Why Biomimetic Dentists Demand A Precision Handpiece

Welcome to Austin, Texas, and welcome to the Dr. Phil Klein Dental Podcast. So as practicing dentists, we all know the importance of a good handpiece. Whether you're using air or electric, whatever your favorite thing is, it's got to be precise. It's got to be comfortable in your hand. It's got to work reliably. And we have to maintenance it because if we don't maintenance it, we're going to have issues with a rough ride when we're working with our handpiece. Now, today we're going to be talking to Dr. Anna Paholiouk. She's a... fan of electric handpieces. She's very happy that they've gotten smaller. They're much easier to use. She gets great access to the posterior part of the mouth, which was not the case when electric handpieces first emerged into the market. She also understands the importance of maintenancing a handpiece. And according to her, she hasn't had any problems since she's developed this standardized protocol for keeping her handpieces running perfectly. She does it despite the fact that we have turnover in the office and people tend to do things their own way. And this is done through automation. And she'll talk about how that automation is really the best way to go when it comes to taking care of her handpieces and giving it the longevity that she expects from a premium handpiece. She's also going to talk about her philosophy of practice, which is precision based on transcribing the pulp as she preps the tooth. Her priority is pulp vitality and minimum reduction of tooth structure. So I think it's going to be a really good conversation. I hope you enjoy it. Stay with us. We'll start shortly. 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. Paholiouk, welcome to the show. Thank you for having me. Yeah, and I just want to let our audience know that we had a brief discussion before we went live here, and Dr. Paholiouk speaks four languages, and she's about to learn a fifth, which is Italian, and English is her fourth language, and she's a dentist. So for all of you who think that you suffered through dental school and had all these issues, I mean, that's English being a fourth language, and you teach too, right? Yes, I do. Where do you teach? I teach at USC dental school, the same school where I graduated, actually. Yeah, amazing, amazing. And she had a whole life before dental school because she started dental school when she was 30, which is, you know, when you're 30 years old, to me, sounds like a very young person, but... other dental students, you were the old lady in the school, right? Absolutely, yes. Actually, I was not the oldest one, believe it or not, but you are correct. I was definitely an older student there. Yeah, everything is relative. Everything is relative. And as you get older, the goalposts keep moving, and suddenly everyone looks younger than you remember. Yeah, that's just how it works. So it's just really very interesting to go through that voyage. All right, so we're going to be talking about some interesting stuff. For one thing, As dentists, we all care about precision. I mean, precision is a big deal for the things we do every day in our operatory. But this is especially true for you as you pride yourself on a practice that emphasizes a very conservative biomimetic style of dentistry. Essentially, and correct me if I'm wrong, at all costs, you want to preserve tooth structure. That's really important to you. And to make that happen, you need precision. So with that in mind, How does handpiece performance impact your ability to preserve healthy tooth structure while achieving the precision and control that minimally invasive dentistry requires? Yes, I do practice minimally invasive advanced adhesive dentistry based on biomimetic principles, philosophy. So it means that I do everything possible. uh to preserve as much as i can the tooth structure and the pulp vitality i would say majority of my patients come to see me for a second sometimes third fourth opinion after they hear that they need a root canal and a crown and when the pulp is vital no matter how severely decayed the tooth we can still preserve the pulp vitality so i worked on a mainly on a posterior dentition as you can tell um and mainly what i do either severely decayed teeth that are i'm trying to preserve the nerve or i do a crack dissection which on a t that is symptomatic due to the fracture and if you would look at my post-operative X-rays, you would see that my preparation design is like I'm circumscribing the nerve, right? So the pulp chamber. And this kind of preparation and design, it does require a lot of precision and control. Just to clarify, you used the word circumscribe the pulp, and that's your preparation design based on preserving it. So handpiece performance is absolutely crucial. based on retention obviously we're out of that era right now for sure and adhesive adhesive dentistry has allowed us to do some amazing things to protect the pulp but i mean as an endodontist speaking um i totally think what you're doing is great but again if the symptoms even if the pulp is vital if the symptoms are overwhelmingly pointing toward what we you know call in our jargon irreversible pulpitis you know, you're still kind of destined for that patient to get endodontal treatment. Oh, absolutely. Yes. And you know, when patients come in for, as I said, a second opinion or whatever, third opinion, that's the patient education is the first thing that I do. And I do my very best to explain them. Actually, that's my line. I'm not doing magic here. I'm practicing evidence-based. it's a science so if the tooth is asymptomatic and severely decayed it doesn't mean that your nerve is vital it means that it could be necrotic we need to test the pulp and I never do any restorative treatment until I verify that the pulp is actually vital because if it's irreversible the root canal is near it it's absolutely not even a discussion so and sometimes when i am unable to uh test the pulp vitality because the you know some patients are very anxious they you and you rely on uh they're gonna jump no matter what you do absolutely so i refer to endodontist so they can verify that it You know, because the dentist I work with, he knows the dentistry I do. So he would test for me. And in this case, I say, I'm sorry, we need to verify that that's what you need. And I do a lot of talking that root canal is not evil. That's the way to save the tooth. Yeah, absolutely. And when you use the term pulpitis, you are by definition saying that the tooth, the pulp is vital. So if you have a necrotic pulp, then you don't have a pulpitis. Sometimes there's partial. pulpitis and then part of the apical part of the root is necrotic. But even if it's alive and it's vital, if it's the symptoms indicate that it's too much for the patient to handle based on the duration of the response to hot and cold or whatever. pressure, not even pressure, just temperature and sweetness, then you're typically looking at an irreversible pulpitis. So let me get back to the handpiece. So what is it that the handpiece does for you? What kind of handpiece do you use? Do you use air? Do you use electric? And what are you looking for in a handpiece that could give you the control and the precision that you need to basically avoid the pulp at all costs and leave as much to structure as possible and rely on your adhesive dentistry? okay so first of all I do use I actually my practice I had a startup so I built my practice from the scratch and before that I was four or five years an associate so I have experience with air driven handpieces and because I graduated USC when USC already had both electric and air driven so I already knew the difference so I knew that I for what I want to do I wanted the control so for me it was not a question that I want electric handpiece so I have NSG electric handpieces in my practice And going back to dentistry, I chose electric handpieces because of the control that it gives me during my preparations. Now, do you use that electric handpiece for everything? Absolutely, yes. Or you don't use air-driven at all? Actually, I do have air-driven slow speed. But for my preparations, I use pretty much all my preparations coming with the high speed. Now, one of the things that, you know, I heard from dentists years ago when electric hand pieces were kind of being marketed and introduced to the profession were that they were kind of bulky, they were heavier. If you have a smaller hand, they're more difficult to get access to the posterior. But that's all been changed and modernized, right? I mean, the newer electric hand pieces. sometimes are hard to differentiate between air-driven. I mean, I'm not using it. So tell me what your thoughts are on that. That's actually, you are so right on point with that. Remember I told you that I first experienced electric handpiece in USC. So not to name the brands here. It was not NSK. My first experience was, I started, let's say this, I was trained for second year with air driven. So I was already used to the size of the head of the handpiece and everything. So now I heard from Dr. Pascal Mania, who was my mentor back in the day. Wow, that's quite a mentor. yes yes congratulations yeah i'm very i'm very fortunate um and i was so excited to start with a electric handpiece right and then here i am and i'm sitting ready to it was still on a type around that was uh still in seam lab getting the electric handpiece and i'm like oh man i just didn't see anything the head was so big i it forget about bulky big on a hand i think i would get used to this but as a new to dentistry itself i already don't have the hand skill yet right and now you put this huge obstacle in front of my vision i'm like um you know what not happening so i pushed myself i liked certain things i i know what i realized right away is the torque so certain things i distinguished right away okay i like this i don't like this but i couldn't force myself uh to work with it fast forward about seven years later when i was opening my practice i really wanted electric hand pieces i really was looking for the best equipment to do the dentistry that i knew i wanted to practice and i came across an ad of the very beautiful female hand small hand with a handpiece on it and it was advertising for a small hand that it's not bulky and it's at nsk and i was like oh my god maybe i should try that and whatever you're mentioning it was actually right to the point because that uh that's how i chose what i wanted and when uh five years ago a little over five years ago when i was test driving the electric hand pieces i actually ended up with an escape because of that because it felt comfortable it felt small in my hand it it that was my main uh reason to go with this yeah the way you described that was absolutely perfect it's amazing that english is your fourth language i mean i mean Very impressed with your decision -making in the dental part of this conversation, but I'm just, the way you're expressing yourself with English is just so very elegant and articulate. I struggle with words sometimes, and this is what I do for a living. But no, very impressed with the way you said that. So you're sold on electric, there's no doubt about it. They've overcome that obstacle that was really keeping a lot of individuals, especially women with small hands, from using it. The benefit is huge. Now you work under high magnification. Your magnification is what? Eight and a half to 10 times in that range. So what kinds of differences become noticeable at that level of magnification when a handpiece is performing optimally versus another handpiece where you don't have that precision? you are correct on a daily basis i work with eight and a half magnification loops and i do have 10x as well so if i would do a crack dissection um i would be using x 10x but um you know higher magnification more you see and more you notice so i think what really stands out is how your preparation look at the end if you like your prep is the true giveaway how your handpiece performs and that's another thing i love about electric handpieces and i heard it actually from several doctors i'm not gonna name them but they're known um out there known clinicians and we all agreed that even if you don't have the best hand skills but Having a good handpiece that give you control, it will make your preparations better because you feel that you have more control over it. So you can be more precise. Let me ask you this. Do you use single patient use burrs when you prep your teeth? I love one time use burrs. Okay, so I was hoping you were going to say that. Yeah, because to me, that takes out a variable. If you're using a new burr on every patient, which I think... at this point should be doing and I know it's hard to throw out a diamond bar after you've used it one time but in the long run when you talk about the cost of sterilizing it and everything else but you as far as we're talking about precision now you could now isolate the handpiece as the true defining instrument for making that beautiful prep possible so I do want to touch on air driven one more time before we give that up since you're a true And 100% diligent electric user. If one of your colleagues said, you know, I've been using air-driven all my life, all my career. I used it in dental school. And I get really good preps with air-driven. And I feel comfortable with the way, you know, the operatory is set up. I don't have to worry about using any additional installation equipment that would, a motor or whatever else. What would you say to them? I'm thinking, I don't want to put words in your mouth, but I would think you would suggest to them to try it to see if they could bring their preparation design to a level above what they currently think is really good. Would that make sense? yes it does it does make sense uh you know there is a several differences actually between air driven and electric hand pieces that i can talk about but if we concentrate on a prep design i feel like being able to control rpm with one single burr you can cut and refine your prep that's amazing that's something that um will improve the outcome in terms of the final preparation but also you know it's efficiency as well um i loved using several births when i was working as an associate for like one prep i would use like i don't know like three to five burrs and many experienced dentists were telling me anna every time you take the bur in out you know like you taking time of your prep so it slows you down and um yes i do believe that steel electric will give you a better outcome but again it's hard for me to talk because i know great clinicians who are so amazing uh with air driven because they they're already amazing with air driven handpieces so if it works great but but it's worth trying it's certainly worth trying absolutely because it it just i don't know it just gives you this control that you don't have with electric handpiece now you mentioned that you change burrs a lot does that mean you're not changing burrs with electric as much no I don't because I and I love that I can use the same burr as a cutting and polishing burr simply by controlling rpm I cut the tooth at the highest rpm right then I can shut down the water I can slow down to let's say 40 and on a dry just finalize the margin with the same fine cutting diamond. So there's a whole level of efficiency that's being brought into the picture. Yeah. Now let me ask you about this. Many dentists focus on buying high quality handpieces. They know that's the workhorse of their practice, which is a good thing because handpieces, you know, are one of those areas where the purchasing decision is based on performance, like we talked about reliability and longevity. And it's not all about price, but buying a premium handpiece is only part of the equation because what many of us don't focus on enough is maintenance. So how much does maintenance affect the long-term performance and predictability of your handpieces? What are you doing in your office for maintenance? And I also want to talk about standardizing maintenance because, you know, when you have a turnover of assistants, not every assistant is going to handle the maintenance the same way. So how do you manage the maintenance part and how important is that for your electric handpiece? Right. So maintenance is actually crucial. regardless of what kind of an handpiece you have so you can buy the best handpiece on the market but if maintenance is inconsistent eventually you will notice changes in the performance so proper and consistent maintenance will help to avoid expensive repairs and i can speak about this because in past five years a little over the past five years that in my practice i never had even one issue with a handpiece nothing at all it performed beautifully and i truly believe that maintenance played a key role in this the key is creating a system that makes maintenance simple time efficient and done correctly by each team member as you just mentioned we've In reality, we get temporary assistance. We hire new team members. So it's important to have the standardized systems. And also, you know, different assistants, they develop different maintenance habits, depending what it was in the previous office. That's a good point, because I've talked to repair technicians. Wonderful conversations with those guys. It's really funny to talk to them. But they told me, and I talked to them actually before this podcast. These are some of the things that are common among different employees that are handling maintenance. Number one, insufficient lubrication. Number two, failure to run the handpiece after lubrication, sterilizing without adequate purging, and debris remaining in the gear train. And these things lead to bearing failure, increased noise, heat generation, and essentially wear of the handpiece. So does that... align with what is going on in your practice as far as your experience so let me share with you a little bit before becoming a dentist i was for seven years dental assistant and here we go here we go yeah perspective when the doctor um got a new hand pieces adrian handpieces the representative of the company came in and he just told me that what to do right and he was like you put this drop of oil in this chamber la la la right so he leaves and here i am you know okay so if you put one drop is good so two is better right so all these human errors comes in with trying to do something better yes you are correct um that's actually When I was opening my practice, I wanted to create a system and avoid these inconsistencies and make it also simple. So the person who helped me installing my electric hand pieces, I was actually asking him, OK, this is investment, right? So absolutely. So I was like, OK, what what can I do to increase the longevity? And he said, well, what do you do with a car? Maintenance and I will never forget this. He said your handpiece requires maintenance as anything else in this world if you wanted to keep performing like a brand new and that's how he introduced me to the eye care system which is automated cleaning system right and he went over the protocols with me how to use it and i love the eye care system because it automates the cleaning and lubrication process with the correct amount of oil You know, there's no more guessing one or two drops. And while properly rotating the internal gears for the optimal lubrication. So you don't have to think if you did something enough or not enough. All this human error is out of the picture. I've heard a lot of dentists from a lot of dentists who use the NSK handpiece system. They love this. They really love this. Oh, I love it. Yeah. And my assistants love it too. Your assistants love it, obviously. Yeah, well, if I was an assistant and had an office that had it, I would love it too. So tell us what the voyage is. What is the trip that that electric handpiece takes? You finished a patient, you did a great prep, you move out of that operatory. What does the assistant do with that handpiece? And talk about the actual maintenance cycle. Like how often do you have to do that eye care process where you purge it and clean it and everything else? Okay, so actually, again, going back to the point where I was installing the handpieces, the representative of the company, he was giving me the whole protocol when, how to clean, you know, and there was a schedule giving and I was like, okay, is there any problems if I just do it every time after the procedure? And he said, absolutely no. It's like, you cannot over... overdo it so that's where I knew that that's going to be my system so as you said the prep is finished assistants breaking down the room they collect all the instruments on a tray so as they get to the back the eye care system you just open the door you connect the hand pieces you press one button done. As the system takes care of the hand pieces, they take care of the rest of the instruments. They do whatever they need to do. The cycle is done by that time. It's like, I don't know, maybe a minute or so. And then they have to process the chuck. It's very important. The chuck is a separate maintenance step. Absolutely. So they open the door and they connect the chuck of each one. It takes a few seconds. They take care of the chuck area. Done. Your handpiece is ready to go to autoclave. And then it goes into the autoclave. So the maintenance of this electric handpiece and doing it properly through this kind of automated system that lubricates it and purges it. It takes out staff variability. You could do multiple handpieces at the same time, right? There's room more than one. And what about the actual record keeping for this? Does it tell you when you do this so you have this in a record form? Well, for me, I do not need any record because every time I use the handpiece, it has to go from the same process. So that's where I was trying to verify with a representative from day one. Is there like a limit that I don't overdo it, so to say? And no, you cannot. It's like one of the few things in life. Yeah, it's one of the few things in life you can't. overdue i mean overdue right yeah i mean if i took my if i dry cleaned my suit every single time i wore it it would eventually take its toll on the suit you know because there's a downside to over dry cleaning um so you want to do it when you need to um or maybe a little before you need to and then you got your suit but if you do it every time you're going to wear it out so you can't wear out your electric handpiece by putting it through this eye care system no so that's a good that's a good system to have i mean they just drop it in there and then it goes in the autoclave and you're all set for the next patient yes you know and it's actually one of the there is a i don't remember exact protocol for chuck because there is something okay let's assume don't quote me on this but let's assume it's like once a week i just truly don't remember what i was told but i just quickly realized i will not be able to track Which handpiece, because I got like five handpieces, right? And how do you keep track of which handpiece was used like once a week, twice? I mean, it's impossible, right? So this makes the most sense. Yeah, it makes the most sense. This makes the most sense. You know, getting back to the chuck, we all know as practicing clinicians that the key sign of a bad chuck is when that burr doesn't stay in there. And there's nothing more upsetting or aggravating or annoying. than having a burr, you know, vibrating inside your hampis. It can be your worst enemy. Worst enemy? A bad chalk, yes. you're right you know as a as a associate i feel like i experienced it all i experienced it being stuck and you just just sit there with a patient in the back of the page behind the patient like trying to take it out using like hemostat right i think any of us experienced it or you're looking for it in the patient's mouth because it came out absolutely and actually you know poor bird retention i think this is like the scariest event right because it happened to me once and i was like petrified no it's frightening it's like a it's like a small missile going down their throat that yeah that's incredible and thank thank god for rubber dam you're right uh but um only 30 35 of dentists use rubber dam well i use rubber dam for each single procedure even when i so i don't prep a tooth for the crown unless it has a crown that requires replacement that to begin with but if i am to replace a crown i actually even prep remove the crown and everything is under the rubber yeah well that's that's very very no that's fantastic i mean you obviously have a good system for using a rubber dam most of the dentists in a survey and i think dr lawson was on that podcast with me where he said that, I think he had a social media poll that he did. He has a lot of followers, Nate Lawson. And he said that most of the dentists that did not use the rubber dam, which is 60%, the reason was inconvenience. Inconvenience. I honestly don't see how it's inconvenienced. For me, it's the best thing that you can do. It pulls the... Tongue is not on the way. Lips not on the way. You are not afraid to cut the cheek. You have beautiful, I use blue colored rubber dam. So you have this nice color that makes everything stand out. And it's peppermint. I used to use a rubber dam that just smelled great. I don't know what it was. No, no. It's latex-free. Again, not to name any companies here, but it's just... uh because i you know sometimes people don't even know if they have latex allergies so it's synthetic material but it has beautiful blue color it makes everything stand out while you're working so it's even i use carriers detector as you can guess for for my selective carriers removal so for me it's um every single tool that we have it's out there for you so there is no reason to not to have a beautiful prep and do good dentistry, in my opinion. Yeah, do you put the rubber dam on yourself or does your staff put it on? We actually do it together. I put the clamp, I call it the ring, in front of the patient. So I always isolate the quadrant. So I would put it on the most posterior tooth and we isolate the quadrant. Wingless? Wingless, yes. Okay, so because you don't want to have any conflict with your sectional matrix and your separator. your two separate and everything else and the wedge goes in there everything i have many different ones but my go-to wingless wingless yeah that seems to be very popular if you're relying on adhesive dentistry and you're doing the kind of biomimatic dentistry that you do in your office where it depends solely on adhesion the last thing you want to do is get contamination from saliva or blood period right because the patient's going to come back with with a failure unless you redo it and then if you redo it while the patient's sitting there just about when you're ready to apply the composite the same thing could happen you know the tongue could get in the way or saliva just just it's like a wave of saliva or those patients that as some of our guests have said love to lick their dentistry um you know that's just how it is dentistry is chemistry Adhesive dentistry is chemistry and chemistry requires absolutely controlled environment. And adhesive dentistry, dry, controlled environment. So Robert M gives you exactly that. Yeah. I mean, it sounds like to me, you have an incredible philosophy of practice. Because number one, you know, what you're doing, not even number one, but overall, you're taking variables out of the picture that could decrease. the success rate of your clinical dentistry, because you rely so much on precision. You've got the handpiece handled. You've got the maintenance of the handpiece handled. You don't have to worry about the chuck. A burr that's moving out of control is certainly not going to give you precision. And then you have isolation. And also, we talked about this offline, you implement a caries. detection dye, if I understood you correctly? When I do selective caries removal, I reapply multiple times caries detection dye. Oh, you saw a blue dye? Actually, it's red. But there are different kinds. There is blue, green, red. It doesn't matter. What matters is that you know how to use it because I feel like many doctors just don't understand how it works. and how to use it it's a great tool especially for those who trying to be conservative and to um do selective caries removal there is a need to understand what you're trying to achieve you're not removing everything that is stained you need to create a peripheral seal zone what we call it it's like you need about two three millimeter of the clean enamel superficial dentin and dj that's what you're trying to do and of course you want to remove as much of the diseased infected affected dentin as possible remember i told you if you look on my postoperative extra you will see that I'm circumscribing the pulp because we apply we I mean those who practice biomimetic dentistry we have what we call three by five rule it's where we know where the anatomical average where the nerve lives right three millimeter from the measuring from the contact of adjacent tooth and five millimeters measuring from occlusal surface of the tooth you're working on right so this three by five rule applied you need to make sure that this band of what we call peripheral seal zone is absolutely free of infected and affected dentin. Do you ever use SDF silver diamine fluoride? I do not. i do not but uh i believe that uh and i cannot you know i i read a lot of literature in science and i i rely heavily on following up with the science um research that comes out but um i cannot even comment on this because sdf is used mainly in pediatric right that's right that's true but but it is very effective against affected dentin so when you have that typical leathery dentin that we're taught to peel off in dental school just keep scraping that stuff off you actually want to leave that there and you just want to remove the mush which is the infected dentin you can even do that with a bender brush you know something like that you don't even need a drill even though we're talking about hand pieces here but for certain cases especially younger people like you said You could leave the affected dentin, which is the leathery dentin, and then put the silver diamond fluoride on, which is just a drop or so, and then go straight ahead with glass ionomer. And that STF will stop the progression of the decay and actually remineralize the leathery dentin. And with the combination of the glass ionomer on top, it becomes a very solid restoration that could last a very long time. And that's about as conservative as you can be. But I'm not saying that applies to patients that you're talking about because... Every single case is different, but it's certainly good for kiddos that come in that may not be coming back to the dentist again. So they could buy, you can get years out of this stuff. yeah yes absolutely i i strongly do believe in this and i do have friends who are pediatric dentists and who use it heavily because they want to be also conservative and you know to minimize right and the patients that are very fearful if you don't if they don't want to get an injection you can actually treat a carious lesion just by using a hand instrument sdf and put class anima over it. But, you know, we got off topic a little bit, but you've, no, I mean, you covered some incredible clinical pearls. And I think what you're doing in your office is so admirable, Dr. Paholiouk, because every single patient that goes to the dentist would love to have a dentist like you who cares about preserving tooth structure. I mean, the aggressive dentistry where you just cut teeth down and you restore. And everything is based on restoration through crowns and onlays and veneers. All that stuff is still necessary. But we do have the tools today to be very conservative. And you're taking advantage of that because you believe in it. That's the way you want to practice, which is extremely admirable. And I'm really happy to have someone like you on the show because I would love many of our listeners to think about it when it comes time to navigating around the pulp. and doing the things that you're doing so is there a way for people to reach out to you if they have any questions or do you have a website um well there's a website for my practice but if somebody have questions they can absolutely email me and i'm not sure how i can share the email well you can say it now and then we'll put it in the show notes okay so it's going to be complicated because it's a and my last name so it's a P-A-H-O-L-I-O-U-K at gmail.com. Okay, so I'll do it one more time. So it's A-P-A-H-O-L-I-O-U-K at gmail.com. So please send Dr. Paholiouk an email if you have any questions. And if you want to learn more about eye care or any of the NSK products, feel free to visit their website. Great discussion, Dr. Paholiouk. Thank you so much for joining us. Thank you.