Hero or Hitman: The Case for Crowns Over Compromise

What I have seen with some doctors that are less experienced sometimes is that they don't realize that the scan, the blood impacts the light refraction. So if you have blood on a margin when you're scanning, it can impact your accuracy. Welcome to the Phil Klein Dental Podcast. Today we'll be talking to a dentist who oversees and provides clinical mentorship to approximately 40 DSO dental practices. Her goal is to evaluate the offices and provide recommendations on clinical productivity and practice efficiency, keeping in mind that, yes, dentistry is a business, but the patient's best interests always come first. Part of the strategy, as our guest points out, is to get the patient to become part of the conversation. This, of course, helps with case acceptance and patient satisfaction. We'll also be talking about the importance of cusp protection in our restorations and why it's so important to consider a crown versus composite restorative in many cases. We'll also discuss how the standardization of dental materials within a given practice helps improve efficiency and productivity. Dr. Derse is a mentor at the Kois Center in Seattle, Washington, and has lectured internationally on cosmetics, restorative dentistry, aligner therapy, and case presentation and acceptance. Dr. Derse , it's a pleasure to have you on the show. Thank you for having me. It's nice to be back. Yeah. So you did a wonderful webinar, by the way, for VivaLearning.com. So for our listeners, if you haven't checked that out, it's called Biomechanics and the 7-Minute Crown Prep. And Dr. Derse really goes through the whole process quite well. I especially like the part about how you use those burrs really efficiently to prep that tooth and get the margins that you're looking for. And we're going to be talking about the margins today. So let's start this podcast with the first question being, as Chief Clinical Director, which you are, of a medium to large DSO, it's called Aspire, you have the opportunity to oversee a lot of things, both on the business and clinical side. So tell us in your experience, what kind of common mistakes are you seeing with the 40 offices that you're overseeing related to the treatment planning of crowns in those practices? This is a great question. So one of the things that I think comes up a lot is almost like a fear to diagnose a crown. And I've even run reports and it sounds really DSO-ish, but I've looked at what is the ratio of what people are doing of a four surface composite. to a crown prep. Because when you start, you know, eliminating that much of interproximal tooth structure, you're weakening the tooth. And a lot of younger docs I see trying to do more than is structurally possible with. composite. And I think it's a fear to diagnose. They get wrapped up in saving that enamel, which we want to save the enamel. All of us dentists want that. But sometimes those really hyper-conservative approaches lead to an increase in failed outcomes in a couple of years. And, you know, my training is with John Coyce and he talks about, do you want to be the hero or the hitman? And, you know, I... I try to encourage younger doctors, don't be scared because you want to put in something that's going to last a long time. My composites are 20 years old. They're occlusal conservative composites on my molars. But if those were for surface, I'd be in a crown in a heartbeat. So I feel like that tends to happen. And then I also notice sometimes they're scared to just do the tooth that's next to it too. I've seen a doctor, you know, who's going to do a crown on 19. And 18's got the MO amalgam. And they're like, well, it looks good enough. But if you don't have the conversation with the patient and open up the door to let them collaborate with you on their care, you might be missing out on treatment that they'll get done somewhere else. Yeah, let me ask you this question. So in that webinar, I found something interesting that you said. and that is you were talking about conservative dentistry. And conservative dentistry has been gaining more traction in the past 10 years than ever before. Minimal reduction of tooth structure because we have these amazing adhesive products out there. Some dentists are doing just what you're saying that you're not super fond of, which is using a lot of composite on teeth that otherwise, before these adhesive materials were available, they were doing full crowns. But you're talking now about... being a little bit less conservative, which I'm not disagreeing with, because of the materials we have. So can you elaborate on that? Because if you were in a debate, the other person would say to you, well, you want more production. You work on a DSL, you want more production. But it seems to me by listening to you and knowing you as a clinician and a really good educator, you would never do anything on a patient that you didn't think was best for the patient. But you still had an opinion about conservative dentistry. So that was interesting. Can you elaborate on that a bit? Yeah. Well, one, when you talk about, and I might go all over the place, so you'd have to ring me in. The part about that is bringing the patient into the conversation. So instead of saying, I'm the doctor, I'm making your decisions for you. I'm deciding your medical decisions. I want our doctors to allow the patients to participate and be active in that conversation. I have an example. I have a friend that once I did a composite on number 19 and I left the amalgam there on 18. And her name is Sarah. I'm not violating HIPAA. And I told her I was going to tell everybody this story because I think it's funny. She went home and she called me and she yelled at me for putting an amalgam in her mouth. She didn't realize that she had had one there. But of course, she goes home to inspect my dentistry. And then, you know, I said, no, that's the other tooth. And she's like, well, now I got to come back in because I don't want any of that in here. So I think it's more about allowing the patient to have that conversation so that if they want to be proactive about their care, like when I had my spine fusion, I saw one surgeon that offered me one level and had another surgeon that offered me two levels because he said, you're going to be back here. This one's herniated and it's also causing you problems. You're going to be back here in three years if I do just the one. In surgery, it's opposite. Like for them, it's better to separate it out longer. But I went with the guy who's like, I'm going to do more because I'm going to save you from having to take time off from work again. So I think it's more about the conversation we have with the patients. I probably didn't word that properly. Okay. So the conversation is important. Let's talk about remaining tooth structure. What is the typical guideline that we go by? I know Gordon Christensen from the past has talked about this. He still does about how much tooth structure is remaining. before we really need to consider a full crown. His is like half the distance from cusp to us. So talk about that. Talk about how much tooth structure is left. Because if we could not put a crown on a tooth, then there's less of a chance of that crown failing because it ain't there. There is no crown there. But you don't want to have the tooth fracture. So occlusion comes into this as well, right? Occlusion is very important. So between the occlusion, the materials, and minimizing... tooth reduction, what is your guideline for like when to do a crown and when not to? You know, in Coisa's manual, it shows up as one third of the distance from cusp tip to cusp tip. So it's almost a little bit more aggressive, if you would say that, than what Gordon has said. But... he also talks about is the inverse relationship between the cohesive and adhesively retained dentistry and the paradigm shift of that being that We have such good materials now that are adhesively retained that when you cover the occlusal surface and hold those cusp tips together, those cusp tips, when they don't move, they don't flex, the tooth doesn't fracture. So now we're looking at risk of being, we're reducing the risk of the tooth splitting in half and then losing it so that we end up with an implant. Do you do inlays at all? I don't do a ton of inlays, no. For that reason. Yep. I'll usually go straight to either, you know, direct composite or I'll do, you know, like do that crown lay is like the trending word where I just feel like I'm getting the occlusal surface covered and then maybe like a millimeter around the occlusal surface to like lock it in place so that it seats. When I have done some inlays, it's been when, cause we mill in our practice. So it's been when I've got like a lot of stuff in a row and I'm already milling a crown, so I might as well mill a composite inlay. And I just charge it out as a composite. I don't charge it out as an inlay. So, you know, just for ease of time when I'm doing that. But it seems like your approach is to protect the cusps. Yes. Like I want to hold them together. My mom is one who had a fracture and, you know, a doctor that, you know, went to go ahead and put a... a crown on it. And I look back and I'm like, oh, we missed that that tooth was actually fractured and it was fractured. She lost the tooth because it was fractured. So, you know, I want to avoid that at all costs. I want you to keep your teeth. Yeah. So let's say we decide to do a crown. And in this country, many, many crowns are done. And the pathway to get to that crown varies. Some of us use traditional impression taking. Others have moved to using an intraoral scanner. And then for fabrication, some rely solely on an outside lab. They don't even do the design work, even if they're using a scanner. Some are more into the design. And then some employ more of a hybrid approach. Maybe that's like your practices where they have, you know, chair side milling for some cases, and then they also send out to the lab. So there's a lot of ways to get there. But what we're all in agreement on is the fact that we want precise adaptation of that crown to the... structure. That margin, we want to get as tight as possible so that we could use our cements or adhesive cements or cohesive cements and seal that margin up where we can get years and years out of it. So given all these different pathways, what could you make to our audience as far as recommendations to help us optimize those crown margins? That's a great question too. One, when you're using these adhesively retained restorations, you get to keep your margins high. which is great. Like you don't have to bury them down in the tissue. You get to keep them up in enamel. So that's a better long-term outcome. And then too, if you do have, you know, for me, when I'm doing one of those crown lay type things and you still, you know, removing some material interproximal and you might be taking out some old amalgam or, you know, a defective composite, those usually do go down where the tissue is. And you want to make sure that you're not getting any bleeding. What I have seen with some doctors that are less experienced sometimes is that they don't realize that the scan, the blood impacts the light refraction. So if you have blood on a margin when you're scanning, it can impact your accuracy. So, you know, do whatever you got to do, whether it's retraction paste or you need to use a core, you put cord and then retraction paste or whatever that looks like. You want to make sure you have a really clean, dry margin when you're scanning. Yeah, you actually showed a case, and I think it was you who was being treated, where you actually encouraged the dentist, whoever it was, to cause bleeding in the margins so that you can show how this retraction paste with blood. So she initiated bleeding. And on her own, you know, by your instructions, which is the first time I've ever heard that, a patient asked to stir up the tissue a little bit. during a you know the process of taking an impression but you she used the retraction paste i guess it's your favorite stuff yeah i love it what is that product that voco has it voco's got this retraction paste that i just call magic um you know back in 20 years ago i was using the old clay stuff and i was like nah i'm never gonna use this again and then um i got some samples of it and it changed my perspective i love it because it not only like causes all of the the tissue to stop bleeding it's not um acidic so when you use like a hemostat because that ph is what is it i think it's like one and a half very acidic yeah yeah you can increase sensitivity if you don't super hyper rinse everything and getting it all cleaned up versus if you have something that's ph neutral that you're putting around that margin you're not going to have as much sensitivity. So I think it's a really awesome product. I carry samples of it in my pocket when I go to my practices and I give it to doctors. Yeah, that's a little odd, but that's what you're into, Dr. Derse . So for someone that doesn't practice, carrying a retraction cord in their pocket is, yeah, that's interesting. You're a fan for sure. So do you use cord anymore with that retraction paste? On occasion. So if I'm doing a smile design, yes. The reason I do is because the margins are so small when you're doing veneers that, you know, they're much thinner. They might be 0.3 millimeters max. So what I'll do is put one long cord in there and then I'll put the retraction paste over the top to manage the blood and then rinse it off and go. And it looks gorgeous. Other recommendations on crown margins. Obviously, tissue retraction is key. What about prep design? Keeping it high, keeping your margins high, like keeping your margins in enamel if you can, if it allows it. Because when you're using these adhesively retained materials, you don't have to take it down so far. And that's what we were talking about, that paradigm shift of being conservative or not. You can really... You don't need much axial wall in order to keep the restoration on. And then your margin is easily seen by your scanner or impression material, whatever you're using. Right. So you're not afraid to reduce the tooth. You are very confident as far as the materials and the cements that we're using. And you make sure there's plenty of room inter-occlusally to make sure that you have all the right dimensions available to restore that tooth. It was a very good webinar, like I said. And you talked about a seven-minute crown prep, and you actually had a timer on there. So tell us how, real quick, clinically, how you can accomplish that. I think it's by being confident and having a system. So using your same three bursts. What I see some people do is change out their burr like eight times, and they go back, and they go first. Just get your reclusal reduction done. And if you use that depth cut bur and then the one I call the donut, I don't know the actual numbers of it. Some people are much smarter than me in that realm. The donut without the hole. Yeah, the donut without the hole. So there's three burrs. So what we're talking about right now is time is money. Tell us about the efficiency of using, like you mentioned, three burrs and any materials also. Like, do you have a formulary that you use to save? to make the system, everything flow. better. Yeah. Well, so coming back to that, it's, it's our time, but it's also our patient's time. And, you know, our, if I have so many people who that come and interview and they're like, I really want to learn cosmetic dentistry. And I don't know if they're telling me that because that's what they think. And these are dentists that are, yeah. So just so our audience knows, you're kind of like, as I mentioned, the clinical supervisor of this 40 office operation. So you, screen dentists or interview dentists before they get hired okay go ahead yep absolutely i hear all of our dentists and if you want to do that full mouth rehab you have to think about okay if your crown prep takes 10 minutes and you're doing 10 units that's over an hour of just prep time so if you're doing quadrant dentistry. Like I try to teach people to get really efficient and precise because when you start doing some of these bigger cases for people, the patient gets fatigued, anesthesia runs out when you're boosting it, it's not the same. So that's a really big part of why I encourage being really efficient is because of the patient experience. And when you're at the opposite side of that, I've had a doctor who took four hours and then the patient called and complained and was like, what was, I've had plenty of crowns, none of them took four hours. So that is important. And so that's why I went with the seven minute, just because it was a play on seven minute abs. Um, but this doctor, you know, I taught the doctor who did the video in the webinar and she crushed it and she did it in what, four and a half minutes and it looked great. And I'd let her prep my own teeth. Um, so beautiful prep. It was a really beautiful prep. Yeah. She crushed it. That was Matt Kelly. Okay. And that was the lower molar. It was a lower molar. Yep. Yeah. And so, you know, these efficiency in systems, they're super important. you know in our strategy because and we and we do have a formulary but we have a really open formulary we have a lot of products in there um you know we have some products from voca we have some from we have them from all these different companies but this the importance of it is that we want to increase predictability but we also kind of want to look for sometimes like that toyota of products we know it's going to last a really long time and we want to avoid remakes because remakes are expensive And they also make your patient mad. Yeah, no, remakes or kiss of death. So you have 40 offices that you're overseeing. Do each of these offices run their own show? Do they have their own formulary? And within that office, is everybody expected to use the same materials? Just curious. They are not expected to use the same materials across different offices, but we've tried to get our doctors to use. the same materials within an office so create an always so that it makes it easier for our teammates like for the assistants to know like okay this doctor uses rebuilda then and this doctor uses rebuilda i get that out for every crown prep versus saying something like this doctor uses composite and this doctor uses rebuilda and this doctor uses i don't know some glass ionomer that you shouldn't be using anyway for a buildup so like we try to get that at least consolidated within each team. By doing that, do you find that, well, let me ask you this question. Forget about the DSO for a second. And somebody has a practice and there's three dentists there and they have staff and everything's going fine. Do you recommend that that office, that private office, operate the same way as one of your offices in your satellite operation where you have 40 as far as materials? They should have a formulary. So a new dentist coming in to that office who's an associate, who joined the practice, loves to use other materials, he or she should start to comply and adapt to the current materials that are in that practice is what the goal would be. I think you could collaborate on it. So when you have, say you have two doctors that have been working together and they're using the same formulary within their practice, and then a third one comes in, then you have a conversation. And you say, like, what can we give on? What can we not give on? What are we willing to try? And try to collaborate so you have one burr block that's the same for all the doctors. You should be on Capitol Hill trying to bring the aisles together with the conversation. Everything is we should have a conversation. Yeah, I mean, I wish politics was as easy as that. I didn't mean to interrupt you. No, it's totally great. That would be hilarious. I wouldn't get anything done in politics. I'd be all over the map. Well, you'd at least be having civil discourse versus what's going on in this world. But this is not the appropriate podcast for that, even though I would love to have a political podcast. It could be fun. Yeah, I might do that next time. So you say that a private office outside of a DSO would run more efficiently if they had a formulary. so that everybody in the office was on the same page, including the staff, who has a lot to do with these restorations, right? And the setups and the inventory and all that stuff. That all saves confusion and purchasing. It reduces purchasing time and everything else. Yeah, it reduces headaches. It reduces confusion when another assistant comes in and is not familiar with... An example would be with future BondU. How you use that is pretty unique. That's a bonding agent, right? Yep, it's a bonding agent. Yeah, single-use bonding agent. Would you go into an office that had a, let's say a new office joins your DSO, and they're all over the place. They have three different bonding agents. One doctor likes this one. I've had that. Okay, you've had that. Right, so would you go in there and say, hey, let's use VOCO as an example. You're talking to the office now. Do you ever think guys and gals of kind of, you know, making this universal for everybody so we get more efficient? Is that the conversation you have? Yes, it is the conversation we have. So you're worth your weight in gold, this company. How effective is that? You know, dentists, sometimes they struggle with change. And we all do because we get so used to like... going on autopilot. But if you do it the way Adam, you know, Adam Grant talks about 1% tiny gains and they're, and they're, and they work better than trying to change a whole lot of things at once. If you look at it from, or no, it's not, it's James Clear. Sorry, wrong author. But James Clear talks about the 1% tiny gains. I like, I'll start with one thing. Like, let's get you all on the same block. Pick the birds that you can't live without the ones that you, you know, don't really use and let's get you on one now let's move to your composite let's try to pick a composite that your assistants and and it's really more for the team than it is for the doctors and i you know i'm sorry if i prioritize the team over the doctor in that point but like I have worked, I realized when I worked with other materials, I can work with almost anything. When we'd go to the Dominican Republic and do dentistry, I was like, I know how to use this. Like, I can figure this out. This is cool. And sometimes I got to see stuff that I didn't know I'd like better. Yeah, I was thinking of saying the dentist is probably pretty resilient and open-minded to the materials as long as the handling characteristics are good, right? Because if you start getting into a whole new kind of... for the material and it's tacky or it just doesn't flow well, that's a big downer. So the handling characteristics obviously are a priority for the clinician, but overall the dentist is not really too sensitive about switching from one composite to another. You can get most of them about 80% there. Like when you're going through this process with a practice of getting them aligned. There might be some nuance-y things where like, I really need this for my incisal edges. Great. But ultimately, like for you, those of you who are out there who are in a private practice on your own, if you can do this and you can just start with your composite, then go to your bond, then go to your cements, then go to your burr block. It's going to maximize efficiency and your team will love you for it. Just curious, how digitally established is Aspire with your 40 offices? Are a lot of the doctors or a lot of these offices fully digital or are they intraoral scanner and off to the lab? How about 50-50? So some are scanning and sending to the lab and then some are scanning and milling. Okay. So when you purchase these offices, some of them have chairside mills in place operating. Yeah. I mean, my practice, we had two prime scans and a trios because we had 12 treatment rooms. It was a larger practice. Wow. Busy. And then, so we were doing both, like on a bigger case and sending that out. If it's a, you know, two units or something like that, I'm going to scan and mill. But then sometimes, you know, when somebody merges in, they've got a system and we don't typically disrupt that system. We let that system just continue. If it's working, leave it alone. What about 3D printing? We have a couple practices that 3D print and then most of them do not. We could go down that rabbit hole. But what I have found with 3D printing, if you're doing just restorative dentistry with it, it takes a really long time to recover that cost. especially if you're in a private practice like if you're in a private practice it's if you think about the overhead of the 3d printer like how many models are you going to get back from your lab that's designed and printed and you can get that within days i had a 3d printer and i loved the workflow when i would send it to my old lab i would send it off and then he'd send me the design and then i'd print it but then i realized i was like why am I doing this? Because then he would still send me the printed models, and I ended up using those, and it became a vaporwave. Yeah, I've heard both sides of the story. Now, what will be a game changer is when you start printing ceramic crowns or zirconia crowns. Now, they are doing this in Europe, but when it becomes affordable, mainstream, and has shown the strength of milled, when it gets close to mill strength, 3D printers are going to become wildly successful. Yes, when you can actually mill the restoration, that'll be a big difference. Sorry, print. Yeah, absolutely, without a doubt. And they're working on that. There's a couple of companies that are launching products on the 3D side that actually have a ceramic component to it. I don't know if it's all ceramic or part ceramic and part composite. I'm not really sure. But we'll all be hearing about that. So last question before we wrap up this podcast. It's been very interesting, Dr. Derse . You talked about zirconia a little bit in your webinar, and you don't love it. So it is a very trendy material. And it's kind of like the rage right now. You can't go to a lecture somewhere where someone's not talking about zirconia. If the lecturer is not talking about it, someone is asking somebody in the audience about zirconia, and it's becoming more and more popular. So what don't you love about it? What I don't love about it is that it increases risk tattoo structure. Because when you go cohesively retained, you got to prep more versus the adhesively retained, you may have some risk to the restoration, but it's decreased risk to the tooth. And so my preference is adhesively retained. That's number one. Number two, if you can see through your restoration on an x-ray, to me, that is preferable because say you have a high caries risk patient or, you know, who's... a lot with some of these things you can see if something's starting to go on underneath it versus a zirconia you can't see what's happening underneath there what's under what what was done under there and i've you know there's still doctors that are newer sometimes that don't get all the decay out so let's start there like let's look at like okay and if you and even experienced doctors sometimes miss a little bit of something and then it starts to you know, break down underneath a buildup or whatever that looks like. I've seen all of that happen under restorations that I can see through. So how do I know that that's not happening under the zirconia ones? Any last word? I think this was a great discussion. No, I think this was great. I can take us all over the map when we talk about some of these things. So thank you for keeping us on task because I'll go everywhere. Oh, yeah. No, it was excellent. Excellent. And we need to do another one on systems because I know if you're running 40 offices, Dr. Derse , you have to be very aware of good systems, which brings efficiency and peace of mind to these doctors that are working in a very tough profession. So I think we should do an episode on how to look introspectively at your own office's systems and say, you know, is there something we could do to move the needle and get more efficient? And I think you know a lot about that because of your job. So we're going to get you on another one for that topic. Thank you so much, Dr. Derse . Yeah, thank you so much. Thank you.