50 Years in Dentistry: Tools, Tips, and Techniques from a Seasoned Pro

Because if you take a class two and you are seven millimeters, eight millimeters to the axial gingival floor, all right, how do you know that you're photocuring that deep when your light can only get into the cavity prep as far as the highest cusp? Welcome to the Phil Klein Dental Podcast. Today we'll be talking to a general dentist who has been around the block a few times, practicing for over 50 years. From time to time, I see him at the various dental meetings where he lectures frequently, and I often ask him to come on the show to talk about what's new in dentistry. He finally agreed to be on the show, so the next question was, what shall we talk about? We went back and forth on several topics, including composites, prevention, provisional materials, tissue retraction, lasers, handpieces, curing lights, and patient management tools. After a bit of discussion, we were unable to narrow it down to one specific topic, so I suggested that we talk about all of it. He quickly retorted that he would need a full day for that. My response was, we need to cover all of it in 30 minutes or less. He smiled and agreed to do it. So, here we go. Our guest is Dr. Howard Glazer, a fellow past president of the Academy of General Dentistry. He's an internationally known clinician, educator, and author. He publishes a bi-monthly column in Dental Economics entitled, I Have It, You Need It, where he shares his opinion on materials, products, and techniques that will make your day easier, more productive, and rewarding. He maintains a general practice in Fort Lee, New Jersey. Dr. Glazer, it's great to have you on the show, finally. Thanks, Phil. I'm glad to be here with you. Yeah, we see each other at a lot of the major conventions. We always walk by, say a few words, and I finally got you on a podcast. It's been a while. So you have a lot of expertise in dentistry. You've been doing this for decades. You have a column. in dental economics, I have it, you need it. So you're very familiar with products. You do a lot of product reviews, a lot of product evaluations. What do you think about when you get something new in your office that you've ordered, whether it's a new version of something you already have or you're trying something totally new? What's going through your mind when you open that box? I don't have all the fancy testing equipment that some other... researchers have to test strength and things. So I'm a practicing dentist. I'm sitting at the chair. I get a new material, or as you say, one that's been revamped. And I open the box. Is it going to work like the manufacturer says? What I'm looking for are things that are faster, that are easier, that are better for me, the doctor, but they have to be better for the patient because the patient is the ultimate end user. So my mantra is faster, easier, better. But how do you know it's better for the patient? Well, research, I, you know, I don't think the, I guess part of my responsibility is to look at the data and to look at some of the research and the supporting documents and to see if what they're claiming makes sense. And it doesn't in fact happen clinically. I mean, I will test products on the bench that have not been approved for patient use. And I'll advise a lot of times as a consultant to companies, but once they've labeled it ready for patient use and I put it in the mouth. I want to make sure the data is there also. Now, what do you say to doctors that say, listen, I've been using a particular product for a long time in my practice? And everybody's definition of a long time could be different. It could be five years for one dentist, 10 years, whatever. And they're happy with it. It seems to be working. They have a nice track record. They're following their patients and they're getting good, predictable success. And then according to the manufacturer, they claim a new innovation has been installed into this product. Now this product has something that's better. Maybe it has less shrinkage. Is it the responsibility of that dentist? to keep moving to newer products, even though they're happy and they have a good track record with the products they're using? It's a very interesting question because I believe in the motto, if it ain't broke, don't fix it. And if you're having great success, look, I'm doing this 50 years. If you're having great success, there's no reason necessarily to go out and buy a new product and try a new product. That said, there are advantages in some of the newer materials that you didn't have when composites came on the scene. For example, we dealt early in composites, they were macro fill composites. And now we're into micro fills. And then from there, we've gone on to now nano fills. You know, and we've, and everybody comes in asking for a composite that they want to, you know, one of those porcelain fillings, doc, you know, and we actually have, for example, Invoco has a product. They have a nano ormosere, O-R-M-O-C-E-R, which means it's organically modified ceramic resin. It's as close as us placing a resin that is a ceramic in the patient's tooth. Yeah, and that's a direct restorative you're talking about. Absolutely direct restorative. So what's the main benefit of the ceramic added to that material? Well, the benefit is strength. The benefit is high luster, high polishability. The nanospherical, the nanoparticles that are in there are so tight that you don't get the chipping or the flaking out and the ditching that you'll get in some of the older macro fills, for example. You used to see little black divots in them. So a good way for a dentist to try these products is to sample them. And I assume many of the manufacturers make samples available, right? Is that how you try new stuff? Yeah. I mean, I'm probably in a little different situation. They love to send me things. It's a holiday every day in my office because I get to play. Everybody will say, what composite do you have in your office? And I say, yes. you know, because there's six to eight in my office all the time. But, you know, we all have favorites and, you know, you have to know what each composite can do for the need you have. You know, the most popular composite shade, for example, is A2. But I have, again, maybe six different A2s, six different manufacturer A2s, because each A2 is a little different in color. So what's the right amount of colors to have and shades to have? Whatever the patient needs to be satisfied. Yeah, talking about shades, since you're an expert in all this, what do you think of these claims that are being made where that particular composite is a one-shade system? A, I think there's a place for them. And I think where you see omni shades come into play more often than not, or where I, let's go the other way, where I think they have a place is more so in the posterior. And the reason for that is nobody ever really, I mean, I'm still a guy that layers in the posterior. That said, I think a one shade in the, in the posterior region. is makes everybody look good and the patient's really happy when they'd open their mouth and they don't see that darkened filling material in their mouth in the anterior they have a place too in a small restoration they blend in very nicely but i would never do like a full direct resin veneer using a single shade there are too many nuances to the shading uh depending on cervical third middle third and sizal third where i probably would use a composite that i could blend i mean you know the the admira and the grandioso materials were great for composites to do both anterior and posterior. But the days of having a box with 50 shades in it, those are kind of gone, right? Yeah. First of all, there are really five shades in that master kit, if you will. A1, A2, A3, 3.5. and probably a bleach white uh and now you could add a sixth one if you will we'd add a a a one shade an omni shade if you will i mean omni chroma really broke the ice tokyama on this and now everybody including voco and kulsar and and uh many of the other manufacturers gc they have they have a unit unit dose shade And simple, one shade. So let's talk about impression taking. There's been a huge shift to the intraoral scanner, which really was a disruptive technology to traditional impression taking. And I think 50 % of the dentists that are out there now have moved on from analog impressions to digital. Talk about the importance of tissue retraction with the intraoral scanner. Absolutely. Whether it's intraoral or analog, you must be able to clearly read the margins. where the finish lines are going to be. Otherwise, if you don't, then you're going to have a technician who needs to fudge it or you're going to have open margins and you're going to have sensitivity and failure and break down very quickly. So you've got two choices in my mind of the way you're going to do this. Three choices. You can use retraction cord, a pain in the butt. Hated it. Hated it in dental school. 50 years later, I still hate it. Number two, you can go with a soft tissue diode laser. There are so many inexpensive, great ones on the market right now that you can work with that are pencil grip and they're... under probably $3,500. And the third one is one that's very simple to use. It's been tried before by other manufacturers, but I think Voco nailed it. Voco nailed it with their retraction paste. It's aluminum chloride. You simply syringe it into the sulcus, wait a minute or two. It dries the sulcus. because it's an astringent, it dries and it's a hemostatic agent, so no blood, and it expands the sulcular area. So now when you insert your digital impression taker, your scanner, if you will, and or you're going to flow in flowable wash material, you're going to get a very accurate impression of that particular marginal area. Now, can you use cord with retraction paste? Yes, you can. In fact, you can use it in both instances. I wouldn't necessarily use it with a soft tissue dialed laser because that really, it's superfluous. But I have instances I have used the retraction paste after I've placed a smaller cord into the sulcus just to give it a little oomph to get it started a little bit more. So just curious, Dr. Glazer, when using an intraoral scanner, is it more critical to be able to visualize the margins all around your prep? than when using traditional materials. According to many dentists I talked to, they say that if you cannot see perfectly and clearly the margins all the way around your prep, then your scan will not be able to see it either. The answer is you must be able to visualize the full margin, whether you're scanning or taking a analog impression, because there is no fudge factor in my mind. You've got to be able to visualize it. One of the easiest ways to check yourself is when you do your provisional for your prep. If you can't pick up and read the exacting margins and get a tight-fitting provisional, then stop right there. Stop right there because something is not going to work in the final outcome. Yeah. So let's talk about provisionals. A lot of dentists believe that provisionals are a key component. to delivering a prosthesis to the patient where the patient is really satisfied with the end result. And also, with those that scan, they use the provisional as a communication tool with the lab because they actually scan the provisional. Tell us about where we are with provisional materials and the need for provisionals in crowns, bridges, and larger cases. Single unit or larger cases, I think the need is absolute. Number one, the need is to maintain, first, the basic one is you need something that will maintain the integrity of the prep that you kept, that you have prepared. It also, you need a provisional that will give you in the interior a pretty good foreshadowing of what the outcome is going to be so that the patient can get a look -see of where they're going to end up. So this will require very often pre-prepping a model so that you can provide a provisional with as close to the outcome as possible for the patient. If it's a single unit in the posterior or a bridge in the posterior, you want to maintain the retracted tissue so the patient can have hygiene. You want to make sure they have that. Remember, most of our provisional, and by the way, you want them to be very strong. So you want a provisional that's going to last. Anywhere from a week to three weeks. The national average for how long a case comes back from a lab is two weeks, depending on your relationship with your laboratory technician. In my situation, if I cut it on Tuesday, the patient's wearing it no later than Wednesday the following week. But that's just my relationship with them. I think that you need to have strong materials. You need to have temps that are long lasting. In particular, if you're doing a bite raising case, you've got to have a very strong material. When you're changing the VDO in those cases, it could be in there for months, right? For evaluation. That's correct. So you want to pick one that is capable of lasting three to six months. And one of them, you know, like Tough Temp by Pulp Dent is rated at six months. It's great. Okay. So they actually have ratings on this stuff. Well, they've tested it that it'll last as long as that. It's also, you know, it's a different formulation. It's not a bisacryl like the most common ones are, but you get strong products like Structure 3. You know, I come back to that. What's unique about Structure 3, you don't have to spend time to polish this at a rag wheel. You know, you've trimmed it, you put it in the patient, the Justin has been made on the occlusion, and you just, you can wipe it with an alcohol wipe and, you know, you get a high luster on it. So you could have multiple products when it comes to provisional materials in your office, depending on how long you want that to be out there. It still depends on patient need, whatever it takes to accomplish the end goal, because the patient is the end user. So yes, I have multiple. provisional products in my practice. Yeah. And like you said, it also has to be aesthetic in addition to- 100%. Yeah. Because otherwise the patient's not going to be confident about the final delivery. So let's talk about rotary hand pieces. Back in the day when you and I were in dental school, we were using air-driven 100%. I don't even know if there was an electric hand piece when we graduated. Where are we with electric hand pieces? Do you use them? What's the advantages and so forth? I use them entirely in my practice. I've been doing so for a while. I particularly like the BN air system, which is interesting because when I selected BN air, I based it on faster, easier, better. Well, apparently I'm not the only one because in our dental schools today, 56 of the dental schools out there were of, I think there's 56 out of 62 or so are using electric hand pieces and the vast majority are BN air. So that says something for. for their choice but everybody is coming out in fact i work with my residents on monday mornings at the hospital teaching and they have all graduated dental school they all trained on electric hand pieces and we're taking them a step back now with air driven ones in the because the hospital can't afford to turn everything over to electric. I'm working on that. So you mean to tell me that dental students are actually using electric hand pieces from the get-go in the lab and then up to the main clinic? Absolutely. Wow. And now they've gotten a lot smaller. Oh, yes. Yeah, I mean, I haven't seen too many recent ones, but I know they're lighter, smaller. One of the reasons why electric hand pieces didn't take off. you know, 10 years ago or 15 years ago, as much as they are now, was because a lot of women with small hands had trouble handling them, and they were heavy. Well, yeah, the Nair addressed that. You're absolutely right. They came out with a Novo line, and the Novo line is 28% lighter and 23% smaller. It's about the size of an air-driven handpiece now. NSK has a really good line as well. They do as well. No argument with that. Yeah, they have a great, great electric handpiece. And I think Dentalese also has a good electric handpiece. When you choose one, I know you have your favorite, but what's the best way to choose one? Because you can't sample that. They can't send you a sample. Does somebody come in and let you use it for 30 days? Not 30 days, but yes, a lot of the companies will now. let you try the product. They have a way of rigging them up so that you can use it for a while in your office. What's the maintenance on an electric handpiece? Same as air-driven, with the exception of some of the lines in Bien-Air have lifetime lubricated ball bearings, but we still lubricate and steam autoclave for sure. All right, let's talk about curing lights. One of my favorites. Yeah. Tell us about curing lights. You're in an office. You purchased an office from someone else. The curing lights are not tested. They're old. There's no validity to the fact that they're even fully curing the material. And the doctor says, I just want to start with an up-to-date modern curing light. What do they do? Well, number one. They probably ought to throw out every curing light they've got in that office because I ask my audience wherever I am around the world, literally, and I say, do you know how powerful your curing light is? And if I'm lucky, I don't get 350 to 450 nanometers as an answer. And I say, no, what's the output of the light? And I get blank stares. And I say, what? And they look at me. I said, that's the answer. What? Do you know how many watts it's putting out? So the average, I would say, around North America, let's just take North America, probably 1,000 to 1,200 milliwatts per centimeter squared. And it's milliwatts per centimeter squared. So you've got to have a light that's powerful that's going to satisfy the era now. We can go back to composites for a minute. We're in an era of bulk fill. where you're getting composites that where you and i started out with a millimeter millimeter and a half and layered it and stepped it now we're having bulk fills anywhere from three millimeters to the five six even rating um that's dangerous because if you take a class two and you are seven millimeters eight millimeters to the axial gingival floor all right how do you know that you're photo curing that deep when your light can only get into the cavity prep as far as the highest cusp, right? So it's not power output. It certainly is power output to some extent, but there's another measurement that people overlook, and that's the direct collimation of the light beam from the end of the light to the depth of the cure. And I use one in particular that's rated at seven millimeters. direct collimation, and that's the DentLights Fusion 5. It's the most powerful curing line on the market at 3,500 milliwatts per centimeter squared with a direct collimation of 7 millimeters. You know I'm photo curing it. Yeah, and that's the thing, because if you have post-operative sensitivity, there's a high chance that you may not be getting full polymerization at the base of your prep, right? Absolutely correct. Now, you know, that's an extreme example in Accent, but theoretically, A lot of these teeth are four, five, six millimeter when you're doing a class two. But let's say there's another problem, if you will. There's a new light that's being introduced by Garrison. It's called the loop LED light. Closed loop meaning it will only cure when it's directly over the restoration. If you start to move offside, it's going to... going to let you know you're moving offside. If you're moving off the surface too much, it'll shut down. The other issue is you may raise the light. And when you raise the light, if you have that 1,200 milliwatt per centimeter squared, what's happening? Your power output is limited, not with the loop. The loop continues to increase the power to accommodate that. Why is that important? There are a lot of practitioners that delegate the photo curing. to the chair-side assistant. And he or she may not be focused or understand why it's critical to keep the light right on the center of the focal point of where you want that cure to be. So this allows for a little bit of slippage and error, whereas a conventional curing light wouldn't. And the one you originally mentioned, DentLight? That's DentLight, the manufacturer, and that's the Fusion 5. Yeah, but that doesn't have that fail safe that you just described that Garrison's- It doesn't have the fail safe, but the power overrides that because pretty much at almost any angle, I mean, yeah, if you're off the tooth, I don't care if it's 86 millimeters length, it doesn't matter. But that doesn't have it. This is just one in which it adds another safety valve, if you will, but it doesn't have that same seven millimeter focal. So let's get into prevention, Dr. Glazer. Tell us about- prevention, what should be top of mind with our clinicians when it comes to preventing dental caries? Well, education of the patient, first and foremost, whether it's by the dentist, whether it's by the hygienist, whether it's by the chair side assistance, whether it's by the front office person saying, don't forget to brush your teeth to keep that smile the way it looks today. And I'm talking back, go back to basics. Toothbrushing, I believe in automated toothbrushing. What do I mean by that? Not the one you hold in the hand, but either it's a sonic brush or it's a rotating brush that's operating for you. And my message to my patients is do not scrub your teeth with this. Let the brush do the work for you. Your obligation is to guide the brush. as it does its tricks. So you're saying manual toothbrushing is not... It works, but I like automated. Yeah, and I think there's been many studies that substantiate that, Dr. Glazer, that manual toothbrushes don't quite do the job of a power toothbrush, whether it's the sonic or reciprocating brush. Either one does quite well. And for sure, they're superior to manual toothbrushing for many reasons. Do you recommend the patient buy these at the local drugstores, CVS, Walmart, Rite Aid? Go to a big box store. You know, they all have them on sale. You can spend anywhere from $70 to $290 on electric toothbrush, which is ridiculous. It won't drive you to the movies. But it'll keep your teeth clean. And I've proven it on my own situation. I travel with an electric toothbrush. And sometimes I'll pick up my Sonicare and sometimes I'll pick up my IORLB. They work great. But there's a third element to this. And that's Waterpik. I'm a big devotee of Waterpik because I think it gets into areas where toothbrushing, even though they make some claims, they do. If you look at the ADA statistics when they tested. Waterpik came out ahead in fighting gingivitis and removing bacteria, removing, you know, all the things that we tick off the boxes for, for maintaining hygiene. Waterpik came out on top. So let me ask you about Waterpik, because when I was a kid, a long time ago, my parents bought a Waterpik because their dentist recommended it. And then it seemed to fall out of favor. And the prevailing opinion was, still is, as far as I know, that you need physical deprivement to remove the biofilm, i.e. floss. So has anything changed in the Waterpik technology where that's not the case anymore? You know, the answer is I heard the same things growing up and growing up as a dentist, if you will, in the profession. I think it's changed to the point where we've gotten better about our instruction on how to use this, that the mechanics of the device have gotten better. with the amount of pressure that's generated by it the angulation on the tip i i still very often refer to it as a miracle device because it will clean your teeth and clean the bathroom walls at the same time if you don't use it properly so i advocate for those that are maybe is not as manually dexterous as you or i might be i like the portable one you can use it in the shower yeah but honestly where it's going You know, and I know you love to talk about products and we all, you know, read your column and you lecture all over the world about things that we need, materials and prevention products for the patient. But when it comes down to it, flossing, really good meticulous flossing is, I don't know, in my opinion, unbeatable. Now, I know, like you said, the dexterity is an issue with a lot of patients. And if they can't floss, a water pick is certainly better than nothing. in many ways. But dentists disagree with me. And for me, when I stop flossing and try a water pick, I don't get the tightness of my gingiva and I don't feel like I'm removing the biofilm. Okay. So I agree with you because in home care, I'll use the water pick at home. I don't carry it with me. I carry floss in my pocket because yeah, I can get... as we mature, we tend to have a little bit more spaces in our teeth. I don't know if you've noticed that as well. Not in my lower anteriors. Everywhere else. Yeah, but everywhere else. So I carry floss with me. And I agree with you. It does a fabulous job. But I have tested it on occasion where I thought I've done a pretty good job of flossing my teeth. And sure enough, I go back with the water pick and all of a sudden I missed. So it's still hard. I mean, I have big hands. I have a big mouth in a lot of respects. And I can't necessarily get into some of the spaces. I can get an instrument to get back there. So I think there's nothing wrong for using all of these. There's no one panacea. Otherwise, we'd only have one product on the shelf. Right. Okay, so let's switch over to something else. Patient management tools. Where are we with patient management tools in dentistry? Well, I think patient management tools, got to give a shout out to AI as it comes with diagnosis and patient education. I think that's important. I think there's a need for AI because when you show a patient what, you know, I remember my dad's a dentist, God rest his soul, and he would hold up that little x-ray number two film to the view box and he'd tell the patient, you see that decay right there? And they'd shake their heads. And you and I both know. They didn't see it. Right. But when I have a color picture on a 20-inch monitor in front of the patient showing them where the machine, which is, by the way, third-party verification, God has spoken, right? There's the K there. And now they see it. Wow, how can we get rid of that? So for patient education, I think that's key. I think there are practice management software tools out there that combine the use of AI and patient communication, which carry it well into patient use. I think there's an overuse. I'm old fashioned. There's an overuse of texting to patients. And I like old fashioned. I'm still old-fashioned. I like patients to talk to a person. So I like my staff to make calls and talk to patients. How are you doing? We're looking forward to seeing you. You have your appointment next week. Or you didn't show up. Why? Don't text you missed your appointment. And it's rude. Yeah. No, it's not a personal thing, the text. It's very automated. And we get it all the time with our physicians. And if you have an appointment somewhere, they send you a text. If you want to bring your car in. The dealer sends me a text saying, we'll see you tomorrow if you're hit here to cancel. So there's a place for it. But I do agree, a phone call certainly is more personable. But some people literally do not like being called anymore. We're in an age now where they feel like it's a complete invasion to have their phone ring. That's where we're going. Most patient management softwares have an opt-in, opt-out feature. Some default to opt in, but if you ask, you can turn that off. And we respect patients for that. They have to tell us once and we make sure they're not going to be bothered again. Yeah. I will tell you a funny story real quick. I spoke to a dentist on a podcast episode and the dentist is an excellent dentist. One of the best dentists around for sure. Brilliant guy. He's trying to reduce his staff, mainly because there's a staffing crisis going on. His front desk is a monitor. with a remote front desk person who's on that camera eight hours a day. And when the patient goes to the front desk, the patient interacts with the person that's being shown on the monitor. And then there's the credit card machine there. And the front desk person tells the patient, Mrs. Smith, your copay today is $50. Just run it through. And that's how he runs his front desk. What do you think of that? Total silence from you. It lost you completely. I'm stunned that somebody would even go that far to do it. No, but I was like, you're kidding me. This person is on a monitor. And he goes, yeah, and it works great. And the monitor is beautiful. It's 40, I don't know, 50 inches. And there's a speaker there. And it's as clear as if the person was sitting there behind the desk. You know, listen, at the hospital, we have on a tripod rolling stand, if you will. We have an interpretation module and we get different languages. And sometimes we need somebody to interpret for the patient. And it's exactly that. There's somebody on a screen in the operatory and it's the patient, the assistant, me, and this guy on the screen or gal on the screen. And they communicate in the language of the patient. And so, yeah, I get it for that. But no, what kind of office is that? You know? I mean, maybe they're right. Monkeys will replace us someday. What kind of office is that? I hope he's not listening. He's a good dentist too. Okay, so let me wrap this up. I said I was going to wrap it up, but let me wrap it up. What would you tell a recent graduate to focus on as they start their professional career? I could sum it up very simply. I want them to focus on doing quality dentistry that is produced by using quality products. Don't cheap out on what you do. You pay for it in the long run. And remember, patients are paying for the materials, not you. Yeah, no, that's great. And that goes along with your column. I need it, you have it. Or no, I have it, you need it. Excuse me. Exactly. Yeah. No, I think that's great. I think you've developed. a tremendous following. You evaluate these products and listen, you pay for quality and we're healthcare providers. We're not putting aftermarket parts in a 1975 Chevy. So buy quality and it pays off in the long run. All right, Dr. Glazer, we did it. 30 minutes and change. We covered all those topics. I knew we could. Thank you so much for your time. Look forward to having you on a future program. You take care. My pleasure, Phil. Thanks for having me.