The Last Steps in Indirect Restorations Make All the Difference

I think everybody I know is doing selective etch. And then for the dentin part of it, your bond is going to start off acidic and it neutralizes as you scrub it in. But to get that mechanical retention on the enamel, that's where that selective etch and air abrasion comes in. That's where you're creating all of the little nooks and crannies for everything to adhere into. Welcome to Austin, Texas, and welcome to the Dr. Phil Klein Dental Podcast. So you're about to deliver the final restoration. Do you realize that what you do during this appointment will play a major role not only in how long that restoration lasts, but also in how satisfied your patient is with the final result? From preparing the tooth and conditioning the intagliol surface to selecting the right bonding protocol and cement, these final chairside steps have a tremendous impact on long -term clinical success. In this episode, Dr. Jennifer Derse shares practical, evidence-based techniques for cementing lithium disilicate and zirconia restorations, selecting the right materials, achieving outstanding shade matches, protecting the pulp, and avoiding the most common cementation mistakes. If you want more predictable, durable, and aesthetic indirect restorations, you won't want to miss this episode. Before we get started, I'd like to thank all of you for tuning in. If you're enjoying the show, please follow us on Apple Podcasts and Spotify, and even better, leave a review. By doing so, you're not only showing support for what we do here, but your reviews are instrumental in getting more dental professionals to listen and benefit from our content. We really do appreciate it. Dr. Derse , it's a pleasure to have you back on the show. Thank you for having me. It's always a pleasure to be with you. Yeah, and I appreciate you running away from your patient. I realize you were in the middle of a case. Listeners don't realize that, that some of the KOLs that we have on our show literally are jumping between patients. So we certainly do appreciate that. Dedication to podcast education when you have all this cherished work to do. So you've said in the past, and you teach quite a bit, and you're a mentor and you lecture and stuff like that. You said that one of the biggest mistakes, and I do agree with you, that dentists make is treating every restoration the same regarding cementation. Let's begin by talking about the restorative material first. How does the material itself influence our cementation process? Well, first of all, the cleansing of the material when you're going to go to cement your crown or veneer. is impacted by the material choice. So if you're cementing glass, like lithium disilicate, you don't want to be using air abrasion on that. glass then at the same time i've seen people put in um phosphoric etch into zirconia and which would impact the bonding as well so knowing your materials and being intentional about what material you're using which also is impacted you know with prep design and you know if you're doing something that's a bit more conservative or versus a full crown prep that You know, your prep design impacts your material decision, which impacts your adhesive decision and how you cleanse the restoration beforehand, what cements you use. So you almost have to think of it like you have two different tracks where you've got like your glass track and your zirconia track. It's interesting because I did speak to a dentist recently and he said, you know, I like using zirconia because I don't have to bond it. And I was like, what? Like, I didn't really get what he meant by that. But he elaborated on that and said that my prep design allows for mechanical retention. So I don't really need the adhesive properties. So he kind of relies on looting cement versus an adhesive cement. At this stage of the game, when we have such advanced adhesive systems out there, it seems to me that it allows the dentist to be really conservative. What are your thoughts on that? I will use a dual cure cement. pretty much for every restoration because of the self-adhesive part of it and what that can do when it interacts with the dentin. So like going through that process and creating the integration into the dentinal tubules decreases your sensitivity. So I know I'm bouncing around a little bit, but I actually would rarely choose a looting cement unless you maybe are like... really, really subgingival. And you need that for like, you know, cleaning off the excess. And eluding cement, you would say would be what? A resin modified glass0i onomer? Would that be kind of a... Yeah. Yeah. So that's what this dentist uses. He loves to use resin modified glass ionomer cement because he says, I get plenty of retention from my prep. And with that, I don't have, these things never come out and I don't have to worry about bonding. So that's, you know, he has the strength of, you know, the additional strength of the resin component. in the glass ionomer, and he has the chemical bond between the tooth structure and the resin-modified glass ionomer. He also has that caries-resistant factor that glass ionomer offers in its ion transfer within the saliva and all that other stuff that we know about. So I think that what we want to accomplish here in this discussion is saying that... should take advantage of our adhesive systems. We just have to use them correctly and prepare the indirect restoration properly. Like you said in the beginning, we have to clean it and prepare it properly based on the material. Yes, yes, correct. So depending what material you use, like once you've tried it into the mouth and you have to make sure you get good isolation as well. I've heard doctors say, you know, I don't need to isolate for zirconia because we're not bonding. the saliva still can contaminate the crown and what happens with your cement to the intangular surface of the crown. So all of it, it all matters. Right. That's the key thing. It all matters. So let's say we have, let's start with Emacs or lithium disilicate, Emacs being the most popular. And we're doing... veneer yet. We're doing a crown. Give us the rundown on, and you know, our listeners have heard this before because we've done, you know, we're on almost 800 episodes here. So they've heard it before, but it's always nice to hear it from someone who's a mentor at the Coise Institute like you are and someone who's been around the block with the latest and the greatest. What is the protocol for a tooth that doesn't have retention on its own right mechanically? You've conservatively prepared that molar, for instance, but you want to go with... emacs how would you tell us the whole story between how you treat the actual material and then on the tooth side what do you do there that's great because now you're keeping me on track because okay so emacs um like the posterior restorations on an emacs crown typically you know i'm trying to keep as much because of the bond with emacs I keep a lot of tooth structure. So, you know, maybe you're changing out this MOD. I will still keep the, as long as the margin isn't in an aesthetic spot, you can keep that margin really high on enamel. So now you've got an enamel ring on your, you know, your posterior crown, or we call it, sometimes they're calling them crown lays now. Like we've got all this lingo. So what's great is that you also have enamel to bond to. So in that situation for the tooth, tooth preparation, I'll still use air abrasion because of the enamel part, not necessarily because of the dentin part, but because you've got that enamel ring and air abrasion helps with that and, you know, that mechanical retention. And then we'll do some selective etch on that little enamel ring. And then you can go ahead with your adhesive bonding protocol. So you actually use air abrasion and etch both? On enamel, yeah. is showing that you get better bond to enamel when doing it that way versus just using phosphoric acid? Yes, but I can't quote him. I totally understand that. You don't sit up reading PubMed and documenting every article. You read the... abstracts and get the message and then that's good enough. Yeah. And then if I'm teaching, I just put the citation into the PowerPoint. I'm not somebody who can quote like in a journal of whatever in 1942. So hopefully it's not 1942. Yeah, that's true. So when you do the air abrasion, what are you using? What kind of air abrasion particles and so forth? What's the details on that? Yeah. So for the air abrasion, I have a Rhonda Flex and I had a prep start for a really long time and I liked it because that's what I learned to use from the Kois Center. And then this winter, I got my hands on one of Kavo's products. It's an air abrasion unit that has, you can do air and water. And in the real world, like either you're going to have your prep start that you're going to hook up in every single room. I understand that. but they're also you know it's a piece of equipment versus when i've got the rondo flex which allows water to go through it at the same time so you can air braid with or without water and just hooks right into you know your adec unit your your coupler where your handpiece would go and i love it because now i just plug this in and it can come from it transfers from room to room really easily as one piece of equipment yeah the portability of it Absolutely. It's so portable. Yeah. And that's a big factor today in dental practices. You know, you try to keep, there's so much to buy. Instead of buying one for every room, you have your staff, your assistant help you move it and set it up in the next room. Yeah. And so, cause stuff, all of our equipment, all of our costs are expensive. So if I can use this for something like for more than one reason, I want to. Yeah, for sure. You use the air abrasion and then what do you do? Wash it off and dry it? and then go straight rinse and dry and then you go with selective etch which is putting phosphoric acid only on the enamel right and you do that for whatever time period what is that 30 seconds yeah like 15 seconds okay wash that off and dry it and now you go to what a universal bonding agent So, yep, that's where you would use your universal bonding agent. And you'll scrub that all over the tooth on the enamel and the dentin. Scrub it in. All bond you is two times 10 seconds each. All bond universal. You like to use. That's a Bisco product. So it seems to me a lot of clinicians and the teachers, the educators, are really going now to selective etch. They're trying to do a gentler etch on the dentin because they don't want to over-etch the dentin by doing a total etch. they're really enjoying the selective etch technique and they're getting the best of both worlds. Do you find that your colleagues are doing the same thing? Yes, absolutely. I think everybody I know is doing selective etch. And then for the dentin part of it, your bond is going to start off acidic and it neutralizes as you scrub it in. But to get that mechanical retention on the enamel. That's where that selective ash and air abrasion comes in. That's where you're creating all of the little nooks and crannies for everything to adhere into. Right. And you also don't want to have phosphoric acid on the dentin. No, never. Right. For a lot of reasons. Sensitivity, removing the mineralized inorganic material, which will take away that availability to the MDP to actually bond with that dentin. And one thing that dentists don't realize is that as you go deeper, I'm an endodontist, so I know this from... when I was in my graduate program, as you go deeper, you have less intertubular dentin available because the tubules are much larger diameter-wise. 25% of the dentin down near the pulp is tubule, whereas up top or more superficially, if you really go all the way to the DEJ, you're looking at 1%. tubules. So you have a lot of intertubular dentin to work with. So obviously the bond is going to be much greater as you move away from the pulp. So keep that in the back of your mind when you're trying to bond something where it's really deep. I think that's really good information to know. I didn't know that. Yeah, intertubular dentin. People don't realize what intertubular dentin is, but that's the dentin that's in between the tubules. That's why they call it intertubular. And there's a lot more of it as you move away from the pulp. It's just something to keep in mind when you're trying to rely on some ideal dentin bonding when you have to do that. So what about the actual preparation of the lithium disilicate? What do you do on the ataglial surface there? Yeah, that matters too. So it depends on if you're milling yourself or not. So if you're milling yourself in your practice, then what you'll do is you'll hydrofluoric acid etch it in the lab, clean it. dry it put your silane on and then you try it in and then otherwise the labs will often do this for you now i know some people how you know you don't want to over etch it with the hydrofluoric acid so i know that some people in their veneer preps actually ask their labs not to do the etch part because they want to make sure they keep control over that so but most of the time your lab is going to do that for you and have a good relationship with your lab so you know you know who's doing what and then after you try it in i still cleanse it with the phosphoric etch and then re-silent it and it might be a little old school there because i think that some people don't necessarily recommend going back and re-cleaning it with the phosphoric etch phosphoric etch but to me i just so the hydrofluoric the hydrofluoric acid is etched in the lab but then after you try it in in order to clean the surface you're using a phosphoric acid yep just as a cleansing agent yeah and that seems very reasonable to me i mean i'm not a researcher but what's the research say on that um you know that don't go back to 1942 no research that's that's anecdotal strictly anecdotal yeah it's and it came from the like when i originally went through the koi center that was in his always protocols and and so that's why i don't if it if that has changed i still can't let that go like i feel good about the it being clean and then re-silinating it because the silane is what creates that that double bond but I feel better knowing that like if there's anything that's in there I've well you could be pretty confident if it's in the protocol McCoy Center you should feel pretty confident unless he's changed it um yeah which he could have so I you know I I would give John a call. Hey, John. Yeah. What's the story with your phosphoric acid cleaning method of the intangular surface of lithium disilicate? He's a great guy. He's an amazing, brilliant man. I knew him from Penn because he was in the perioprost program when I was in the perioprost program when I was in endo. He was a little bit older than me, but great guy. And he doesn't do anything without a reason. Yeah. Brilliant man. Great educator. He's doing it. I'll go with it. Yeah. The Koi Center is just so unparalleled. So before we get into the veneer, we're doing a molar. So you do a try-in, then everything looks good. And now you go in there with your phosphoric acid to clean it. You're re-silane it. So you just use your plain silane. You don't want to necessarily use silane that's built into... a bonding agent because the silane the silane needs to be separate if it's in your bonding agent bonding agents are all acidic like i think the highest ph is all bond you around three two i think it is they're probably gonna be like jen's quoting our ph Does that break down the silane, the acidity? It does. It destabilizes the silane. Right, over time. And especially because if this is an adhesively retained crown where we're not doing a ton of ferrule, you want to make sure that silane is working. Right. So you've approved the try-in. Tell us about the occlusion. When do you actually check the occlusion? Do you do that during the try-in very carefully or not? For most of my posterior teeth, I've designed them myself, and I know that they're going to be right or really close. or same thing with the labs that i've worked with so the occlusion i check afterwards and the reason is it's also your your restoration is stronger once it's cemented so we've got more strength with the cementation process and with some of these really conservative preps you also just don't want it you don't want to have inaccuracy from it dislodging so to me it's easier to like i know we're I'm going to be really darn close. We'll put it on and then make the adjustment. What do you use to design your preps in-house using software? Yeah, I've been a CEREC user since it was probably risky to do. I mean, when we first had the red cams and then the blue cam and then the, you know, so in that process, for me, it's really comfortable once you know your settings. So we just use the Emacs blocks, fire them, stain glaze them and love it. And my patients love it too. I mean, one day you'll be looking at 3D printing because some of these restorations are pretty awesome with ceramic components in it where you can actually very quickly print a crown. Some of them are very small, these printing systems where they actually cure the material. It looks like an espresso machine. Unbelievable how 3D printing is advancing. Okay, so you've used your universal adhesive, you did all your stuff, and now you cement it in. What cement did you use? This is where you're going to want to use your dual-cure cement. So because you've got some thickness to the occlusive surface, your Emax thickness is going to be one and a half, sometimes two millimeters thick. You want to do a dual-cure cement for that space. Any recommendation on that type? Oh yeah, I would use a dual link all day long. Oh, dual link. Okay. So that's a specific dual cure resin cement. Yeah, just resin cement for these. Right. Now, if you're doing a veneer, so we don't have to go through the whole, is everything the same with veneer except for the cement itself? Correct. So everything's the same except for, you know, with the veneer, you're in all enamel. So you're going to air braid the entire surface. That's maybe a difference there. Otherwise, also doing the light cure. So the choice two is an awesome cement for doing veneers because it's light cure. You have so much more control and your veneer is only like 0.3 millimeters thick. So you can light cure through. And then you have the try and pastes, which... are such a key component of cementing veneers that I think a lot of doctors don't know about. Yeah, so what's the big advantage of the try-in paste? So when you try in your veneers, you try them in with a glycerin-type gel that's tinted to be the same color as your cement. And because your veneer is so thin, cement impacts the way the the veneer shows with its color okay so you can actually in advance see what the what the actual final product is going to look like after you cement it even though you're not really cementing you're just trying it in what about the transparent try and paste. Do they have that? Yes. So they have a transparent, they've got like this milky white, they've got, there's a range of shades. You can do your A1, you can do a little life hack that I think is kind of fun in cosmetics is when you have your lab do a block that is brighter with a little translucency. So maybe you're doing like an OM1 or OM2, and then you can put a warmer cement underneath it. So then when it gets closer to the gingival area, it warms it up a little bit. The other thing is sometimes you'll have a patient who who wants really, really, really white as hell teeth. Am I allowed to say that on a podcast? I guess so. You already said it, yeah. It's 2026. When do you make the decision to either use something that tones it down or increases the value to make it brighter? So once we've taken off the temporaries and we put them on with try and paste, what I'll sometimes do is compare it. Like we'll, you know, I'll have like... right side up to number eight are one shade. And then the left side is, you know, nine through wherever is a different shade. And then I can compare and see what color I like more. And that's actually what was just happening in the other room before I got on this podcast is we were doing a four-unit cementation. Social four. Yeah, the social four. And I was working with a doctor. is she you know like we all agreed that the the milky the milky white one just looked prettier and then the b one gave the veneers a little bit of an ashy tone so we just and and it just depends on the tooth structure that's underneath the ingots that's used so you've got that little bit to play with and i've even been in situations where i've used more than one color while cementing a case because you get everything back from the lab and one tooth underneath is a little you know the little darker than the others yeah because trauma or something absolutely that colors from the tooth itself is going to come through in the veneer um so does that all come in the choice two kit all this all these goodies where you can play around it sounds like the old days where you used to use like 18 different shades to get something done but it's a lot simpler than that obviously yeah yeah because you can buy the whole kit like i would tell somebody to just buy the whole kit to start but then you might find that you have like three flight three flavors they taste great yeah you didn't know how good it tasted so when you do the so this is the choice two system you're talking about but when you do the actual try-in do you do the delivery that visit like right so you finish you don't do a try-in and then bring the patient back for delivery when you're doing the try-in they're going in permanently that visit yes and that's a really good question that i wouldn't even thought to add in here because the the try in that gel is just like vaseline jelly it is not adhesive so you know if i have my patient um you know verify that we like the color before cementation i usually leave the bib on and have them hold it up because sometimes they get excited they're like wow these look so good and then a veneer falls out and so at least the bib is like up like a little tray underneath them yeah that would be that would be unfortunate so yeah so there's no there's no real retention on this so when you have the patient look at it themselves when they're holding the mirror you got to make sure they're not like closing their mouth and moving around because that thing could disappear on the floor of the operatory yeah oh and i used to in my old practice but we were on the sixth floor and i would like to i would sometimes take them outside for that metamerism effects of like okay let's go outside and look you can see these are really bright like you can see how how i mean okay let's all be real Maybe this doesn't happen to you because you have a beard, but for those of us who are over 40-something women, we start to get these chin hairs. We all complain about them. And you see the chin hair in your car, in the rear view mirror. You don't see it in your bathroom lighting. And that's why I would take my patients outside because the lighting is different outside than it is inside. You have this natural light and I can show you, okay, we've put the brighter color underneath or we've put the A1 underneath. And that way you can really put it into effect so that you don't go out and be like, we picked, you know, white opaque. cement underneath and then they go outside they're like oh these are really really white so it is and how do you keep them from falling out when they're moving around they had to hold their bed oh they're holding it up like that yeah and you can't see you can't see dr durst but she's holding she's showing how the bib would be held out horizontally so it's like so it kind of serves as a safety net in case that veneer comes flying out um yeah okay so let's talk about zirconia do you ever do you ever do zirconia veneers is there any need for that yes um it's not usually my first choice because historically Zirconia has been so opaque, but now there are newer zirconias that are in a 5Y or 6Y where I have a handful of cases where we've done zirconia, and just a handful because I do love the glass aesthetic. But we've done some zirconia veneers, and now that we have some translucency in some of the newer zirconias, I think it will probably become more popular. and the timing for that is like if you have somebody who's got maybe tetracycline or really dark undertone teeth or you're like say number nine is part of a bridge so you're using zirconia and then eight is you know your veneer you can blend that a little bit easier. So my default is still Emacs and then I prove myself out of that. So if it doesn't seem like I can use the lithium-based electric kits, then I'll go to a zirconia. Can you still use a light cure cement with zirconia? I would use a dual cure cement with the zirconia because you can't cure through it. What you can do though, if you're trying to tack it, which I have done for just for cleanup sake, is I'll I'll shine the light from the lingual and then just use the light a little bit on, you know, like the margins for cleanup. But otherwise, you're not curing through it the same way you would for Emacs. So I would steer more towards using a dual cure. Right. But generally speaking, you're going to go with Emacs for veneers. generally speaking and aesthetically right now that's 99.9 percent of the time right that's just that do you do veneers on lower teeth a lot of dentists that i talk to because the teeth are so small try to go with direct restorative composite enamel bonding kind of no prep minimal prep with the lower teeth they don't want to have to prepare the teeth for an indirect do you do that too yeah i agree with them on that i mean i've done lower veneers they're very like itsy bitsy i've done plenty of lower veneers but your bite matters so you know now we're getting into occlusion and how much space do we have and also like how much shade shifting are we doing because composite can only shift your shade so much compared to then emacs and compared to zirconia so it's pretty case dependent on the lowers but it's nice to know that you have all of these tools in your tool book and this is why it's so important to actually take ce and and we've got this you know this awesome program that's online but then also doing some of the live ce where you connect and make friends with mentors and then you can send them cases and say hey like what do you think of this because the networking part is really an important part of dentistry yeah no doubt about it that's that's incredibly good advice dr doris tell us about zirconia real quick Yeah. We're basically preparing, let's say we're bonding it. We're not using eluding cement. We're not using resin modified glass on where we're going in. We don't have the retention or we're a dentist where we want zirconia there for strength on a molar, but we want to be extremely conservative with our prep design. So we need to rely on adhesive systems. How do you prepare the two side? Is it the same as what we just discussed on the lithium disilicate? But I know the intaglial surface of the zirconia is much different. yes the entire surface on the zirconia you're going to use the cleansing paste for zirconia Zirclean, yes. I am such a dentist because I just grab the thing. You're not the only one. That's why I have to know these names because you guys are too busy. You're doing the clinic work and I'm like memorizing the names of these things. I think it's Zirclean. I think Ivoclar has something called Ivoclean or something, whatever. Yes, Zirclean and Ivoclean, like one of those. So you can use those or also you can use your air abrasion unit. and just air braid out the intaglio surface. And you want to make sure you don't have any blood or saliva in there because saliva's got your phosphates in it. Yeah. And I think we're looking at 30 to 50 micron particle size on the aluminum oxide and the power one to two bar. So no hydrofluoric acid for sure on the inside of zirconia because there's no silica inside zirconia. What about this primer? 10 MDP primer. Tell us about that because that's got to be used after you aerobrade, right? Correct. So your MDP is like basically the sticky stuff. And what that does is creates that chemical bond to your cement. So the MDP is, the primer is really important. And so you can use, you know, the Bisco's got a primer. You can use the Monobond is the IvoClar's brand. You know, some people will even use the All Bond U as their primer because it has MDP in it. Oh, that's interesting. That's interesting. Yeah. Okay. So you just need some MDP. And for the cement, dual cure adhesive resin cement is what you go with. Yep. Let me ask you about isolation. It's one of those topics that can spark debate. It's that, you know, is absolute isolation really essential for successful segmentation or are there clinical situations? And, you know, be candid with me. where other isolation methods are perfectly acceptable because some dentists abhor rubber dam. They just whatever they do. Some patients do. Some patients hate it. Like, you know, I've been in situations where the patient is like is freaking out because the rubber dam is on. And then we put in an iso light, iso dry, whatever we're calling it these days. Yeah. Yeah. And. And they love them. I've had work done with that on and I loved it. I, you know, like, so I think that like, how are we trying to make everything super predictable? Yeah. A rubber dam is going to increase your predictability and love the and word. You know, a lot of things work in a lot of people's hands differently. I mean, I love. having my rest, I had some curidon put on and we had the isodry in and I'm like, this is really comfortable because I can bite on it. It's sucking everything out. I wasn't like, you know, the rubber dam when you start drooling out the side and then patient, like you've got patients who are like, it's drooling in there. As an endodontist, every case we had to use a rubber dam, but you know, we never did anything in approximately everything was occlusal and we just dropped, you know, one clamp on mostly. Maybe we had two or three clamps that covered everything. And, and that was, you know, Put the frame on. The rubber dam went on in probably 15, 12 seconds before the patient even knew. Yeah, they're easy to put on. They're not hard to put on. Yeah. But yes, approximately, sometimes when you're doing those interproximal restorations, it can be, you know. So do you primarily use a rubber dam or do you like to use the devices? I love the device. I love the suction with the thing that like the, you know, the rubber piece that wraps all the way around. Yeah, they're very clever. I mean, those things make sense. Yeah, especially when you're sitting multi-units. Like most of the time, I'm not living in a single unit space. It's typically. You don't do endo. You don't do root canals, do you? No, but I just watched an endo class and it made me kind of wish I'd learned endo. I thought, this looks kind of fun. It's funny though, because when I talked to General Dennis, oh my God, I would never do, I, you know, they're out 20 years and they go, I wouldn't even know how to do a molar root canal. It is something you have to keep, you have to keep up with it. But, you know, I love, you know, I love. it. That's what I did for a living for many, many, many years. But some dentists just don't like it. But I just think it's... It seems so then. Yeah, it is. You can just meditate and go off into Never Never Land. Right. Yeah. Yeah. I'm probably too hyper to be an endodontist. I don't think I could have been an endodontist because I'm really hyper. Yeah. I mean, it's interesting though, when you talk to endodontists, most of them will say the case is over when they find the canals. everything up to the point where you've located the canals and be able to get a number 10 in there and it goes down that's it case over the rest of it is just talk to your assistant about anything you want or yeah it's just so relaxing it's like a vacation once you find the canal but when you can't find the canals or there's so much bleeding in there that you don't know where you are that kind of makes up for all that yeah that's a bad day um Okay, so we're wrapping it up soon, but I do want to ask you a couple of things. One is post-opera sensitivity. It still remains one of the most frustrating complications after indirect restorations. You know, you think we've got that solved by now. Patients still come back and they are uncomfortable when they get a crown cemented in on a vital tooth. What are the biggest contributors in your mind, Dr. Derse, to sensitivity post-cementation? And what specific steps can clinicians take to prevent it? Yeah. Well, that's where I think that the dual cure cements are nice because of how they, you know, they start off like a little bit acidic and neutralize and get into the tubules more. So I think they help with some of that post -op sensitivity. I also think knowing where you are in relation to the pulp, I mean, this is now your world, but, you know, if you are close to the pulp, are you putting in a base or are you putting in... you know, some MDP, whatever it is that you're wanting to, or sorry, MTA, MTA, sorry. Whatever you're using for that management and how close you are, that matters. So when you're planning for an indirect restoration and you're doing your buildup and you're pretty deep, what do you typically use for pulp protection? Then I would lean on some of the MTA. It's just a thin layer of that. And then put, you know, put like a little bit of your flow bowl over the top of that and then finish your buildup. I think everybody does things a little bit differently. And if you're not super close, I think also just using this, something that's self etching to put in that place. There's a great Bisco product. And I say the names backwards all the time, but I can tell you which Bisco product. Because I can pull it up and find it. Thera something. It's probably a thera. And I say that I flip them all the time. Yeah, there's thera cow and there's thera sem. You're going to have to probably cut that out. No, we're leaving it in. Well, it's good because... The yellow one. Okay, I'm sorry. I was wrong. It's the yellow one. So the thera sem is what I'll sometimes put on the... So I had it backwards. Okay, so what's in the thera sem that you're using? It's just a little self -adhesive with some calcium and fluoride. As a liner. As a liner, yeah. So using a liner when you're deeper, I think, makes sense. I'd make that in all ways. When you're deep, you would put that in all the time. Yeah. And it also creates some bridge formation there. Yeah, those names are a little bit confusing. So to our listeners, we're just trying to expose you to the concepts here. Don't be taking notes now. But if you're looking to get some help when you're really deep. and you're near the pulp, I know that there are some Thera products, TheraSem, TheraCal, look up what they do this way. Dr. Derse will be doing that too after this podcast. She's going to go do some more research. You got to go back to the treatment room and pull it out of the drawer. Well, that's the thing. Once you've established what your armamentarium is and you have a good team, they hand you the stuff, right? Because you're not, you know, you're not like reading every label as long as your team knows what they're doing. then you should. Yeah. And once you know your IFUs for each product, you go, okay, I know what this is. I'm going to put it in. I have to scrub two times for 10 seconds each. Right. It's like when you see a person you haven't seen for a while, you recognize them, you know all about them, but you don't know their name. That happens to me a lot. Um, okay. So last question, we're going to wrap it up. Um, this has been an interesting podcast. This is the kind of episodes we have when, when the dentist is like jumping between patients because it shows you how, what's on your, I mean, you're, you're all over the place because That's what's happening in your office. Par for the course. That's good though. Yeah. I think we're all a little ADHD. I know I'm really ADHD, but I think we all are a little bit. You mean as dentists? Yes. Oh, okay. Or is that everybody in general? Just you're talking about the dental professional. The dental profession. I think I read that there's like 35% more ADHD prevalence in dentistry than other careers. I don't know where I read that. That's interesting. Probably. Yeah. Another 1942 study. Right. Probably. Yeah. So if you didn't exist yet. Right. Well, yeah, we did dentistry quite centuries ago. I did a podcast episode on the history of dentistry. I don't know when it was, but we used to treat patients. They used to lay on the floor and put their head between the dentist's legs and the dentist was on the floor and they used to. Yes. The head of the patient. That's what I do, how I clean my dog's teeth. Right. The head of the patient is between the. thighs of the dentist on the floor and that's what's stable yeah and someone else held the patient's legs yep i mean that's not going on now i hope when did that happen what what era was that um 1700s 1600s oh my god yeah something like that yeah i mean it if you read the history of when the dental chair was developed and the reclining dental chair in in the You know, the concept of time, it wasn't that long ago where dentists were just standing up the whole time. I remember, you know, when I was a kid, my dentist never sat down and the chair didn't even recline. It was an old dental office on the second floor of my grandmother's house in the Bronx, New York. And this dentist was 75 years old and he rented the space above my grandmother's store. Yeah, you're talking Bronx, New York, 1960s, early 60s. And I was a very young kid. Okay. Last question. If you could watch every dentist cement their next indirect restoration and correct just three things before they seeded it, what would those three things be? And tell us why. Stop the bleeding. So if they've been wearing a temporary, make sure you're cleaning everything up and you're not getting like a bunch of hemorrhaging. Like just like what I've seen. in newer doctors because i've lived in a space of mentoring a lot of doctors hands-on um is not properly isolating so we've got saliva and especially it's always the lowers they've got you know saliva everywhere blood everywhere and they just shove the tooth on the crown on because they think oh i'm using eluding cement i don't have to keep things clean you still want to make sure you're keeping everything clean and dry um so that would be probably number one two if you're doing veneers do your try-ins Do your try-ins and use the try-in paste and coordinate that to the cement. I think that is really important so that you don't have somebody who comes back and say, this isn't bright enough, or these are too bright. You want to be able to say, hey, this is what we're doing. Show them in the mirror, show them what their teeth look like, and then have them sign off and approve it before you cement them. And then use the coordinating cement. And then the last one would be like... the intaglio surface properly. So I've seen people flip it a lot, where I've seen people put the phosphoric edge into a zirconia crown. And I've seen people use air abrasion on glass and just flip it. So just pay attention and remember, you've got two different protocols for the cleansing of both materials. Yeah, that was very well organized, very well articulated, no ADHD. Even no, yeah, no glimmer of it came out in that conversation. So very good. All right. Well, listen, Dr. Derse, that was great. Do you have a patient, you have to go back to our patient now or you're done for the day? I'm, I'm, I'm helping a doctor with a patient today. So that's what my world is, is coaching and mentoring. So I'm, I'm going back in there. At Aspire, this is Aspire Dental? This one is an Aspire one, yes, but I am actually. I've moved out of my role at Aspire. I'm really excited about it. And I'm now doing coaching and consulting for private practices and vendors. My ADHD can't have me in the same role for seven years. I could go out back out into the world. So I'm really looking forward to- Yeah, no matter what you're doing, it certainly looks like you're enjoying yourself. So, and we appreciate that. We have to have you on more shows for sure, because it's just a lot of fun interviewing you. A lot of fun. Yeah, I actually enjoyed it. You're a great interviewer. Oh, I just asked the question. You should just go all over the map. I just, yeah, I try to keep things in line and just ask the questions. But our audience is growing rapidly. The show is doing great. And we just, we're trying to have a good time here and cover some important points that are timely to our listeners. So that's the goal. Thank you so much, Dr. Derse. Have a great evening. Thank you so much. You too. You too. Great to chat with you and great to see you.