on a bur cut and how many burs do you need to do a crown prep and what number of burs would you say, "You're now officially neurotic and need psychiatric help?"
Edward: [00:44:33] Great story. Just to add to the funniness of that. When I did private practice before I did academics, and most people do that reversed, they start academics and then private practice. I remember watching a guy do a Class II amalgam and he used seventeen burs.
Howard: [00:44:52] Yeah, I know.
Edward: [00:44:53] That was seventeen burs. The only thing I could possibly say about that is, when I designed my bur blocks, I try and keep it same thing, five or six burs, and then I would design a bur block. You got to have those discussions obviously, where you have Dr. Smith's or Dr. John's bur block, and then I would have the standardized burs and then I would have like three or four extra slots that are just open, and then when the Dr. So-and-So practices, you just grab those three or four for that person. But yeah, you have to have some standardization and I always try and tell people, as you get older you get wiser, you try and do one bur as much as you can, because all of this stuff adds time. Yeah, we want to be as best as we can, but we also got to pay the rent too. And you have to learn to do those things. You just have to. I'm private practice fee-based, but still there's just a limit of what you can charge and there's time involved.
Howard: [00:45:52] There's another thing that confuses the kids where, you know, every once in a while they read an article that a 57 bur is much more atrauramatic than a 557 with crosscuts. And some people are saying that, when you use some of these aggressive burs, you're micro-fracturing and shattering the enamel and all that stuff. Do you think some burs are too aggressive? Some people say, "I will only cut with a diamond." What are your thoughts on microfracture from bur selection?
Edward: [00:46:24] Well, the research actually shows that that's true. So, I kind of handle that. I use the most aggressive bur to do the gross reduction and then I use a fine diamond to finish for just the last two-tenths of a millimeter. I believe that solves the problem, so that I get the best of both worlds. That's how I handle it.
Howard: [00:46:44] And then the next question is a two-part question. You talked about your bur block, but what about your polishing? Obviously, everybody polishes anterior composites on incisors far more than on a posterior or a molar, but what is your polishing kit for an anterior composite?
Edward: [00:47:09] I like Ron Goldstein's burs, that he developed, ET Burs, ET Carbides, and then I use the fine and the superfine little rubber points from Brasseler. I give Ron Goldstein credit for it, him developing those. I like the Enamelize from Buddy Mopper's company, its name escapes me, his company right off the top of my head, and I got to tell you...
Howard: [00:47:36] Cosmedent, Inc. Cosmedent.
Edward: [00:47:36] Cosmedent. Everybody, you need to try this. This is the coolest little trick I learned from a dental technician. He was a denture technician and I think two companies sell it, I'll give you the name of two companies in a second. So, I was watching this guy polish denture teeth, composite denture teeth and I thought, hey, this would be really good, no composite entity, this would be really good anterior composites and it's called leather buff, leather buff. You can get it from Brasseler or Comet. It's a small laboratory product, but it works up to first bicuspid, you can get it in the mouth up the first bicuspids. It goes only in a straight-nose cone and it's a little small thing that looks like a shammy and it's the best thing. Little pieces of shammy, leather basically, and it's the last thing I do for a high shine on composites. And you do everything that you're used to doing and that's the last little final polish and it brings up just an amazing finish on composites, or bis-acryl or any form of acrylic, called leather buff from Brasseler or Comet.
Howard: [00:48:49] And what's funny is, when you say Brasseler or Comet, originally when Peter Brasseler started Brasseler burs in Savannah, Georgia he was just reselling burs from the German company Comet. And then Peter Brasseler passed away and then over the years Brasseler started making their own burs. So, now you can actually buy Brasseler and Comet burs in the United States, but originally they were just the distributor for Comet.
[00:49:11] And Buddy Mopper, that is so amazing, he's an established, well-respected cosmetic dentist in Chicago with the company Cosmedent, but he started out as a pediatric dentist.
Edward: [00:49:26] Oh, I didn't know that.
Howard: [00:49:27] Yeah, he was a pediatric dentist, which leads me to... I hope I'm not stealing too much of your time. I can't believe you gave me an hour of your time.
Edward: [00:49:34] No, I'm okay.
Howard: [00:49:34] Here is another very stressful thing for young dentists when they love literature. Again, you look at a hundred million insurance claims filed for all claims and it just looks like a heart with like four pulses, two number three, two number fourteen, two number nineteen, two number thirty-one. I mean, 80% of the dentistry build-out is on four flipping teeth. It's these first-year molars. So, now you're a dentist and it's your own daughter being born and her six-year molars just erupted and this is your baby. And that's the tooth most likely to be extracted someday. And they look at this sealant research and so much of the sealant research says that you're accessing pits and fissure filled with crap and you're putting this plastic layer up, they chew off. So much of the research says that in one year 40% of all failed, and then in two years 80%-90% percent are filled. Do you believe that? And then there's the other side where they say, "Well, maybe I should get a coarse diamond and take out the prep of the incisors", kind of like a minimally invasive old G.V. Black and blow out this. But talk sealants, because you're a master in adhesion. Do sealants even work? And if that was your own daughter or granddaughter, what would you put on her for newly erupted six-year molars?
Edward: [00:51:01] Well, not being an expert on sealants, but being an expert on adhesion, here's what I would do, and I don't see them at that age. But the clear answer to that question, understanding adhesion, I would at least sandblast the surface of the tooth, OK, to make sure I've got the biofilm off, like you said the crud. And then I would do an adhesive procedure and with my loupes I would make sure that there was no caries, I mean that obvious caries, and it's also clear from the research that, if you seal the caries, then it'll at least arrest, if there's microscopic caries. It will stop if it's sealed, if you take its blood, its food supply away. So, I wouldn't have a problem. If it was my kid, I would seal it, but the key is it has to be sealed and it has to be clean.
Howard: [00:51:48] So, would you use the Danville microetcher?
Edward: [00:51:51] Yes, I would use the Danville microetcher.
Howard: [00:51:54] That's what I use.
Edward: [00:51:55] I have several. I can't practice with... And let me just tell one thing about a laser. I wouldn't buy a bunch of big lasers. I would just buy a small diode laser. It is a must-have for me. You mentioned lasers, I do so much tissue recontouring with a diode laser.
Howard: [00:52:13] Which diode laser do you use, AMD?
Edward: [00:52:15] I use the one from Ivoclar, but I heard they stopped selling it recently.
Howard: [00:52:21] Really?
Edward: [00:52:21] The Navigator.
Howard: [00:52:22] I use the one from AMD, which stands for Alan Miller Designs. He started out in Indiana, now I think he's in L.A.
Edward: [00:52:30] But young dentists out there, you do not need one of these big (inaudible) or anything like that. But a diode laser just for soft tissue, a little bit of minor crown lengthening and tissue leveling is phenomenal. I use it every day.
Howard: [00:52:46] So, we went over the hour. Can I ask a couple of overtime questions?
Edward: [00:52:51] Sure, sure.
Howard: [00:52:53] You know, it seems like, to me, dentistry in many respects is going backwards. When I got out of school the go-to restoration was amalgam and it lasted thirty years, because it's so antibacterial. Half the amalgam is mercury, you'll never find that in a multivitamin, the other half is tin, silver, zinc, copper. Tin - the hygienist's stannous fluoride, very antibacterial. Silver - look at the pediatric dentists using silver diamine fluoride. Every ingredient in amalgam is toxic and bugs don't like to grow under it. Now we've replaced that for this esthetic health compromise with this inert plastic composite, and a lot of good research that I see says that amalgams last, posterior amalgams last twice as long as composites. So, now the trending composites is, well, maybe we can kind of make them bioactive or antibacterial, and you see these composites that are now claiming almost like the... We're going from inert to active properties and ingredients. Do any of those excite you? Do you like any of those? Do you believe in any of those products today?
Edward: [00:53:58] OK. The bioactive composites so far, what I've seen, nothing appears to be bioactive like they would like them to have, right? We would love to see just rapid growth of secondary dentin. Do we see some activity? Yes. But the biggest problem with them is that they look like crap. I mean, they're not esthetic, we need something esthetic. So, there are some good materials on the market, calcium silicate. I would just go to something like TheraCal, but then you've got deep caries or you want to do an indirect pulp cap, TheraCal LC or TheraCal Dual-Cure.
Howard: From who? What company?
Edward: Sorry? From Bisco. Bisco. Phenomenal material and they've got some good research on the material. And there's a couple of knockoff products, just don't come to mind right now. That will give you, your little bioactivity, form a secondary dentin and then do your composite on top, simple. That's what I would do.
Howard: [00:54:53] Yeah, that Bisco, we had the founder on, Byong Sah, that is just... What an amazing mind Byong Sah is.
Edward: Yeah.
Howard: The founder of Bisco. Just an amazing guy. You're talking about bioactive as opposed to growing secondary dentin, but do you think someday the active ingredient will be antibacterial? You know, something to kill Streptococcus mutans, when it comes to one that live underneath it.
Edward: [00:55:18] Yeah, I mean, that's going to be the goal, to have something that prevent or at least neutralize the effect of bacteria, absolutely. Yes, that's the goal. Whether they get there or not we'll see.
Howard: [00:55:28] OK. Last and final question. When I ask any dentist, I don't care if he's fifty-five years old like me... I don't know how many fillings I've done from 1987 to 2017, thirty years. When you ask him, "What's the worst part of an MOD composites? It's the gosh darn contacts.” Whenever you get done with the amalgam and Jen hands you that piece of floss, you're just like, "Oh please, please!" You know. What advice would you give on making interproximal contacts?
Edward: [00:56:06] I couldn't agree more. I couldn't agree more. Basically you got to wedge them and you buy one of those special systems, like the Trios Ring system or the V3 Ring system to wedge them. And you know what? The reality is, if you just get large interproximal spaces, you maybe want to consider indirect. And the technique where you build up the interproximal first, that I don't know who came up with the technique, that's a good idea, where you build that interproximal wall first and cure it, that seems to help develop a contact. You know what I'm talking about, right?
Howard: Right.
Edward: Yeah. So, that seems to help. That's not my main area of expertise. Mine's more indirect. I mean, I'll do them if I have to, but if it's just large, I'll just do it indirect.
Howard: [00:56:58] And my last, last, lastest question. Are you a big believer in caries indicator, like Seek from Ultradent or whatever? Do you think routinely... Again, first five years out of school or at any age. Caries indicator, yay or nay?
Edward: [00:57:19] Here's how I think about it. I'll generally put it on just once when I'm getting close to done, because I know there's a lot of false positives and false negatives, just to see if I may be missing something near the margin, because I obviously don't want to have caries at my margin. And knowing that the research that, if you left a little bit of caries inside of your prep, as long as it's sealed, it's not a problem. I just want to make sure I'm not missing something near a margin, (inaudible: 00:57:47). So, that's my thought process, so I'll just do it once. And I won't keep doing it, keep doing it and keep doing it.
Howard: [00:57:54] Well man, in a world of dental fish you are a blue whale. I've been a fan of yours for decades. Thank you so much for all that you've done for dentistry, thank you so much for coming on the show. It would just be the hugest honor if you would do an online CE course for us, because these kids, they'll download it. We have a quarter million dentists from all 220 countries on Dentaltown and 60,000 of them have downloaded the app, and what they do, is they take that online CE, they sit at their house with the Apple TV, they throw it up on their big screen, I assume they're drinking beer while they're watching it. They just love that stuff. If you ever want to write an article, build us an online CE course. Ed, thank you so much for all that you've done for dentistry, Dentaltown and for coming on and talking today on Dentistry Uncensored.
Edward: [00:58:48] Great! Thank you, thank you and have Ryan follow up with me on that, OK?
Howard: [00:58:53] OK, buddy, have a rocking hot weekend.
Edward: [00:58:53] All right, thank you. Take care.