Doing More with Less: Restoring the ‘Hopeless’ Tooth with Composite

Just this morning, I had an 11-year-old come in. So the mom's out in the waiting room with three small kids, and I brought her in to look at this 11-year-old who came in for her first cleaning. And she had like four bombed out teeth. What are you going to do? You're going to take number 19 out on an 11-year-old? And she had three more to go with that. Thank God she came here because I'm going to restore these teeth with composite and they're going to last 20 years. They're not going to have root canals. They're not going to have crowns. I'm just going to treat her very conservatively. Welcome to the Phil Klein Dental Podcast. Today we're chatting with Dr. John Gammichia, a general dentist who's been in practice for over 30 years and has made a name for himself saving what many would call bombed out teeth. all with conservative direct composite. Dr. Gammichia believes there's a third option between pulling a tooth and placing a full crown. And for more than 25 years, he's been proving that it works. His talent for restoring even the most damaged teeth with direct composite has earned him glowing Google reviews. And he grows his practice almost entirely by word of mouth. In fact, he even gets referrals from other dentists up to three hours away, who trust him to save teeth affordably and conservatively. We'll dive into how he handles deep decay and pulp exposures, the materials and techniques that make it possible, and how his approach has become a real practice builder, showing that fee-for-service dentistry focused on preserving tooth structure can be both patient-centered and profitable. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases, and our entire production team will really appreciate it. Dr. Gammichia, thanks for joining us on our show. So happy to be here. Honored, really. Yeah, very happy that you're doing the show with us. And I love the fact that you do conservative dentistry, and that's why I'm really excited that you're on the show. You've become known for your conservative approach with your colleagues and your patients, and you do this with direct restorative techniques, primarily using adhesive bonding system and composite resin. And I think it's fair to say that you've really pushed the envelope using composite to restore teeth that others might consider non-restorable. So to begin, tell us first what this has done for your practice. I mean, I feel like I'm in the real world, and I have a lot of people that come in with a broken tooth. I got a 40-year-old occlusal amalgam, and the lingual cusp breaks off. It's a, say, a 50-year-old woman, and you say to her, listen, I think you're going to need to build up in Crown. And she might say, well, how much is that? And I would say, well, so right in my office, it's $2,100. Maybe she would say, well, how much to pull it? Right? So I really feel like we need something between. a buildup in a crown and extraction so in my early years i would say well i'm gonna put a filling on this and we'll see how it goes right and i put a big filling on it and five years later still on recall it's there and it looks as good as when i put it in so i've found that it's kind of a practice builder like this woman trusts me to do the best thing for her right And so my box, your little box where you just have some fillings and some crowns, my box is getting a little bit bigger. Well, now I feel like I trust my adhesive dentistry, my adhesive. And if I need to do something that's big, I really feel like it's going to work. Yeah. And you talked to me once about, I think it was Dr. Bertolotti, who they call the bondadonist. Tell us about something that he talked about that kind of inspired you. to really take advantage of the adhesive materials we have today and the technique that goes along with it. I mean, talk about expanding your box. When I was one year out of school, maybe even six months out of school, I saw Ray for the first time, and it just blew my mind. He's like, I want to be that guy, right? And he, in 1996, he was taking a crown. His crown packs were flat. flat across the top. And he says, I can bond, I can bond a crown on a flat tooth surface. So I don't have to cut more tooth. That was revolutionary. It was crazy. But here I am 30 years later, kind of doing that same thing. Yeah. And you see a lot of your cases over the years and you see that it works, which certainly gives you the confidence. You kind of covered this in what you just said, but I'm going to ask it anyway. Can you walk us through your thought process when deciding whether a tooth can and should be saved with a direct composite restoration? Well, I'll tell you, I saw, gosh, I saw a 25-year-old today with a crown on number 15, and I was just like, wow, that's so rare in my practice. I can't tell you anybody that's under 40 that has a crown in their mouth that I've treated. Right. So really, young people, I don't do crowns on young people. I would much rather, you know, start that circle of death much, you know, start it later when they do the first crown. We're starting to see kind of deterioration this too. So and I'm not saying we're not getting deterioration in a big feeling, but I don't like to do crowns on young people. And the reason for that is that you. obviously need to reduce the tooth more. You need to take away valuable tooth structure in order to put a crown on it. That's what your point is, right? You're trying to preserve. Yes. So you're trying to, and you feel that- And a lot of it's visible. Like if you have a filling that needs repair, you can see it. And sometimes on a crown, you can't see it. It's got to be pretty big for you to even feel it, right? And radiographically, too. Correct. Yeah. Some dentists may say, well, crowns are- 2000 bucks or whatever. And I'm going to be sitting there spending a lot of time hand crafting a composite and getting paid a fraction of that. What's your answer to that? Well, if you really break it down per hour, you know, can you do two fillings? Can you do two fillings in an hour? Can you do three fillings in an hour? Right. You know. I do a lot of fillings. So I could do three fillings in an hour. Let's say a person could do two fillings in 45 minutes. That's six, let's say $650 in 45 minutes. That's really around $800 an hour. A crown, $1,500, $1,600 in my office, about an hour for the preparation. You know, some assistant time for the temporary. You bring them back for the second appointment, 30 minutes for the seating. Your hourly rate on a crown is somewhere around six, seven to eight hundred dollars. And, you know, if you're doing two fillings in an hour in 45 minutes, it's about the same. So and then, God forbid, the contacts aren't right or the color's wrong and you got to send it back. Now you've really broken into your profits. Really, I think from your standpoint, we talk personally about this offline. want your family, if you weren't a dentist, to go to a dentist that has the same philosophy of practice that you have, which is remove as little tooth structure as possible and manage these blown out teeth if they are the case with direct restoratives using a really good adhesive. So let's talk about that tooth that is really blown out. No pulp exposure, but it's very, very deep. What do you do clinically to protect the pulp vitality knowing that you know, this big composite resin is going on top of it. So in 2014, I saw a lecture by James Bader out of North Carolina, and he was basically saying the science, the systematic review, the reviews of the reviews say, if you have a vital tooth, now we've established that the tooth is vital and it's close to the pulp, you can do an incomplete caries removal. So for the last... 15 years or so, I see a deep, I established that a tooth is vital. Then I am going to go and take the decay out until I'm getting a little bit uncomfortable. in the depth, then I'm going to leave, if I have to, I'm going to leave decay above the pulp. Now, my periphery is going to be super clean. My enamel layer and my two millimeters of dentin are going to be super clean. No decay, just a little bit of a bevel. I mean, everything is perfect. So I don't want to hit the pulp. And so even on a deep lesion, what I will do, I know it's deep. I know there's bacteria. What I'm going to put down on the deepest part is I'm probably going to put down some TheraCal by Bisco. And this is a calcium silicate cement. I use it as a liner. And then I'm going to use my adhesive, my flowable, and then some layering technique and make a really beautiful, large, deep restoration. When you say you leave decay, I assume you're talking about affected dentin. The mush part is going to be gone. But if it's still leathery, you're going to leave that. And that is what I hear many key opinion leaders doing now. They're even using silver diamond fluoride on top of that. So that's in the case when it's really deep and you're using that liner. The one you mentioned was Theracal. Is that something you have to light cure as well? Yes. Okay. So that has a resin component in it. Correct. Okay. And then you put the adhesive right over that and then you like to use a flowable to get good adaptation and then you layer in your composite also light curing. So now let's talk about where you went into this large lesion and you get a very tiny exposure. Let's say it's a vital case. How do you treat that? So I'm going to try to get it to stop bleeding with just a pellet and just some light pressure. Okay. And I'm not going to overdo it. If this thing stops bleeding, I'll put some vitre bond or a glass ionomer right over it. Adhesive right back to my other technique. Okay. The problem really becomes when you can't get it to stop bleeding. And there's a lot of research out there and it's changing. And so at that point, if I can't get it to stop bleeding, I'm probably going to temporize it and refer them to an endodontist. What I'm going to tell you is the research is changing. I'll have multiple conversations with endodontists about talking about doing full pulpotomies as a permanent restoration. And that's a little out there, I know, but have some discussions. I want the listeners to really kind of be on the cutting edge, and that is cutting edge. You're putting a little MTA over the orifice or some biodentine and doing a permanent restoration. And that's kind of what the research is saying. And if you can get it to stop bleeding at the orifice, this is going to be a healthy pulp and avoid root canal. Right. If there's no bacteria that's involved with the canal, the hope is that the... tissue inside the canals survive and they maintain vitality. It's pretty awesome. Yeah. And then you're just obviating the root canal in the first place. We'll see how endodontists respond to that research. Exactly. Yeah. I'm an endodontist retired, so it doesn't matter to me. But yeah, we'll see how they respond to that. And again, if you're putting a big case on it, you may have to talk to the patient about... this is not 100% long term. Oh yeah, there's definitely some conversations being had. Right, there's conversations being had. But the nice part about it with you is that if you do send it to an endodontist in the case where you can't control the bleeding of a pulp exposure and they end up doing a pulpotomy with the MTA at the orifice, they could send it back to you and you can go straight back to your wizardry, that's a word, wizardry, with your direct composites, right? Because again, you can go straight down in there with composite. and build that whole thing up. Now, one of the things dentists have trouble understanding when you teach and we talk about how you are really heroic with your composite resin is that they feel like it's too time consuming to carve up these things because there's nothing there. The anatomy is gone. The cusps have to be built up. There has to be, it has to work. It has to be functional and occlusion. So how do you do that so quickly? You don't have a matrix. You don't, you just freehand it. to get this all done? Yes. A lot of practice. And so if you've ever seen my work, I mean, if you gave me like a dentiform tooth right now and you just took the whole anatomy out, like 80% of the top layer, I can put anatomy in that tooth with an Explorer in less than a minute. Okay. So. And it just takes practice. Right. And you know, what's, it's funny as back in the day, you know, 15, 17 years ago, I was back in my office doing anatomy on dentiform teeth and then doing it, wiping away, doing it again. You know, so I, I have a skill that you have to practice. So I would do it on dentiform. I would do it on denture teeth where denture teeth, people would have come in with no anatomy in their denture teeth. And I would say, Hey, do you mind if I just sit and take a bird to this denture teeth and give you anatomy again? It takes practice. practice so you are not it's going to be tough to do but i can tell you if i have a blown out tooth and i have one wall and i can use i can use one wall and put a toffermeyer on there i can i can do the cutting i can do everything from start to finish on this thing in 25 minutes Yeah. And do you accept insurance? Do you accept insurance or do patients have, are you fee for service? Yeah, we're fee for service. What do you charge? If someone comes in and you say, you're going to need to spend $2,200 to have this restored within direct means, or I could do it right here in the office today. And you need to do everything to that too. There's nothing. $575. $575. Yeah. And with your success, with your adhesive. systems and your composite and the layering that you talked about for pulp protection with the TheraCal and everything else. What are you talking about as far as years with this usually? I mean, again, it depends on the occlusion, depends on the patient, depends on the home care. But what are you seeing? You've been doing this for 15 years. I'll quantify my 575. 575 is the filling. If it's deep, right, if I'm doing electrosurge, I'm charging a little bit extra for electrosurge or gingivectomy. If it's close to the pulp and I have to do indirect pulp cap, I'm charging a little bit extra for that. Okay, so it could be in the range. It could be $700, right? It's about a third of what you would charge for a crown. Exactly, and they're walking out the door in a half an hour or done. And then what about the success rate? How many years? So I saw a woman yesterday that I did. I literally, there was a speck of tooth left that I could just put a Toffermeyer on there. And I held the band down with my finger because there was nothing there, right? She was at four and a half years and the filling looked amazing, okay? There's another story I did where I helped. My hygienist had a person that cleaned her house, and she gave her the story like, I have a broken tooth, and I can't afford the crown. And my hygienist said, why don't you see my boss? He'll probably do it with composite. So she comes in. I already told her, I'll do this for you, no problem. And I took the occlusal amalgam out, and both lingual cuffs broke off. So she already had the mesial buckle cusp broken, and now she's got both lingual cusps broken off. And so all she's got is the distal buckle cusp. And I know she can't afford a crown, so I put this Telfemeyer on it, and I do the best I can. It looks amazing after a half an hour, right? I was so happy with the way it turned out. I took some photos, never saw her again. So I talked to my hygienist. What, you know, where is, you know, Betsy, do you ever see Betsy? No, she doesn't clean my house anymore. So I call Betsy up and I call her and I say, Betsy, hey, is that filling still there? And she says, well, you know, it's funny. It just broke. And I was like, oh, like, what do you mean broke? Like, is it chipped? Is it gone? Can you take a picture and show me what this looks like? She took a picture of it, and it turns out it was the tooth behind it that broke. And she didn't even know that this filling was there. That's eight and a half years later. The filling looks, it was still looking very, very, it looked a little worn, of course, because it's almost 10 years old. And the whole thing is composite. Those are the results I'm getting. So I don't really quantify that with my patient. Like, hey, look, I don't think this is going to last. I just say, see you later. So you don't even have that discussion with them. that a full coverage crown is kind of holding the tooth together. That one I'm telling them. Like, look, we're pushing the limits. But, you know, on some OLs, right, the whole lingual cusp broken off, I don't quantify it, right? If something's four cusps, I might say, hey, we're pushing the limits here. And if it breaks, we'll talk about it. So you use this composite that Bisco has. Quantium. How do you like that? How is that working for you? It's really great handling. You know, it's a nano hybrid, which you got to be using nano hybrids. Great finishing, great strength, really easy to use. And as I told you before, when I put anatomy in, it really is a nice composite to kind of put anatomy in, even before it's cured. So I've been really happy with it. Yeah, that's a relatively new composite that's out there, more of an advanced material. So tell us about practice growth. how patients respond to the way you handle teeth that otherwise, maybe they came from another dentist where they said, you know, you need to have this extracted. If you don't have a full crown, this is the way to do it. You have to have, we need to send this to the lab, take an impression, send it to the lab. This is what you need done. Three visits or whatever, $2,200 or whatever it costs. And then they go to you. How has that helped your practice overall when you talk to patients about this? direct approach, this direct conservative approach. My biggest referral is Google, right? I don't do any, I don't even know what my web mutation is or reputation in the web, right? Web mutation. But people say, I saw your reviews, right? Isn't that just, isn't that what it's about? Like people are telling other people, right? For instance, I got a referral this week from an endodontist in Vero Beach. Vero Beach is two and a half hours for me. And she says, I have a patient that I want you to see because I know the type of dentistry you do. Oh, by the way, this patient is my mother. And they're sending this patient to you because everybody that's closer is not going to use restorative composite the way you do. Right. And they want, she wants her mother to be treated conservatively. I mean, I'll tell you what's really crazy is I got a guy that is about 30 minutes from me and he refers me all his composite fillings, the big ones, right? I don't know how to do these. You're a master at it. I want you to do this on my patient. Yeah, it's amazing. Yeah, it's crazy because, you know, when you listen to a lot of the lectures in the continuing education courses, the commonality, the common theme. between all of many of them, is differentiate your practice. And the way you do that is airway specialist, wellness center, TMJ or TMD. All on fours. All on fours. Invisalign. You don't hear anybody lecturing about differentiating yourself to get referrals from 50 miles away based on doing direct composite restorations. But you have found that unique flavor, dentists and patients are going to to get your services i mean it's very unusual and it's not something you would expect you know i love doing dentistry you know and some people i know my age hate it right and they're just they it sucked the life out of them you know and i really get a lot of energy by doing art right and helping people You know, and not, you know, crowns to me, they're pretty, but I think a really good, you know, composite restoration posterior is just so pretty to me. So I know I'm weird. I know I'm weird. No, I think part of the enjoyment you're getting out of this, Dr. Gammichia, is that you're getting immediate satisfaction by doing this. And they come into the office with something pretty bad and they're embarrassed about it. They can't chew on it. It's probably painful. And they're at the verge of like, they can't afford the indirect. They're at the verge of extraction. And then you come in like a hero and you literally build this tooth up out of nothing. And it looks beautiful because the composites today are just outstanding. Your technique obviously is pretty flawless as far as isolation and everything else, because we know fluid and contaminants in the area certainly don't help the adhesive strength of that complex that you're developing. But I think there's an immediate satisfaction to it. They're so happy that you're there to do this. And like I said before, I think the problem that dentists have for them doing it is that they don't want to spend the time manually hand crafting this thing. They just feel like it's too manual. And having a lab do it is just, you just take the intraoral scanner, you digitally scan the tooth and you send it out to the lab and they send you back, you know, you get back a crown. They do the design and you get back the crown and you insert it. There's a lost art there that you have preserved. It's because you're artistic and you enjoy it. And that's why you have a strong passion for dentistry because you're able to do this. I want to ask you, how do you train your team or how do you keep everybody consistent to achieve high quality outcomes using these direct restorative materials so that you could consistently get this high bond strength and high success rate? Well, I've been lucky that I have had the same assistant since I've graduated dental school. So, I mean, my assistant has been with me for 30 years, right? Her family lives in Maryland. All her family comes to me. So, like, that's how much she believes in what we do, right? And she can smell BS from a mile away. And she will tell people, like, your dentist is full of BS. And, like, you know, like. Listen, come. She's at the grocery store. Come to come to just come to our place. She's at the, you know, restaurant. You got it. No, no, no. She's telling people like they just believe in it. Right. And so when you have one of those, then then then your new assistant who might, you know, I don't really have turnover turnover in my office. I'm blessed to have the same people. So my that, you know, so as soon as one person comes in here, they get it really fast. Like this is the type of crazy stuff they do here. And it's it's fun. Yeah. So you're enjoying your career. You're getting tremendous satisfaction out of it. Your team loves it. It's a happy place to work. So what would you tell a dentist who's in their office right now listening to this podcast or at home ready to go to work tomorrow about really being open-minded about what you can do with large restorations that you would typically go in direct, what you can do with direct restorative and how you can actually build that segment of your practice up? I would definitely say you know, start small, you know, get the right materials, right? You can call me, email me. I would love to talk to you, but start small. Like one, say the mesial buckle cusp breaks off of a lower molar, right? And, you know, there's still a lot of tooth left, but you're... of challenged by you know this is a pretty large restoration but just start there you know and then as you start to believe then go a little bit bigger and then a little bit deeper open your box a little bit challenge yourself but not too much to start right because you know then you'll get frustrated but i would just say continue to just you know start small and then just push it a little bit more every time yeah and then the practice will make perfect as as the old saying goes Dr. Gammichia, thank you for your time. I know you are very busy today. You took some time for our audience who can't see him. He's dressed up as a dentist. He's in his office ready to go back to his patients. So he fit us in and we really appreciate it. Thanks for having me. I love talking teeth and I hope everyone enjoyed it. Thanks, really. Yeah, you're inspiring. Thank you so much. Take care.