Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1219 Romero Dental Seminars by Mario Romero DDS, Associate Professor Dental College of Georgia : Dentistry Uncensored with Howard Farran

1219 Romero Dental Seminars by Mario Romero DDS, Associate Professor Dental College of Georgia : Dentistry Uncensored with Howard Farran

7/12/2019 5:45:23 PM   |   Comments: 0   |   Views: 85

Dr. Mario Romero is an Associate Professor and Director of the Advanced Education in General Dentistry Program at The Dental College of Georgia at Augusta University; he is a 1995 graduate from the University of Guayaquil School of Dentistry in his native country of Ecuador. 

VIDEO - DUwHF #1219 - Mario Romero


AUDIO - DUwHF #1219 - Mario Romero



He completed a two-year Advanced Education in General Dentistry Program at the University of Rochester, Eastman Institute for Oral Health where he was granted the Handleman Award for Excellence. In 2016 Dr. Romero was awarded the Augusta University and the American College of Dentists Outstanding Faculty award for his achievements in scholarly, research and service. In 2018 he received the Research and Scholarship award from the Dental College of Georgia for his contributions to dentistry and in 2019 he received the Excellence in Dental Education Award from the Pierre Fauchard Academy. He has over 40 publications in national and international peer reviewed journals and has lectured extensively on topics related to direct and indirect restorative dentistry. He maintained a private practice with emphasis in Esthetics and Restorative Dentistry for 15 years prior to joining AU in 2013.



Howard: it is just a huge honor for me today to be podcast interview and Dr. Mario Romero DDS he's an associate professor and director of the advanced education and general dentistry program at the dental college of Georgia at Augusta University he's a 1995 graduate from the University of McGill School of Dentistry in his native country of Ecuador did I get it wag Louie why you kill yes okay he completed a two-year advanced education and general dentistry program at the University of Rochester Eastman Institute for oral health where he was granted the Handelman Award for Excellence in 2016 dr. Romero was awarded the Augusta University and the American College of dentists outstanding faculty Award for his achievements and scholarly research and service in 2018 he received the research and scholarship award from the Dental College of Georgia for his contributions of Dentistry and in 2019 he received the excellence in dental education award from the appear for chard Academy amazing he has over 40 publications and national and international peer-reviewed journals and has lectured extensively on topics related to direct and indirect restorative dentistry he maintains a private practice with emphases and esthetics and restorative dentistry for 15 years prior to joining au in 2013 it is just a huge huge honor for me to have you come on the show today thank you so much for taking the time out of your busy day to come on the show 

Dr. Mario Romero: No thank you very much for inviting me I mean like I was telling you at the beginning I'm a I'm a fan I listen to your show I think it's a great show because there's so many things that you talked about in your show that are really not taught in dental school and like you called kindergarten dental school and you know it's just only that you learn with time I mean you just gotta you have to go by experience and sometimes you can make that shorter when you have shows like this that we are able to have today thanks to technology you know we can we can talk about anything we want and people believe it or not they learn I've learned a whole bunch of stuff listening to so many people that you interview following your show 

Howard: well you know you're on you're on cutting edge I mean you're you're talking about minimally invasive procedures bleeding and bonding prototypes micro abrasion veneers I love your YouTube channel if you haven't been to his YouTube channel its Romero dental seminars you have several thousand subscribers I was watching some of your videos on my iPhone and I said I want to get this guy to come on the show so um if you're an old guy like me when I get a school in 87 the fillings were all amalgam hell they lasted forever the crowns are all gold they lasted forever and in my generation it kind of seems like two sets forward one step back we replaced this long lasting amalgam with a shorter acting composite how does a gold crown break and now we replaced it with you know porcelain fused a metal I can't believe I'm so old that I saw the invention of porcelain fused the metal and then it's extinction but I lived through the birth and death of an entire species I don't even know if they do pfm anymore do you think it was an aesthetic health compromise do you think we should go back to amalgam and gold or do you like this tooth colored resin

Dr. Mario Romero: you know I think that if let's look at this in two ways let's look at it first on the passion the energy passion way the way that you peak in the way that you talk about different materials and products you don't personally I think and I agree with you know I've seen patients that come to see me and have an amalgam or a gold on li and if this been there for 50 years and you look at the margins everything is beautifully see oh there's no staining and there were cemented with zinc oxide I mean sing outside cement I mean they were probably use very old type of cements that we don't even have today we don't have any access to them today anymore and they're still there and if and then you know you go into newer materials today where they're all ceramic or white because that's probably what the market is pushing towards and that's not the dentist making the decision but the mark and making the decision people wanting white restorations or white fillings and then you see suddenly you start seeing some staining some recurring decay around the margins now the thing that I always try to express and teach when I'm teaching dentistry is that the reason why gold has been or amalgam has been so successful throughout the years longevity-wise is because they were less technique sensitive so you know you didn't have to worry about isolation when you were building up amalgams you didn't have to worry about any adhesives or bonding if it was a fifth generation or a sixth generation or seventh generation did you have did you need to edge or no edge there's so many decisions that we have to make today when we're actually performing clinical dentistry that if you don't understand the process and you pee or you miss one of the steps obviously that's gonna affect the outcome of your product and that for me is what really happens with with with white materials today when you see them fail they fail more because of lack of a good technique then because of the of the product being a bad product and I'm gonna give you a good example just a couple of a year ago actually because I saw this patient just two days ago oh yeah then this was a one-year follow-up this patient a patient came to me I know the tennis he's a friend of mine that he did 35 years ago she had stained teeth with tetracycline stained teeth 35 years ago he bonded composite to all you know cleaning a cane and all the way back to the second premolars 35 years ago now you know what we'll were using 35 years ago I mean they're nothing to do with what we have today and 35 years later I removed them and I and I and I placed porcelain veneers because the patient just did not want to see you know you composite as that as opaque as porcelain so you you're gonna see some some of that grayish underneath the composite you're gonna see through the composite but and I have the photo 35 years later you're a little bit of staining here a little bit about fake resin here and there but they were bonded they were still in the patient's mouth so this for me is proof more than proof then when these products are handled the same and open open and with right with a correct protocol they will last if they are failing in your hands many times it has a lot to do with your protocol more than with the actual material we cannot fight what's going on to the in the market you really have patients that come to your practice and tell you please remove this old amalgam and replace it with a new amalgam that doesn't happen so because that doesn't happen every day or doesn't happen so often we gotta make sure that if we're gonna change an amalgam using a composite we do the best we can to get that composite to new to last as long as as possible if we follow a good protocol

Howard:  so um most of the feedback I get Howard at dental town comm or the comments and the and the YouTube the comments end after the YouTube video they would like to know specific so they do you kids it just got out of school and the first thing they're thinking is I and what dental adhesive do you use because you know it started off with conditioner primer adhesive then they rolled it all into one and some of the night regretted I hang out with a bunch of old 50 60 year olds but we're gonna say everything it really wasn't that hard to put on blue and then rants and put on primer and he really really had it be just one drop because I don't want to be getting a heart bypass and the doctor says oh I don't want to make two steps to save how he's hard I just want one step so it is the one step is that just too fast I mean should it be you know but what would bonding agent you use 

Dr. Mario Romero: well you know and that's a really good question because again you know we we talk about all the time and even in private practice I mean when I was in private practice and I did it for 15 years so I know exactly what it is and the way it should be read is you know we all talked and we're all saying and defending oh we're doing this because of evidence and this is the evidence here they have everybody talking about evidence but do we really use evidence now if you think about that simple word evidence what is the material or the type of adhesive that has the most evidence that we know that works very well and that we know that is the least technique sensitive compared to any other adhesive out there and it's going to be the fourth generation just like you said it has an edge prime end bond in two separate bottles and I told my I know I tell a lot of my residents and many dentists that you know that that when we're doing CE courses I tell them how much time do you really say how much time does it take you to address separate drop five ten more seconds this ten seconds really gonna make a big huge deal at the end of the day money-wise or timelines know the answer to that question is no so if I were to use and today I'm think that you have to really think about the adhesive better based out of what you do in your practice let's say that you're a recent graduate what are the recent graduates doing the most when they become associates in a dental practice at a bread and butter dentistry operative dentistry 80 percent of the day so if I'm gonna be bonding direct restore the composite two molars or anterior teeth I would use you would only need to have a for generations and releases in your practice and you don't gonna have any problems now if you have a practice that has a lot of indirect restorations and less direct restorations so then maybe I will go to a single bottle adhesive because many of those direct restorations like for example porcelain veneers you're gonna bond to strictly or the majority of the tissue that you can upon - it's gonna be enamel so you own enamel you don't have the difficulty of the body step as you would do as you do have indenting so we all know that dentin is a difficult subject to treat compared to enamel so you got to look at it in many ways now if you ask me I have a practice and I run up and I run a clinic with residents but I see my own patients as well and I do a little bit of both so I have a fourth-generation dental he said and I have a universal dental adhesive and I use both on difficult clinical situations and they'll want to know your brand now what brand a universal wall brand the fourth generation I use I use for fourth generation I use octave on FL from Carol and 4/5 generator I'm sorry for universal adhesive I use one code seven from codeine and I use opti bond Universal from Curt DeBaun Universal from car yes and and one code seven from call team one coat seven yes sir hi I must have missed that one code seven from Kerr are going from Colgate co LTE yes sir okay and uh interesting that that is very

Howard:  interesting um so I'm back to mentally evasive when I am I've had the honor to meet some 90 year old Dennis still practicing what was in st. Joe Missouri George ruie the first son george are-- ii was at that as his son george lugo third was at us but whenever I'm with a 90 year old Dennis and I say you know what tooth lasts the longest they you know thinking is it a molar Kenai incisor they always say it's the tooth that dentists never touched every time you touch a tooth you condemn it to retreatment and I love the fact that everybody's trying to get minimally invasive what is minimally invasive mean to you 

Dr. Mario Romero: well that's a great question because I talk about I talk a lot about this because my understanding if you think about the word minimal invasiveness means that you're gonna do the minimum possible to that tooth in order for it to be to lube it to be restored and obviously minimally invasive dentistry today has a lot to do with aesthetic dentistry has you know that they both kind of like have merged together because if you have a patient that has decay everywhere there's no minimally invasive dentistry that is possible for this patient you can only do minimal intervention on patients that have fairly healthy teeth that's why you're minimally gonna intervene now the thing is that when you merge these two when you merge these two different Sciences aesthetic dentistry and minimally invasive I believe that we make one big mistake you can see many cases and many lectures today and many and many publications where you see people that end up having 12 in years and somebody calling that that's a minimally invasive procedure for me a minimally invasive procedure is I don't want to touch any tooth I want to do anything that would does not require removal of tooth structure so I have a lot of these cases and and again you I start asking and I always start thinking about aesthetic dentistry that beauty is in the eye of the beholder beauty doesn't mean to me every food has to be B 1 or B 0.5 Beauty doesn't mean to me every tooth has to be perfectly straight or every tooth has to be perfectly symmetric beauty is based out of what my patient likes or dislikes that's the first thing that I do in that mentality will keep you in track with that minimally invasively because I've had a whole bunch of patients come to me and say you know what there's something up about my smile that I don't like and I look at their teeth and you know they're healthy they don't have they've never had any feelings you can tell that these have been very patient that have been taking they've been taking care of very well but they just have something in their smile that they don't like and they just don't know what it is if they fall in the wrong hands you can end up with 12 in years or you can fall in the right hands have your teeth bleached go from a 3.5 to a 1 or b1 and probably that was just what the patient wanted once he looks at his teeth and he notices that his teeth had brighten and that the smile is brighter maybe that's all they wanted and I have found that to be true 9 out of 10 times places that are healthy that they come to me and told me I want to have my smile improve and I did something I don't like about my smile but they cannot tell me exactly what is it that they dislike and those patients for me are the number one candidates for minimally invasive dentistry now minimally invasive dentistry I see it him with 2 3 3 different steps and only when I have completely used those I've gone through first second and third stages minimally invasive that I can go to the next step which to be now slightly invasive meaning there's some modification of the tooth structure that I'm gonna need to do for this patient before I get it I go ahead and we stand and make improve a smile and those are bleaching number 1 number 2 micro abrasion of the enamel that we'll be able to remove a lot of white spots brown spots a lot of extrinsic staining on the surface of the enamel and then finally you can always do resin infiltration if you have some of the white spots left behind I mean again if you have different colors and textures of the teeth there's so many things that you can do before you put a burr on set and that for me is what I consider invasive minimal intervention or no intervention I can do anything of these three steps that require no birds no numbing of the patient before I get to any procedure that requires for me to be more aggressive to the tooth structure and again if you ask any dentist and I have a lot of dentists that are my patients you know when they come to my to my practice and they see me here at the school you know I asked them you know our warmup I want to improve my smile and they and all of them would like to go through procedures of minimally invasive and you I even have a lot of cases where I have a lot of you know chipping of two of the incisal edges because of trauma minor traumas I restore those with composite with no preparation I do not reduce enamel if I don't have to I will double my edge in time and I will restore that with composite without applying any bird to the tooth and that makes my treatment always reversible if it fractures in the future if it stains if anything happens I can remove it with us with the disc with the finishing disc you know all I have underneath it is 100% the patient's enamel so there's a lot of things that you can do without touching the tooth with a bird even for veneers in some cases well you know you talked about Melanie Mason

Howard:  I also love your YouTube video and some articles you've written on be fep bonded functional aesthetic prototype where you do a long term provisional technique called the bonded functional aesthetic prototype be fep allows dentists and patients to work together to enhance the outcome of therapy when increasing occlusal vertical dimension so you're an increased vertical you can work it out in and temporaries talk about beep you should have named it something that's BEP BEP would have been better but you had the F in there well how do you say bf EP is that before the thiw bond a function i said a

Dr. Mario Romero: prototype is that a name that i brought into the it was actually brought in by dr. McClaren but this is something that has been in dentistry for years I mean I would say the body model probably was the first one ever to start placing composite on T using them as a temporary or immediate restorative material before getting Porsche veneers into his patients so that's where this trend comes and then finally gets to the hands of dr. McLaren and he brings out this this term bonnet functionalist era prototype into the literature now the ring what I've done with this with this with this prototype because they use it a lot for veneers what I have done is I actually have incorporated the same concepts but now I use them even to increase vertical dimension in other words I use them to build full crowns on to my patient's teeth using flowable composite you know and using the same concepts behind the bonded functional instead of retired technique and you know this has become such a useful thing such a useful thing for me and I use it I mean almost a weekly basis on my big big cases because what it has done for me is that it allows me to put something in either mirror type of prosthesis in my patients mouth without having the patient have any huge compromise and if we think about this together you know you do dentistry and all your listeners they will understand this very well you get a lot of patience today with a lot of erosion and young patients you know there's soft drinks water and all that has a whole bunch of acid you get a lot of erosion and you get a lot of wear after the erosion because the erosion will break down the enamel the dentin will be exposed if the acid is still involved you will now get more enamel eroded and a dentin because you know dentin is less mineralized so it will just wash away easier so let's put this picture in our mind is a patient with a lot of wear all around its mouth upper and lower arch now you have to you know that you can have to modify you have to increase the vertical dimension because this patient most likely because of the aggressiveness and of and how fast the tooth was was eroded this to that this patient has lost vertical dimension so if you were to increase this patient's vertical dimension there's only two ways that you can do this were three one way you can fabricate a splint give it to the patient send the patient home and test drive your new vertical dimension to see if there's any pain or tenderness or any discomfort in the TMJ with this new vertical dimension or you can go ahead and prep all the teeth prep them for but temporaries at a new vertical dimension and then send the patient for your test ride with the downside that number one the patient is already invested in the treatment because he's gonna have to pay not only biologically by you removing the enamel and some dentin but money-wise financially because you're gonna have to build you know there's a lot of hours involved in your church time to get that patient to that point or third my proposal you don't prep any tooth structure you don't remove any tooth structure you bond these prototypes pace out of a wax with an increased vertical dimension directly onto the patient's teeth and send the patient home now not only there is no preparation of the tooth so there's not gonna be any hypersensitivity there's not gonna be any issues because a tooth structure of what the patient presented with is right underneath your product not only if you're gonna be able to use them for that but then once you're ready for the treatment once one week or four weeks or six weeks which every time you decided to leave the patient with the prototypes to get your diagnostic information now you can prep through the prototypes meaning that you can use those prototypes as your preparation guides or calibration guides which integrates the whole treatment into that and it makes it a lot easier through the whole process and you know just just to let you know we are actually this has become such a big thing in what I do and what I teach today that September 28th in Atlanta Georgia we're gonna have a course hands-on course only on desktop and wanna teach people not only how to do the body for this but how to how to use them my preparation guides how to calibrate the preparations using these disparate apps so that they can make it a lot easier in their practice when they have these big cases and this I think is something really good for the younger because every dentist and when I say younger I'm saying kinda like between the 1st and the 10th year out of dental school they're getting comfortable now I'm prepping single crowns three-unit bridges but they still some of them still feel uncomfortable doing full mouth reconstruction full mouth rehabilitation because as me you know that's a more complex thing you gotta you know you gotta maintain the vertical dimension that you increase and you cut maintain that throughout the whole process of all the impression and sending all the cats to the lab well guess what if I am able to do the prototypes now I can segment or divide my rehabilitation in different areas so that I can do full crowns at a time so I can do six crowns at a time without losing the information on my vertical dimension and keeping the prototypes in place so there's a whole concept the whole big concept as you have been able to see in and read and my articles where this is super useful and not only for big cases but also for partial cases I'm gonna give you another example they say that you have a patient that needs for seven ears and because he's got wear on the incisal edges where on the facial aspect of the teeth and you think that porcelain veneers are the indicated type of restoration for this particular patient so what do I do for these patients before I go ahead and prep those teeth I'm gonna wax the case up and I'm gonna fabricate a prototype and bond the prototype directly to the patient's teeth now I now I have a new location of the insights village I have a new emerges profile and I have a new buccal surface or buccal volume of all these new teeth that I'm gonna restore I can send the patient home have her or him wear it function with it have other people around them see my prototype who they like disliking do they feel that the teeth are too big they're too small I can add remove I can do anything to my prototypes once the patient is convinced that this is what they want I make an impression of my prototypes and I prep through the prototypes that impression I sent it to the lab the lab will scan my prototype and they will reproduce the length and the contours of my veneers on to their final restorations so the delivery day I don't have to spend any time thinking about do I have to add joseon's isolate am I gonna have to adjust a contact here or emergences profile over here everything was set from the get-go with my prototypes so it simplifies your  actual workload it simplifies the way that you manage your cases in the practice 

Howard: I will give anything if you that hands-on lecture and Maeda online see course on dental town we've made 400 they're all about an hour long hour and a half they've been viewed almost a million times because a lot of dentists before they close down their office and fly across the country go to the course they kind of like to see an hour teaser right III think the paint Ian suit and Dawson was very smart they have week-long courses so they did a one-hour summary of each one of their courts kind of an intermediate between I read I saw your name versus I spent the day but man it would I would just love it if you know and I have and I have what I can do for you is that what I'm gonna do I'm actually gonna do for you this is my word on this I'm actually gonna fabricate an online course where I'm videotaping myself doing every single step of their hands on that we're gonna do in Atlanta Georgia September 28th so that your homies is the way that you call them I think it I'm taking please can actually watch now you now you know that I was listening to your podcast man homies are gonna be able to watch me I'm gonna walk them through the process so they can actually watch me do it on the cast off my do live on a video for you so they know what the steps are and again once you watch the video you take the hands-on course you do this with us it's really easy to transition from that to your practice because normally every single dentist is using flowable composite and know exactly how to use him in the practice we're just taking the public ambassadors to the next level 

Howard: well you know um one thing that I call Bologna on when I got asked 187 all the cosmetic gurus I know to say we're always filing down everybody seats for veneers but when they're exact daughter needed it oh it was bleaching and orthodontics and I started to not trust any cosmetic dentist who couldn't unravel the teeth with ortho and even with veneers like I if it was my eye I didn't have any daughters I just had four boys but my one granddaughter if she needed veneers I would do direct veneers talk about million bases I mean the direct of veneer cases that I've seen look the most natural and they don't hurt hurt the teeth and so I really love the direction that's going towards mentally invasive I like direct composite veneers better than filing down enamel and doing indirect veneers it's just but you said the most mentally invasive was the easy Sanders bleaching are there any - is bleaching bleaching bleaching I liked your YouTube video on bleaching tray fabrication what would what tips would you give on something like bleaching there's a trail even matter does the brand of the bleach even matter what matters in bleaching

Dr. Mario Romero: you might think that it really matters and you know this but here the dental school dr. van Heywood is one of the faculty here and dr. Brian Haywood is the first-ever dentist that published I have a publication on my car bleaching so if you want to talk about a guru in bleaching we have him here at the school so when I was in private practice and I know what many of your of your homies are probably thinking and you know the same way that I thought when I was in private practice you know the stronger the product the faster and the better and you know if it's kept in my office patients are going to feel that they're gonna you know I'm doing something for them it's like if I send them home with a tray they feel that I'm not doing anything for them you know that is probably was part of my bleaching protocols when I started dentistry but with time and in learning and reading and just seeing my cases I found out that with ten percent cover my peroxide you can do everything and it's the cheapest the most efficient and safest product out there so I would say that for the last seven or eight years of me being a dentist all I use is ten percent cut on my peroxide and I have yet to find a case and I'm telling you we do bleaching for singles our teeth we do bleaching for you know we do internal bleaching using you know and I rarely do internal bleaching but if I have a case of what I need to do internal bleaching I would do the I will use 10% cup of my peroxide so I use it for everything and the good thing about the video that you just watched if you watch the video closely you will see that we don't use any any blockout resin I mean there's no spacer on my die on my cast I actually fabricate we fabricate the trade directly onto the cast with no type of of spacer placed on the teeth that we're gonna beat and the reason for that is because you really don't need a lot of the product you could just need some contact of the product with the tooth so without with without if you don't use any reservoirs that means that the patient is gonna be using less of the product and the patient is gonna you know at the majority of my cases 9 out of 10 cases that are just regular normal cases vital teeth my patients you I give them one kit and I use opalescent such an percent made by the oxidant I give them one kit that brings 8 syringes and 9 out of 10 of my patients end up doing their entire mouth with 5 to 6 syringes meaning that they have to at least 2 to 3 of them left over but I always tell them just keep them in your refrigerator 6 months from now if you want just touch it up for a couple of nights and you will you know touch up your bleaching and normally they do it once a year they don't even have to do it every 6 months because it's so effective and again we just had a publication we just have one that's coming out soon in the Journal of cosmetic dentistry a research that we did in Mexico using different concentrations and using patients that have kind of like same ecology they all had singles our teeth and we treated did all these patients using four different concentrations and we were not able to find any difference statistically and clinically visual amongst all these patients color wise at the entry using ten percent all the way up to 35 percent card carbamide peroxide so you know and we know that we know that is not about the concentration it is about the time and the greater the concentration any concentration above 10 percent is gonna create gingival irritation so you're gonna have to have some block out resin placed on the cast you're gonna have to have some spacer and you're gonna have to trim your bleaching trays you have to scout them when you're using temp you don't need to do any of that just cut your tray straight give it to the patient it's not gonna harm the tissue at all 

Howard: I'm getting a little carried away because most podcast listeners are young a quarter more still in school and the rest are all under 30 I'm probably the oldest guy that's ever been on a dental podcast but if you look at the insurance claims I mean there's a hundred million claims here now I've lectured at dental insurance conventions in Florida I've seen their data and you look you put out the 32 teeth and it looks like a flatline with four big spikes on the six year molars that's the tooth most likely to get a filling a crown a root canal extracted it's all that so I want to bring this down to the six year molar and she wants and she's got to go in there and do an mo D composite and she's hearing some people bulk filling the whole thing in one increment and curing it so just bring it down a level to an mo D composite on a six year molar brand name how how would you do it well there's a couple of things that I think that I did this should be considered

Dr. Mario Romero: I just wrote a paper and it's gonna be published soon on Robert dam isolation you're gonna ask me we'll worry oh why did you write a paper on rubber dam isolation I mean Robert time isolation is 152 years old is there anything new that I need to learn well I think it is there is something new that you need to hurt there was a recent study published in the United States it was in 2017 and what the study did was a day they interviewed 3,000 dennis all over the United States and asked them general Dennis and asked him you did you use a rubber dam how many time how often 63 percent of this dentist said I never use a rubber time for assorted dentistry never out of the 63 percent 32% said I don't use a rubber dam not even to do a root canal now failure the words again sixty-three percent never usual dam user over time for any restorative procedure any restorative procedure and 37 32 percent of those never use a rubber dam for root canals which for me is scary because when we do a root canal and I don't do any root canals well I am I'm not gonna talk about endo but I am gonna talk about one thing that I am 100% sure up there are number one reason why you treat a tooth by means of a root canal is because the pope has become necrotic or there's some type of bacterial contamination so your number one goal is to remove that and to keep that area clean right so if you first molar which is the two that gets everything just like you said it on a mandibular first molar what are the chances of you getting saliva contamination extremely high without a robbery done so I think that there's still a discussion to be made with the robber dad and I know what you're asking the question of the class - now let's think about this together you have a class - word is a class - normally fail on the gingival margin the Gintama margin let's say that we're not talking about a deep class - let's talk about just a regular class - gingival margin - millimeters above the  papilla so you know that we have in a mall there what is the best tissue that you can bond to enamel is there any way that you without a rubber dam using let's say an iso back which a lot of people are using today using a nice comeback yes you're gonna keep you're gonna protect the patient you're gonna keep the tongue away you're gonna protect the back of the mouth you're gonna have light you're gonna have a just right field but what's up with the curricular curricular flow right on the liter change of a margin you just a millimeter away how do you control that without a rubber dam does the ISO vac can't control it for you so if you look at every single study that talks about contamination of enamel and dentin during operative procedure and the damage or the how negative they are they impact our restorations you will find that the negative impact of contamination of the operative field is extremely high so my question to many of these young dentists or even older tenders because I promise you that out of those 3,000 many were older like me and you so if you ask these students or these young page these young dentist how if this affects your upper field how in the world are you thinking of what kind of restorative material I'm gonna use to make this better I don't care what you use you can use the best bottle you can use the best layering technique the best composite the best instruments the best bonding agent what do you have as a substrate you have a contaminated field you have contaminated with glycoproteins with saliva and sometimes even with blood if you have a deep glass tool how do you control that and how do you want that to be successful Howard I don't care if you use a Malcolm if you have a contaminated feel your amalgam will fail as well so for me the number one thing is having an isolated field with composite is extremely important then we can talk about materials now we can talk about bulk pills or layering but first have control of the field now if you if you told me what would it be the same to do a class two or a class four on an anterior tooth well if it's a maxillary anterior tooth and you want to use some controlled isolation you have no control in that area then you would have on a motor so this is why rubber dam isolation is so crucial and you know why those you know those that thirty or sixty three percent of Dennis said it I never use a rubber dam because what is the number one thing that a young dentist does when he goes into practice he stops using the rubber dam which he was good at when he was in dental school so they stopped three four years go by it's like doing anything like that you stop doing if you don't do this every single day you will get bad at it but if you use a rubber dam every single day it'll take you literally not more than 30 seconds to isolate or to think and be ready to through your restoration and in a way that is predictable and this is just a fact I mean we can't change this we cannot lie to ourselves saying oh but there's other ways of doing this with blood and saliva in that gingival margin there's just no other way and if there's one please I want somebody to enlighten me and teach me how to do it

Howard:  if somebody swallows if a root canal fails I'm just talking about a root canal fails and the Dental Board gets your whatever and they cannot see an x-ray that confirms a rubber dam clamp on you're lost 32% 

Dr. Mario Romero: of these 3000 people are taking that risk which is is it's game over if you cannot prove that you had a rubber dam on during an endodontic procedur

Howard:  so okay so we know it needs a rubber dam so number are you gonna bulk Phil you get an increment Phil I think that both Phil's they have a huge

Dr. Mario Romero: I have a huge sake in what we do every day I think that they are something that came out to dentistry that is very very good there's a lot out there in the market and there and we have to understand that there's different types of them you know you have the ones that are like cured that they're gonna be more of a translucent type of shape because you need to like to go through and then you got the dual cured type of bug Phil's that have that they're more opaque because they are either you can cure them with a light and if the light doesn't reach it doesn't reach that the deeper areas they will do cure that will stop you in those areas so you got these two types these two different types of both Phil's now one thing that you gotta keep in mind here is if you are using or you decide to use a bulk fill that is a both field that you are going to do that you have to like here you gotta make sure that your preparations have a depth no greater than four millimeters now you will find a lot of manufacturers I will tell you five millimeters but what happens is that I'm gonna ask you a quick question so I'm gonna interview you for one second how many times do you as a dentist use a probe to measure how it beeper preparations are

Howard: never

Dr. Mario Romero: never so you can see the nasty honest truth I don't do it either so if you we never know how deep they are so my advice is if you for whatever reason think that this is more than four more than four because four we know that the light is going to go through but you got to make sure that you give 20 seconds of light you got to give them enough jewels enough energy for that composite to polymerize but if you for whatever reason and I have a lot of cases like that where there super super big so I know that there's more than four millimeters I still use a bug fill but I do I use my bug fill in increments instead of using two millimeter increments I use three to four millimeter increments so I know that if I have six millimeters I'm gonna be used to three millimeter increments to bulk fill that rest that too and I cure both increments separately so I make sure that I'm still using the benefit of the buffer which is faster quicker and as you know and we know that we're gonna like you're through it but the other reason why I think that both fills are so important in our practice is because how many times you think one of these large class tools is gonna end up with a crowd or an onlay very frequently maybe in a year from now or six months from now so I try to keep my inventory small when I say inventory I mean amount of products I don't want to have a composite fork or buildups and another composite for bug fills and another composite for layering if I can keep it simple and keep let's say that I'm going to choose to do all boxes on post your teeth then that setting both fill is what I'm using today to seal my endo chain my BOB chambers on root canal to the teeth and that same boat fill is the one that I'm using for my core build ups so I will prep the tooth and if I need to using that as my core builder material and I use it as my final restoration and then I know that if I have a unit from now I got a you know for whatever reason one cause fracture and I need to now do a crown on a tooth I can use that material as my core builder material underneath my preparation so I don't have to remove it if it's still in good conditions so I think that using the boat fills simplifies a lot of what we do but can we get away completely out of the layering technique no because you're not gonna use boat fills on and your teeth so you're still gonna have to have some microfiber or nano hybrid type of composite in your practice for those other cases or for the very minimally invasive type of you know slab preps very small class tools or class ones where you don't you know you don't you're not because it you know the bob fills they come in these little computers where you have to literally throw them away once you want to make sure that you have your large preparations and the other thing is at the tip the size of the tip of that boat is kind of wide so but for very small preparations is probably gonna be too wide as it kind of be hard for you to control the way that the material is expense on your preparation 

Howard: okay they're gonna want to know your brand though on the when you talked about bonding agents you said Opta bond universal curve or one coat seven Cole team for Bonnie agents adopt a bond fluoride curve for generation assets what would what bulk Phil do you like 

Dr. Mario Romero: I use sonic Phil three from Curt and I use Phillip from Cole team and why do have boat sonica all three from Kirk yes from Kerr and what was the other one you're the one is Phil up from Colton fill up from Coltine okay now reason why I have these two is because sonic Phil is like your Philip is dual cured alright so I use fill up a lot let's say I'm gonna give you a good example I use it a lot for when I have implant crowns that are screwed retained and now I have to backfill that screw hole I use filler because it's really it's very opaque so it doesn't let any metal show if it's a pfm it's tooth color so it looks nice on a corner type of restoration and it's do cure so I don't care how deep my chimney is if it's three four millimeters it's still going to polymerize completely without the president fully laid all the way down for bulk fill sonic fill three composite for light cured and then for Philip from Colton for dual cured yes sir okay and Howard: and you already told us your bonding agent I have I have heard people on this show come on and say that dental supply reps but they can go out and say they have say they have twenty five dentists on their account and they go and they test the light of alt five dentists half the lights aren't even acceptable and there they're saying that Dentist always want to know what Bonnie agent to use and what composite you and they're saying dude your light doesn't even work what so what light do you use and how does this Dentist drivin she's driving to her office right now and she's gonna get there and she's got a do an MOT composite on three how does she even know for lights even working well you know for the light even working

Dr. Mario Romero: you have to use a Radiometer and you have to make sure that the light the output of the light is at the minimum I would say four hundred and fifty mega watts per square centimeter at the minimum you know ideally we today we have you know six hundred twelve hundred and it's not about the intensity it's more about the time you know the time that you'd like here and you know this is another good advice that I can give the younger dentist is that yeah you normally they use as the reference they're  uh you know the person that this is him you know the guy that the rep that works for the dental company well guess what the rep is not a dentist you know the rep is somebody there he's there to sell and he's there to help you out he will answer many questions but he doesn't know the facts so you know a lot of them go out I say oh if you use my curing like you can only kill you only need to queue for five seconds well we you know here at the school doctor for a group ever he's done a whole bunch of research on curing lights and what he has found is that the lights that say that you can only kill five seconds the conversion rate of the composite with that light intensity at that time is a lot lower is less is always less than sixty percent I would say closer to the thirty five to forty percent range compared to using the same light for twenty seconds four times the intensity were you now gonna be in the numbers that are sixty five to seventy percent conversion from the monomer to the polymer and that's what you want because you know you're never gonna get 100% conversion because you have oxygen and algae and inhibits polymerization so the higher that number the better off you're gonna be and that's a really good point you see then is were Oh what adhesive to use what composite do you use but nobody's capable of measuring their own i'ts and their practice and guess what the reps that base in your office they normally have a Radiometer so if you have a rep come to your office once a month just ask him to measure your rights and make sure that you have the highest output possible for the brand that you're using here at the school we use we use the lights made by ultra dent during the entire school so the Velo light is the one that we use here at the school and you know that's the one that has the most research it's a great light the good thing about the ones that we have is that we have the cables so they're connected that they're powered through a cable that goes onto the wall so it gives you constant output you know with the same intensity when you have the cordless ones you gotta make sure that the charge on this coordinator wants is high enough to get the output that you're looking for but regardless of that you want to make sure that you have that time is an important factor that you consider time and you know I never liked your anything for five seconds everything is for 20 seconds minimum and you know if your light has a lower output you're gonna have to increase that time from 20 to 25 because again you're having now less energy coming out or that tip of the right so you have to increase the time in order to forget the right amount of energy output okay Howard: um it's really scary when you're young you just got out of school you just got your first job you did an MOT composite and you're driving to work and the patient came back is on your schedule cuz the tooth is sensitive and she's like oh my god I you know so so talk her through it you should get a mo d composite a week ago and the patients coming in it's sensitive  

Dr. Mario Romero: normally me and you know this is quicker than a week ago it'll happen the next day patient go home and say hey you know what I had this amalgam that you said it was bad it was there for 30 years never bothered me you removed your mouth and you put this white stuff now it hurts and let's think about that a little bit but you don't think about pain many things can cause it's one of the most important factors when we're talking about class tools is what I call the remaining dentin thickness or our deets so how much dentin is still solid nice and healthy dentin is still on top of that coat and all the studies many studies have shown that the minimal amount of dentin required so that the dentin can protect the pulp a hundred percent is minimal 1 millimeter so you need to have at least one millimeter of dentin on top of that pulp chamber so that you can acid ice pump and bond and have no and have complete protection of that top meaning that you're not gonna get any resin globules into the pub in contact with that live tissue that will create a sit to toxic effect that will be felt by the patient as those are pretty sensitivity if you are in doubt and this is my best advice for young dentist if you are in doubt clinically on how deep you are and how close you are to that poke chamber the best and easiest thing you can do use a liner use a resin-modified glass ionomer like bitter bond right on that NT right on top of that pulp and seal that dentin and then you can go ahead a select from a bond and have no issues because now that you seal the dentin there is no chances for that for the monomers in your adhesive to infiltrate and get to the pulp because don't forget if you have less than one millimeter of remaining 10th in thickness on top of that Pope you will get resin globules into that pulp in contact with that live tissue and that will create a problem that will be one of the caught one of the things that manifestations is hypersensitivity the following day or two days later so people many young dentist think that that is normal it is not normal you can do a lot of operative dentistry without having that secondary effect and the way of doing that is managing the remaining dentin the right way and that is either through the liner or through choosing a specific system for your adhesive dentistry let me give you another example let's say that you don't want to use a liner and you don't know how deep you are you are very deep and you think that you are probably up to a millimeter or slightly less than a millimeter away from the pope well you can now use a universal adhesive or you can use so itching adhesive that I like because there's a lot of them that come in two bottles and I like the wind when they come in two bottles because now you have control over the primer and the bonding of these self etching adhesives now I don't use self etching adhesives on my enamel I selectively etch my enamel always with was phoric acid but if I am in fear that I'm too deep and I may cause some irritation of the pot I rather use a self etching adhesive for that for that dentin instead of a total edge technique where I'm gonna remove more of the smear layer and I'm gonna edge more into that tooth I'm gonna be my depth my edge in depth is gonna be greater using phosphoric acid than using a weak acid that like the ones are coming to the sub matching adhesives so those are two ways that you can combat this either with a liner or not edging the dentin and using a sub-question adhesive 

Howard: okay but a lot of times when they're young and out of school they don't know is this the bike how does she know if I should adjust the bike or if it was everything you just said 

Dr. Mario Romero: and it and if she does everything you just said should she still adjust the bite well that's a really good question because if it let's say that it is a crucial trauma you're hitting the truth more than you need to and now the truth becomes sensitive well the easy thing to do there the patient is not gonna know why they have sensitivity they're just gonna tell you I have sensitivity so the number one thing that you're gonna do is first check the occlusion centric and lateral cursors and look at the tooth if the causing factor of that hypersensitivity is a hyper occlusion and it's not been going on for you know for five weeks it's just been going on for a couple of days most likely when you eliminate the interferences on that tooth the patient is gonna feel the improvement right that moment because you're not gonna place any anesthetic if there is no improvement and or you did not find any interferences latter exclusives or centric interferences then you know that most likely is something to do with the adhesive layer on that tube with that hybrid that is not is not ideal and that's why you're having the postoperatively and the only way of getting rid of that is removing the restoration so that's an easy way to assess what is the causing factor for this hypersensitivity 

Howard: you do so many different things you also did a YouTube video on the hoenn technique what what made you do that and talk about the my pronounce aright the hone technique yeah technique 

Dr. Mario Romero: well that whole technique what you're seeing on the video was actually done by the ended on is that I work with here at the school dr. Bergeron he's the chair the I mean he's a director of the endo program here at the school and that was one case that we had together this patient had had a root canal and an APA a picot ectomy done on that tooth initially and you know couple year later he had a recurrent infection and it was a large large infection and so the whole technique is it's kind of like a minimally invasive type of treatment meaning that there just is it's just like a like a like a like treating on fistula you know it's just very small opening where they just remove out they drain everything out of that area they clean that area very well but they don't they don't they don't they don't have to go ahead and redo the AP correctly so they did you know everything is done by a through a very small little access and is more of a draining process and it's a way that they then follow up and then you know if it if it doesn't if it doesn't if there's all recurrency of the infection then they know that they're good and what they follow-up for the patient for a full year so that that video was done by dr. Bergeron during that specific procedure of a patient of mine and the reason he videotaped it and I and he shared it with me because what I did for that patient was a restorative site and it was interesting for me that even though the tooth had you know had you know because what do you hear after me you hear that oh if you have if you have two root canals on on that tooth most likely you're gonna remove the tooth and place an implant well for this particular patient he had a root canal yeah he had two root canals when he pick awake to me and then he had the whole technique done by dr. Bertram so that tooth was treated because of issues in that canal four times and even though it was treated four times right now I think they were like in the third year of follow-up of that patient so we were able to get rid of the issue with a technique that dr. Bergeron used but we didn't have to remove the truth and the truth is now restored and it's been in good shape for the last three years so that's kind of what we did that video we did the video kinda to show that you know that that endo is a really good option when it's well done and one is done by a trained highly skilled and trained person and as you know I don't have anything against general Dennis doing endodontics I think that if you like it and you're good at it by all means go ahead and I mean I think that is something that you should learn how to do and do it well on my particular case of Howard I'm really bad at it and I can I know it and I just I'm sleep I'm very frontal about it and I chop everybody I'm really good at I'm really bad at this you would never want me to do any root canal for you so I refer everything that comes to my practice and I've been doing that for the last 22 years I don't do any endo at all and obviously I feel highly and I thought highly of the specialist because they've helped me so much with so many difficult cases that have been successful that worked out well in my hands because I've only dealt with a restorative part 

Howard: and what did you say his name was the ended honest doctor who dr. Bergeron Aires for that be you are no BER bird GE ro and Bergeron so you're on an endo man huh what does the word micro abrasion mean to you we know when back in the day there was that danville unit that's sprayed and that cleaned off I just loved it but my dental assistant for 30 years hated it because it was so messy but you know your crown came off or whatever and I take this little micro Arab razor from Danville engineering and then they made some bigger ones I had like a six thousand dollar micro abrasion unit I forgot the name of it back in the day but I I loved it but nobody loved the mouse it didn't take off and you know looking back was kind of a fad but what does micro abrasion mean to you and do you use any girl air abrasion 

Dr. Mario Romero: I use microwave bridge and I use a micro etch or two from Danville engineer and I use it to microwave my either you know the the metal crowns gold crowns I used to micro edge I use that to my courage my the integral surfaces of my circular crown which is I think you know something that we should talk about a little bit because obviously this is everybody's using that today and there's a lot less of metal real metal black metal be using in and energy today pfm type of our gold crowns but I use a micro I don't use it a lot on patients teeth the micro abrasion that I the technique that I use it's actually I use a product from ultra dead called Opel Astra and an open lustre is a product it has a hydrochloric acid 6.6% combined with pumice and some abrasive particles carbide abrasive carbide particles and there's two ways that you can do abrasion of enamel is either macro abrasion and you must remember and I used to do this many years ago where we just used a little bird you know diamond find them and burn you you know white spots and you just kind of gently run on top of them until you slightly remove them and and you and that's called micro abrasion so you're using a diamond bird to actually roughen or remove some stains on patientsí micro abrasion is at the micron level so you're removing I would say 70 to 100 microns of enamel when you're applying this and I actually I just have a nice case that was published just recently in the Journal of cosmetic dentistry and when we submitted this paper for publication this clinical case for publication one of the comments of the one of the reviewers was well you know how much enamel are you removing how can you consider this minimally invasively so we'll be moving enamel and what we did is that we actually took a photo of the patient a very nice photo where we were able to capture there was a side photo but we were able to capture all the micro texture that was in her enamel after the micro operation and we they actually added that photo to the article and the beauty of the photos that you're looking at all beautiful intrinsic characteristics of the enamel new micro an atom of the enamel that was never removed by the micro abrasion because again we're at the micron level you remove in 1720 mike rizzo enamel where those things are where those white brown stains aren't located but underneath that you got some nice translucent enamel left behind that now once you remove the one that the the surface layer you're able to eliminate the whatever the patient disliked about our smile sometimes you know fluorosis things either white or brown stains depending on the level of fluorosis but that's what micro abrasion is all about micro bration is about using this product that you use on the surface of the tooth and you use it with special cups and these special cups are special because they are very stiff bristles within them so that you have a little bit of mechanical removal of enamel at the same time that you're having micro abrasion so it's a combination of mechanical removal with those stiff bristles and my chemical removal with a micro abrasion of the product with the acidity of the product and Andy and the abrasive never of the product on top of that enamel so this combination is what removes that surface cinema where these things are located and that's what we that's what I normally use for my adult patients that have white spots either for fluorosis or just hyper mineralization of enamel that I you know that have been there for years and that will not be they're not suitable they will not be removed correctly or completely by enamel residental tration so you gotta kind of choose between resin in filtration and micro abrasion to see which one would work best for that specific white spot that you're trying to eliminate

Howard:  I love your website Romero dental seminars calm Romero dental seminars calm I mean September 28th yeah mastering the aesthetic prototype for partial and full mouth oral rehabilitation May 17th oh you're already past that and what is this the days on July 1st 2019 so your next one is September 28th 

Dr. Mario Romero: right that's what in September 20 normally we I mean when I'm out there probably I would say you know five six big dental meetings a year where I'm lecturing a lot of hands-on courses this we have we I like perfect I really like to eat into smaller courses 30 participants like the one that we're gonna do in Atlanta Georgia on the 28th because it allows me more time to kind of sit down you know one  to one and kind of you know work with them and kind of guide them to the process because again when we want them we really want them to like the word like the title of the course says we want them to master the prototype and when you say master it really depends on the you know regardless of the case at you that you normally have in your practices it can be partial or full mouth cases this same concept is gonna help you understand and guide yourself to an easier process from start to finish when you deliver your restorations 

Howard: well you know I love that I'm always harping on my homies that the average American buys 17 cars in their lifetime for the average new car is thirty three thousand five hundred and they on average that they'll buy 17 cars between that and eight seventy six and then I look at every dentist that retires and ninety percent I've never sold one case for the average price of a new car and they spent their whole life saying wells of insurance and Delta and PPOs and it's like no dude if you didn't you know when they buy a new car they're exhilarated they post a picture of it on Facebook they come by your house and you know you walk out there and act like you know you're enjoying this new child that was born I mean I grew up in Kansas they upgrade a new f-150 for fifty thousand or an f250 are a hundred thousand f-350 you know every five six years they buy that and then that dentist that small town has never once suggested hey how would like to have all your teeth done a new smile makeover and you know what you paid $40,000 that f-150 truck this won't even cost you twenty thousand you know the only you know living in fear is not an option and when you're when you're practicing dentistry in the richest country in the world where they buy a new car every five years they buy a brand new car you know I I just love the fact that you're sitting there doing courses mastering the aesthetic prototype for partial and full mouth oral rehab if you haven't done a full mouth of aural rehab hopefully you just graduated from dental school in the last year or two and you're not quite ready and of course like this will get you totally ready or you just don't love dentistry you just don't think people want to drive a new car with their new smile I mean I I've done full mouth rehabs on women when they looked in the mirror they burst out crying I mean I this one in particular where she knew she was a 10 for a denture but but you know I convinced her nah you don't want to do that you know we working out every remaining tooth placed a couple implants in each corner made her a couple you know all fixed I mean it was the greatest moment you know I mean of the year first she just loved it and I hope you are listening to this I hope you go to Romero Dental seminars calm was there anything that I should have asked you that I wasn't smart enough to ask you

Dr. Mario Romero: know i think that i mean i think that you conduct your interviews in a very special way and i really enjoy the way that you do it i think that you've asked really good questions that are gonna be helpful for the young dentist and sometimes even up for the older dentists as well i mean it really depends on what you're doing in your practice you know i just want to tell everybody that i mean i'm i've been teaching for 23 years i've been teaching for 20 years I've been a dentist for 24 years but I've been teaching for 20 years out of those 24 years and you know part time initially now I do it as a full-time job and one thing that I can tell you is that I love sharing the knowledge if it's through webinars I write a lot you get you know you can you go to my web page there's a site where you see publications you can there's out a lot of my articles are there we have over 100 hours of of actual teaching videos in Spanish and in English so because I used to teaches it's only up to seven years ago that I moved to the United States I've been here only seven years so you'll find out you know over a hundred hours of videos me lecturing for over an hour and different topics occlusion aesthetic dentistry restorative dentistry and all that is free I mean I always I always joke about in my lectures that my website is the only website and then I says that you can get stuff for free because everybody's charging for that there's stuff I ain't charge you for myself I just give it away because I think that one of the you know one of the most beautiful things of what I do is that I share my experience and I've seen a lot cuz when you're in an academic environment you see everything and you know just getting these younger dentists feeling powerful what they're doing and just getting them motivated to continue you know they're learning this you know this this is a lifetime learning commitment when you become a dentist every single year you have new products every single year you got new techniques and you got to stay up-to-date to that well we do a tremendous dental seminar so we try to simplify that we do have our our hands-on courses that we do and obviously those have a cost because obviously there's a lot of cost associated with us getting it done but we do a lot of stuff that's out there in our inner and our YouTube channel that is free nobody has to pay for it you can just go ahead click on it and you're ready to go we have a very active Facebook page as well call Romero Dental seminars and there's a lot of cases that I that I upload they're just showing little tricks and tips free no payment no subscription no anything so it's just let people know that we do this because it's really what I make I mean it this is really what I what I today what I live for teaching and sharing knowledge and 

Howard: you know why Facebook is so awesome because Mark Zuckerberg is dad ed Zuckerberg is a dentist and he Wow he comes on the show once a year he even posted on Facebook on dental town the other day he always updates I the what you should know best about marketing you practice on Facebook or running your Facebook pages it's just amazing but I thank you for all that you do for dentistry thank you for sharing so much I and congratulations again I mean you got the the excellence and Dental Education Award from the pier for shard Academy I mean even published 40 times and you taking the time to come on my show it was just an honor it's a podcast interview to you today thank you so much for coming on the show no thank you very much for this I really enjoyed myself and I really  enjoy your YouTube channel I've watched every single video in your YouTube channel and left some comments after Sam so thanks again for coming on the show thank you thank you very much for your time.

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