Holy Cow! I Didn't Know You Can Do That With Composite!

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. In today's episode, we'll be talking to a general dentist that has done thousands of composite fillings, of which many were placed on badly decayed, severely broken down teeth. In fact, in many cases, the patient was given the choice by a previous dentist of either extraction or spend thousands of dollars for root canal therapy, post and core, and a crown. So the question is, when the patient presents with a blown out tooth and can't afford to spend a ton of money, can we restore the tooth with a composite filling, and will it last? Our guest today, Dr. John Gammichia, says, yes, we can. In fact, a great deal of his practice is based on doing this as he pushes the envelope with today's advanced composite materials, utilizing the latest bonding technology and, of course, meticulous clinical technique. Dr. John Gammichia owns a private practice in Orlando, Florida. He has lectured throughout the country, published articles on direct restorative techniques, and is a courtesy faculty member at the University of Florida in the Department of Operative Dentistry. Before we get started, I would like to mention that Dr. Gammichia’s webinar, titled Holy Cow, I Didn't Know You Can Do That With Composite, I love the title, is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Gamicia, G-A-M-M-I-C-H-I-A, and you'll see it. If you want to see what you can do with composite, I highly recommend this webinar. Dr. Gammichia, it's a pleasure to have you on the show. Oh my gosh, thanks so much. I've heard so much about your podcast. I've listened to them for a long time. Before we get started in this podcast episode, I want to tell the audience. that i saw some of your webinars on viva learning.com and it was amazing i mean i've been in this business for 40 years and your webinars one was from 2015 one was recently in may about how you did composite dentistry on patients that were told by their doctor that they needed root canal they needed a post they needed a crown and some of these patients were in their 20s and that's what we call dental burnout they get all this dental work done before they're 25 years old and they get discouraged and you know how it is. I mean, there's a lot of research that could show through the statistics of procedures that the more dentistry you have, the faster you lose your teeth. Now there's, you know, some dentists are going to say, well, that's crazy, but there are stats that support that. But regardless- You start that circle of death, right? As soon as you cut into that tooth, you start that circle of death. Exactly. I'm sorry, I didn't interrupt you. No, no. So you're going to be doing most of the talking here, but I want to just tell the audience how- the work that you showed because you know i'm an endodontist so i saw cases that were so blown out these teeth were blown out they look like they were all the way down to the pulp they look like they might have had some furka involvement which you talked about in that webinar and you took a shot at it when i laughed when you said you told the patient you don't even know if this is going to last until you get to the car in the parking lot That's what you told the patient. You said, I can't make any guarantees on this. You may get to the car and this thing may be broken. Eight years later. Yeah, eight years later, the thing's still humming. And it was just a remarkable thing that you did with direct restorative composite. And I'm actually interviewing a lot of people on this show, a lot of KOLs, and they're starting to say that they could do things with composite that just wasn't considered normal dentistry a few years ago. Like they're not afraid to bond. They understand the bonding process. They understand how to do this stuff. And the bond strength is great. It's strong. And you just need to know what you're doing. And you could do things with direct restorative composite material and the right bonding technology that is just incredibly successful. There are a couple of doctors that are major proponents of this. And one of them said recently in a podcast, they'll bond something flat broken down at the gum line, flat across the gum line, they'll be happy to bond it. I'm going to let you do the talking now, and tell us about your whole concept of how you practice dentistry, where you could take teeth that most dentists would say, no way is this going to be a candidate for a composite, and you turn it into a beautiful tooth that lasts. How do you do it? Okay, so, you know, I've been around, I graduated in 1995 from the University of Florida, and the very first course I saw was Ray Bertilotti. And you know Ray, and that he... You know, he would call himself a self-proclaimed bondodontist. So I saw him almost 30 years ago. And some of the principles that he was talking about back then is some of the stuff that I use right now. And he was a big photobond from Curare guy. And, you know, he was crazy. I mean, people thought he was crazy. He was doing crowns that he would just, it would be like a tabletop crown. And he would just have the lab. make a crown that was flat and he would bond it right to a flat surface. And, um, I took that ball and I just ran with it. And, you know, my practice is, you know, I'm, I'm in Orlando, but I'm on a kind of a blue collar, you know, bring your lunch pail to, you know, to work kind of town. And what was happening to me was people were coming in with broken down teeth. And the reason they didn't come to the dentist is because they've heard they needed a crown and they just let it go. And so when they've gotten to me, when they got to me, the tooth was so badly broken down and they're like, well, I need an extraction, don't I? Or, you know, I can't afford, or I tell them, I think you need a crown. And they're like, I can't afford a crown. And so was, is the option extraction or $2,000 worth of work? And you're telling me there's nothing in between. So what I ended up doing, was, you know, taking this blue collar guy and realizing that, all right, let me just try the filling. And this was back in 1995, early 2000s. Let me just try a filling and see what happens. And then the next thing you know, this, and I told him, like I said, I give the taillight guarantee. When I see your taillights, the guarantee is up. But what was happening was I'd see them in recall. And then I'd see them in recall again in this kind of test. This kind of let's see what happens is now 12 and 14 years old. And then what happens is I've done a thousand of those and they're all still around. Right. Now, some of these teeth are so broken down that we were taught the principles of restorative dentistry that you need this circumferential coverage to protect the compromised tooth structure. Otherwise, the tooth is going to fracture. An inlay, no. An inlay, yes. A crown, even better. Now, Dr. Gammichia, you've been doing these cases a long time and you've done lots of them. And you're getting great success. Now, I know KOL sometimes show their best cases in their webinars, but still your cases were remarkably successful based on using direct restorative materials, considering the state of that tooth when you started the work. So how do you maintain the success of your direct restorative restorations in these compromised teeth, which goes against many of the doctrines that we've learned, you know, in our dental school education? Okay, so that's a great question. I would implore some of the listeners to go to the webinar because you got to see it, right? So it's, I show some, I really try to show some really kind of great stuff and it's so much fun to do this. And what happens is like I do something and I don't know what's going to, and I do now know what's going to work, but I would use to say, this is too deep. The studies say this is too deep, right? What's happening is they don't have a choice. So I said, I'm going to do a deep filling for you. I know you can't afford a root canal, and let's see what happens. And once again, I've got 1,000 of them that are so deep. And almost the science sometimes catches up with that. And like 2014 at the Academy of, Merit Academy of Dental Researchers in 2014, Bader puts on this lecture and he talks about incomplete caries removal. And that's something I talk about in the lecture. It's like, look, if the tooth is vital, you know, we all know what the symptoms are. They come in and they say, this tooth hurts when food gets in it. When you tell them, well, does it hurt? Does it spontaneously? Does it wake you up at night? Does it throb? No, no, no. right? But it is a little sensitive to cold. That means to me, the tooth's vital. I'm going to do my best. I'm going to stay away from the pulp. There's a chance I might not even take all the decay out. But the periphery of the prep... I don't mean to interrupt, but I want to ask you something about that quick. So we're talking about reversible pulpitis, what you just described. Correct. When you determine the patient has reversible pulpitis, which is exactly what you just described, and you have a case where the decay is very deep near the pulp, if you removed all the decay, you would... involve the pulp tissue. You're saying that you not only leave affected dentin in there, but you leave some infected dentin? I know from an endodontist, that sounds crazy. But do you remember what the Hall technique was? Have you ever heard of that technique? Yes. Back in the kids, they didn't have enough time. So what they would do is they would leave decay. Leave the whole thing. They wouldn't touch the tooth at all. They would put IRM in a stainless steel crown and put it over the top of the tooth. And almost 99% of the time, the decay stopped, right? Right. So that's just kind of the principle that now they're kind of using is I don't necessarily love leaving infected dentin. Right. And I hardly ever do. But if I'm getting close to the pulp and we all with our loops nowadays, you can get close to the pulp and not touch it. I'm going to get as close as I can to the pulp. I don't care what the tooth, what the dentin looks like. I'm going to put some glass ionomer over the top of it and just do a filling. So I assume your next step is bonding. Everything that I do is predicated on having an unbelievable adhesive. OK. Everything I do, the small class ones, my class fours, everything I do, the deep ones, the big ones, the five cuss, everything, I use the same product. And that's Essie Protect. Let me tell you a little bit about Essie Protect. And that's from Curare. And we, you know, the gold standard of self -etching used to be Essie Bond, right? And we all know Essie Bond from Curare. Now, there was a time where everyone was putting chlorhexidine into the kind of antimicrobial, right? And then also chlorhexidine would be an MMP inhibitor. What MMPs are, if the audience doesn't know, is they're proteinases that break down bonds. We activate the MMPs by etching and everything like that. And what would happen was you would etch, then you put your chlorhexidine in there, then you would use your bonding system. was the gold standard. Then Curare made SE Protect and they put an MMP inhibitor in the primer. So now all you have to do is use the primer. It has an MMP inhibitor, which means your bond is going to be better and is going to last longer. And they made it even better by putting fluoride in the bonding agent. You're optimizing your bond strength by using this Protect product from Curare for sure. And you show that in the webinar. So what I'm just trying to clarify is that you go in there, You've got a really deep restoration. The prep is all the way down near the pulp. There is some possibly infected dent in there. You leave it. Not a lot of it, but you leave it. And then right on top of that, you put glass ionomer? Yes. And then you use this product called Essie Protect? Yes. Okay. Then flowable, then my nano hybrid resin. Well, where's the adhesive part? The Essie Protect is a primer and a bond. Oh, it is in one. I see. I see. You use that on top of the glass ionomer, and then you go ahead and use a flowable resin composite on top of that? Correct. Very small layer. Just for what? Adaptation and seal? Yep. Okay. And so if you talk to biomimetic guys, they talk about immediate dental sealing. That's exactly what you're doing here. And then you go in with like a bulk fill? Not a bulk fill. Layer. That's right, a layered nano-hybrid. And what I use for my flowable is Majesty Flow by Curare, and Majesty ES is my nano-hybrid, all from Curare. Right, yeah, and they have incredible chemists over there. They've been leading the way in bonding for many decades. It's been around, like I said, since the 90s. Yeah, yeah, they have a brilliant research and development team. Because you're getting such a tremendous seal and you're removing that MMP, those proteases, and you're optimizing your bond, that some of that infected dentin that's sitting there just dies off. Yeah, I mean Bertilotti used to say if you seal, it will heal. Right. And back to that Bader lecture, he talks about it doesn't matter if you put glass on or calcium hydroxide over it. If you seal it well, you will have a 99% chance of success. So it's amazing, as I mentioned earlier, what you do in those webinars. And again, I would like the audience to take a look at them. And the question is, some dentists may ask, well, how do you make a profit using composites as the majority of the restorative material in your practice? Is it profitable? Oh, that's a great question. So yeah, it's going to be an obstacle for most dentists. You know, we all have numbers. We got to pay our staffs. We got to keep the lights on. I want to tell you a little bit about in 2018, the ADA did a survey on office production, and the ADA did a survey on salaries. They don't do it every year. So in 2018, they talked about, I won't tell you my fees or what I make or my production, but I'm going to tell you in the 75th percentile, there was a number and what a solo practitioner does, okay? There's no bragging. I just want to convince you that you can make a profit by doing a lot of composite. And that is my production was 30% higher than the 75th percentile in the ADA study. Okay. And what percentage of your practice do you actually do crowns? That's a great question. That's my next point. I called my ceramist and I said, how many fixed units did I do this year in 2018? Okay. 53. I did 53 units. a fixed that year. And he's still, he's still your friend that's ceramics. That's right. And so it was, I did 30% higher than the 75th percentile in the ADA study. And I only did 53 crowns that year. Okay. So let's talk about how I do things. Well, I'm, first of all, you have to be very efficient. Okay. There are things that you, if I do fillings, I've done, I've done 50,000 fillings in my life and I've done, I do big fillings. I charge accordingly. So anything higher than a three-surface resin in my office is going to be almost an hour worth of productivity. But it only, you know, I can do any filling. Shoot, I can do a class one filling in about 12 minutes. I can do a class, you know, an MOD in about 16 minutes. And I can do probably a four-cusp molar in about 26 minutes. You do show some of that in your webinar. And a lot of these systems that you use to do multiple boxes at the same time, DO and an MO at the same time, it's these ring systems that you use, these matrix systems that really help. Excellent. Yes. You know, if you watch the seminar, I don't go into too much technique, but I show some photos of great matrix bands and not just regular Toffermeyers, the good, the V rings, as you guys have known, you know, I think the biggest deal and we... get to talk about it is the curing light. I mean, I use a Valo Grand and now I use a Valo X and these lights will cure in three seconds. And so we can get it. We don't have to get into like the science behind it, but you know, there's a Monet light that cures two millimeters of resin in one second. You know, it's about time and efficiency. And we, you know, at my office, we get pretty efficient. So the bottom line is if you have the mindset. to approach dentistry in a conservative way where you're actually doing a tremendous favor to the patient when it's indicated. And I know you're pushing the envelope because a lot of dentists would not do direct restorative composites on cases that you're showing. But again, like you said, it's either extraction or a crown. And you're saying, why is there not something in between? As long as the patient knows what the risk is. Exactly. Then, and that's, you know, clearly. described to them and stated to them, then there should be no problem. There's only upside there. And the upside is huge because, you know, I'm an endodontist. Root canals are very successful percentage-wise, but some do fail. And then, like you said, you call it the circle of death. Once you start drilling that tooth, the more complex your dental treatments, the more apt you are to run into problems down the road. I mean, that's just how it works with anything. But I think that your approach with conservative dentistry and making these teeth look beautiful, I mean, they're so aesthetic. They look really, really good. And do you spend a lot of time on the occlusion to make sure that these teeth don't fracture after the final restoration is put in? I mean, I really think the material mimics, you know, dentin and enamel. So I'm not like taking them out of occlusion and like cut them low and watch them grow kind of thing. All my anatomy is... you know, specific to the tooth. I see the, you know, I know where the oblique ridges are and I put them all in the right spot. I see the occlusion and all the anatomy, a lot of my anatomy is done before the last cure. So I don't have a lot of work to do afterwards. So you can kind of manipulate the material. It's just, it's fun to do. It's art, you know, so it's good for the patient. It's good for me. It keeps me energized. Yeah. Now, do you think this has been a big boon for your practice by doing? Absolutely. Tell us how one could grow their practice with this kind of mindset in the culture. This is absolutely how I grew my practice, is when I listen to that patient and they say, I can't afford a crown. If I took this out, I can't afford a $6,000 implant or a bridge, right? So I said, let me do my best to save this tooth for you. I'm going to do my best. We're really pushing the envelope with this material because even... know, the books would say this can't be done, but I've done enough of it that I really feel like it's going to be successful. And so that person says, you know, Gamicia is really fair. You know, and back to that 2018 study, I am 30% higher than, say, the 75th percentile. I do not market. You know, I don't market at all. The only market I have is internal marketing, and that's just people talking about me. And your online reviews must be pretty good. Yeah, because I really feel like I'm just fair and I do good work. We're excited about the kind of work that we do here. Even, you know, my staff members are. Everybody's kind of excited about helping people. That's what we're all called to do. There's no question the career satisfaction that you're getting from your approach has to be incredibly high and rewarding to you as a human being because these patients open their mouth and they want to trust the doctor. And, you know. Listen, scanners, intraoral scanners are a big thing now. They're trying to be sold to every dental office. You have a scanner. Now you're starting to think crowns, right? You scan a tooth. You send it off to the lab. They send you this beautiful indirect restoration. Your propensity is to do more dentistry. You have a hammer. Everything looks like a nail. Yeah, exactly. Yeah, yeah. And that's a shame. Although, listen, crowns are important. I mean, that case that you showed, that molar. what was it, number 19 or number 30? It was one of those number 30. I mean, it even looked like after you placed the direct restorative composite, I don't know when the post-op was taken, how long after, it looked like the furka healed. The bone actually looked more dense in between the roots, which is remarkable. That case is incredible. Yeah, that's what you call the coup de grace. Something like that. I think that's what you said, yeah. That's the case where you want to do the death blow to the tooth and instead you just basically saved it with minimal dentistry, really minimal dentistry. That is an outstanding case. That's kind of the proof of concept right there. So we talked about a lot of stuff and we definitely want to have you on another podcast that we could talk about more because we're probably going to get lots of interest in this podcast episode. We did a social media piece on your webinar, which was about a minute on Instagram. And it got more likes and views. It had over 550 views in the first 10 minutes, that Instagram post. Yeah, it really burned up. And we're just starting to really grow our Instagram and social media audience. We have a huge online audience, desktop-wise and mobile. We have over 400,000 subscribers to Viva Learning. Are you telling me I'm famous? Well, I'm telling you, one of the people in our company said to me, Gamicia, do you know that guy? I said, no, I don't know him. He works out of Florida, but he said we just did an Instagram on him and he had more views than any other Instagram post yet. Now, we've only been doing this for two or three months on Instagram. Don't minimize it. I'm the Kardashian of the dental Instagram. Oh, are you? No, I don't even know. That's what happened. Maybe that's what it is. Maybe they like the look of the picture. It could be my kids, maybe. Yeah, but no, when you look at it from the standpoint of the population, I think there are more people around that could benefit from a dentist like you, who's doing the kind of work you're doing, than a dentist that is just looking to do root canals and crowns all day, right? Well, I really appreciate that. And, you know, this is not really for me. You know, I do it because I love my job. I do it because I love I try to love on people. And yes, I have I I'm very satisfied in my job. I'm satisfied in my team, the piece, the people that come in saying, you know, I heard good things about you. I heard your affair. I heard that you helped my friend. You know, those kind of things keep you going every day. Exactly. Yeah. I'm part of the spear study club and I know how to do, I know how to do full mouth rehabs, but you know, if you do three of those a year, you know, the bread and butter, the meat and potatoes every day are fillings. Right. And I, I've gotten really good at it and I feel like I've gotten efficient at it. I've gotten profitable. I make them profitable. And so I don't have to say you need a crown to be profitable. I mean, my fillings, the overhead for my fillings is like $12. Right. And I can do it in a half an hour and go to the next one. And if I do a crown, it's profitable. If I do a filling, it's profitable. It's not about the bottom line because they're both very profitable. Yeah. And you show that in your webinar, how much money a practice can make using your approach. You know, we're going to wrap up this podcast now, but I do want to say is like when I practiced endo in Philadelphia, that's before I moved to California, before I moved to Austin, Texas, when patients opened their mouth and I looked at their mouth and they referred to me for root canal therapy, I would look at it as if how would I want to be treated if that was me in the chair? Look at that patient and say, okay, that could be me. I could be going to a doctor. I want to trust that doctor. I want the doctor to do only what I need to have done and be conservative. but also treat me correctly and make sure my teeth are healthy. That's the kind of practice that we had. And I think that's the kind of practice that you have. And I'm super happy that I took. a look at those webinars before this podcast. You know, I heard about it and I got some clips of it to prepare for this podcast. I ended up watching both of them from 2015. You did one way back and then in May. So hats off to you for doing a tremendous job teaching and we look forward to having you on future podcasts, Dr. Gammichia. Thank you so much. Thank you. I really appreciate it. I had a great time. if you like our podcast and want us to keep it going please leave a review on your favorite podcast platform leaving a review is a fantastic way to support us and help others discover our show we really appreciate your support see you on the next episode