How to Make Difficult Dental Procedures Easier, More Predictable, and Successful

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to Dental Talk. I'm Dr. Phil Klein. Today we'll be discussing the tools and techniques that help make the most difficult procedures in dentistry easier, predictable, and more successful. Our guest is Dr. Ankur Gupta, who has a private practice in a suburb west of Cleveland. He lectures extensively for several dental society study clubs, annual sessions, post-doctorate residency programs, and several CE programs throughout the country. Before we get started, I would like to mention that Dr. Gupta's webinar titled, Mitigating Miserable Odontics, the tools and techniques that help make the most difficult procedures in dentistry easier, predictable, and more successful. That's available as an on-demand webinar on VivaLearning.com. Simply type in the search field, Gupta, G-U-P-T-A, and you'll see the webinar. It's an excellent webinar for every dental team member to watch. Dr. Gupta, it's a pleasure to have you on Dental Talk. Oh, it's a pleasure to be on again. Thanks for having me, Dr. Klein. Yeah, you're doing some really great stuff for Viva Learning, and we're really enjoying your feedback and insight. You've been practicing for, what, 20 years now? Yeah, just about 20. yeah so the experience that you have is perfect and you're up on all the new stuff so we're glad to have you talking about some of the things that dentists do that are typically difficult and you have some input that could really help them get through some of these difficult procedures so to begin what do you think is the biggest cause of stress for you personally after 20 years of practice while performing a procedure in the dental operatory back when I graduated I was under the impression that certain things would just get so easy after a while that they would never cause me any stress. And I found that even though I enjoyed several aspects of being a dentist, there were certain limitations that I had, either just from a hand skill perspective or hand-eye coordination or whatever. I mean, there's certain areas of the mouth that I found difficult to reach. There was... times in which the decay extended below the gingiva and i knew that i would nick up the gums i would create bleeding in an area where i couldn't have it there were just so many times clinically that i i thought back then oh this is just going to get easier and i was wrong it's been 20 years as a clinician and yeah general dentistry has gotten easier you know there's muscle memory into 20 years of being a clinical practitioner. However, some stuff is just hard. I mean, the disto buckle of tooth number 15 or tooth number two, that's still hard. The distolingual of number 31, it's just difficult. And the fact that decay often extends under the gum where I have to remove the decay with a rotary hand piece and muck up the gingiva that's probably already not that healthy. that still happens. That's still difficult and that probably never will be made easier just because I've been a dentist for so long. There's certain elements of just working in the mouth that are difficult. So when you asked what's the most stressful, I think controlling bleeding is probably one of the most difficult things and I want to deliver really high quality dentistry so it causes stress because I know that having blood in an area is not going to allow me to deliver high quality dentistry. Yeah, so visibility is a big issue, right? Physical access, actually getting your handpiece in there. So when you have a patient that doesn't open their mouth that wide and you're working on the tooth that you just talked about, the distal buccal area of tooth number 15, no matter what, that's going to be tough. I mean, as an endodontist, when I worked on patients, it was really the access was the... challenge. If we had a patient that just did not open their mouth, you're looking at a challenging case, no matter what tools you have. So, you know, and then of course, like you said, bleeding is going to be another impedance to visibility, and that's going to cause more stress. Let's talk about the margin, which is really important for impressions. How does one choose the best system or tool to use to get that clear margin? There's a lot of options. While a laser and while packing cord is extremely effective at allowing us to see beautiful margins that are dry, they have some drawbacks. And those drawbacks are that they're time consuming. It takes a little bit of time to set the laser up. And it's painful. The patient is going to have tissue that's either pushed away by the cord or it's going to be zapped by the laser. And that's going to result in a little bit of soreness for the patient. And what I've found is sometimes I just don't want to go through the trouble, especially if there's only a small amount of bleeding. I just want to be able to do something non-invasive and easy for me, easy for my assistant when there's just, you know, a tiny little corner of my prep that needs some gingival retraction or needs the bleeding to stop. I don't know why I didn't utilize this earlier in my career, but I feel like gingival retraction paste are very effective, especially when used with a copper cap. Gingival retraction paste is really effective and it's easy and not painful for the patient. And I love that. I love the fact that that tool is available to me. What is a copper cap? Okay, so imagine a cotton roll and that cotton roll is cut in half. And one side of it is hollowed out a little bit so that you take that hollowed outside and you put it over a prepped crown. The periphery is still pushing down on the gingiva, but the hollowed out portion makes room for that prepped crown. So that means that if you put pressure on that half cotton roll, it's going to put pressure with cotton down onto the gingiva. So A, it's putting pressure on the gingival. B, it's actually keeping the gingival retraction paste in place. And there's a lot of gingival retraction paste that are out there by a lot of different companies. The one that I like the most, the one that I use the most, is actually the one made by Premier Dental. It's called Traxedent. And the reason I use it is, A, it's the least expensive because it doesn't come in single-use compules. So it's affordable. And B, it's easier to wash off. And does the retraction paste come with the copper caps or is that purchased separately? Great question. I don't know the answer to it because I don't do the ordering for my office. Well, that's good. If you knew the answer to that question, I'd be wondering about your practice. Like you should be doing clinical dentistry and not wondering how to order Traxedin and whether it comes with this cap that you talked about. So that's good. So we talked about retraction paste and using it. And we talked about the importance. And by the way, this works very well with traditional or scans, right? It doesn't matter. Absolutely. Yeah. Yeah. I would say that. 75% of my crown and bridge impressions are with scan now. And so this is actually very effective even when I'm using a scanner. Yeah. So let me ask you this question. Even though we're all trying to do our best and be good or great dentists, we all are human and we all make mistakes and we try to learn from those mistakes and try not to repeat them too often. But there is a chance of litigation. So what do you think is the best way as a dentist to avoid litigation? So I have a pretty nice relationship with an attorney that works for a dental malpractice provider. And I have always been curious about that because I think that every moment that I'm practicing clinical dentistry, there is a little tiny voice inside of my head that says, okay, don't blow it. Don't blow it, Gupta. You're going to get sued. And I've been lucky. It's been almost 20 years that I've been a practicing dentist and I haven't gotten sued. And I don't think that's because I'm a superior dentist. I think I'm an average dentist. But I think the one place where maybe I'm above average is that A, I'm very nice to my patients, and I'm especially nice to them if things go wrong. And when I mentioned that phenomenon to this attorney, he said that's the key. That's the key to all of this. He says, be nice. Don't be dismissive. And he says the vast majority of the cases that he defends are on dentists that carry an ego. and that are very dismissive about the suffering and the inconveniences that their patients have gone through. And I think that's really interesting. A lot of times we put so much emphasis on our own clinical perfection and we beat ourselves up for maybe not living up to this imagined idea of clinical perfection. And I think sometimes we need to just be nice to ourselves. know that we are we're humans and we're not always going to be perfect but one way in which we can be perfect is how we treat that patient and being cognizant that that work that we did it created some inconvenience or some suffering on that patient and and to be mindful of that and to be sympathetic and to look at that patient like a human and That has worked really well. And I would say that most dentists who are either in the same position as me or not in the same position as me, they would probably have to agree. The time in which they've had the most contention with a patient is probably the time in which they themselves have been the biggest jerk. So let's get back to more of a clinical scenario. Class II composites, very popular. hopefully will go well on the first round when you treat the patient and not too many complications but then you get those tough ones where we talked about earlier where you have bleeding and you have poor access tell us about the marginal ridge matrix bands anything in particular that you like to do that could make a difficult procedure easier and also i want to add on one thing there was a kol that i just did a podcast with recently who actually builds the marginal ridge and the contact first and checks it before all the layering or the bulk of the material is placed where the occlusal anatomy is then placed. Because if you do all that work and do all the occlusal anatomy and make it beautiful, and then you realize when you take the matrix band off, you've got a contact problem or whatever, you've got a void, then you got to do it all over. So that was an interesting thing I heard where she actually builds the marginal ridge first, then removes the matrix on those class twos, and then finalizes the beautiful anatomy of the occlusal part. Okay, your comments. Okay, first of all, Are you willing to share who this person is, this KOL who you interviewed? Dr. Tam. Yeah, actually, I just did a podcast. I need to personally reach out to Dr. Tam and thank him because that is so smart. Yeah, Clary. Actually, it's a woman dentist. She's in Australia. To our audience, if you're interested in that podcast, it's Dr. Tam, T-A-M. And you can look that up on Viva Learning. Just type that name in the search bar. And yeah, and you will love her podcast, Dr. Gupta. She's got some amazing tips and insight. But anyway, that was her comment. So I thought I'd like to hear another viewpoint on that from you. So, okay. So I'm not going to argue with that. I think it's fabulous. It's an excellent idea. And I love it. actually can't wait to get back into my office and utilize it for, you know, probably the rest of my career. Boy, you're easy to sell. You're an easy sale, Dr. Gupta. Yeah, no, that was easy. I can imagine that going so well and so easily because that's the biggest pain. Just imagine at 4.30. Your office is closing at five. You're finishing up with a class two. It was already a pain in the butt. And then you remove that matrix band and there's a void or an open contact. It's such a psychological killer. And to avoid that would be amazing. I do have a couple of ideas. Number one is maintaining a strong contact. I used to only rely on wedges. That was inadequate. thing to rely on um now my class twos i almost always if i can i use a sectional matrix system and that's where you use a ring you put a ring that that kind of squeezes in between uh the two teeth that you're working on and what that does is when you after you fill your class two and remove the ring the tooth bounces back and you get a very nice tight contact And there's several really nice class two sectional matrix systems out there. I think Garrison, they're the OGs. They're the original class two sectional matrix fixers. And I love their product. I also love the product by Ultradent. And recently, Premiere came out with a product. It's called the X5. And the difference between the three is minimal. They're all great. The one thing I like about the Premier product is their ring is made out of a cheaper, more disposable material. And that's really nice and really valuable because for some reason in our office, we lose those rings. I don't know how, I don't know why, I don't know which dental assistant does it. um but when we lose a ring it sucks because those things are expensive the other reason is those rings sometimes they get composite like caked onto them and they're just gross after a while and so i like having a disposal i like having a ring that i can throw away if it gets gross i have a ring that if a assistant loses it if i run over it with the chair it it's not as psychologically jarring um and so but every uh these three companies Their ring systems are all really good. I want to add to Dr. Tam, and that is the avoidance of a void. I've had voids. I'm sure every general dentist has had voids. And one thing you can do when your matrix is in place is put just a little couple of drops of flowable material and don't cure it. Don't cure the flowable. just put a couple drops of flowable material and then smash in your composite your your packable composite on top of that flowable and what happens there is as you're packing that packable composite your flowable will just kind of get squeezed into whatever potential void is there most of your flowable it's going to flow to the top and you're going to wipe it off anyway but what you're doing by putting that little bit of flowable composite that's going to get replaced by packable is you're eliminating the possibility of a void. And so while I'm going to use Dr. Tam's idea, I'm still going to use a little bit of flowable composite to make sure that I avoid getting those voids when I'm doing those procedures. So when you use the flowable composite, what's the curing process? So this is how it goes. Place my matrix band, place my wedge, place my ring. Add a little bit of flowable composite right along the margin, that proximal box margin. Do not cure. Then add... packable composite, my first increment of packable composite against that margin and pack it around the margin. What happens is flowable kind of seeps up to the top and gunks up my instrument. So I have, I wipe that off and then I cure. Yeah. So, and what's the thickness of material you're curing? Oh gosh, I don't know. Maybe one to one and a half millimeters. Okay. That's including the packable. Yeah. Okay. So you're making sure that the bottom of the box is sealed. And that's where your concern is. Yeah. Yeah. I've had enough times where a void has ruined my day. So yeah, I'm actually over careful during that particular part of the process. Dr. Gupta, thanks so much for being on this podcast. Excellent insight, great clinical tips, and looking forward to having you on future podcasts soon. Thanks so much. Thank you very much.