Streamlining the Everyday Dentistry to Make Way for Success Every Day

You're listening to The Dr. Phil Klein Dental Podcast Welcome to Dental Talk. I'm Dr. Phil Klein. It's no secret to any of us listening to this podcast that costs are up and reimbursements haven't kept up, and in some cases, they're going down. Inflation, supply chain issues, and short staffing have made it harder than ever to be profitable. So in light of all this, it's important that we work efficiently. Today, we'll be discussing strategies to increase our efficiency and keep costs down without sacrificing quality. Our guest is Dr. Joshua Austin, who maintains a full-time restorative dental practice in San Antonio, Texas. He is an editorial director and monthly columnist for Dental Economics Magazine, focusing on dental products and technology. Before we get started, I would like to mention that Dr. Austin's webinar, titled Streamlining the Everyday Dentistry, To Make Way for Success Every Day is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Austin, A-U-S-T-I -N, and you'll see it. Highly recommend this webinar for the entire dental team. Dr. Austin, it's a pleasure to have you on our show. Hey, Dr. Klein. Good to see you again. And thank you for all your contributions with CE to Viva Learning over the years. We really do appreciate it. So how much of a role does efficiency play? in making a practice successful and keeping the stress levels down to a minimum? Yeah, that's a great question. I think it's hugely important because like most people listening to this, I accept some PPO plans. And I think that's okay to say. And I just love, there's nothing I love more than going to a great CE course and having the CE speaker talk about how they're totally fee-for-service and they don't accept any insurances and all of that. It's like, well, great, cool. Now, you know, basically we do completely different things. Right. And so, yeah, I mean, as much as we'd like to say that that it's all the same, it's not. And while all of our costs are going up around us, right, every cost that we have that goes up around us, the one thing that ever goes up is our reimbursement. So we're kind of held to that level. And so that means in order for us to stay. profitable, it means we have to get faster with the restorations that we do, get more efficient, do things in less steps, have less post-op issues, things like that that cost us money, reduce those things so that we can stay, you know, lean and mean and not have to, you know, make other sacrifices, you know, with poor materials or things like that. So, you know, I think it's hugely important. Efficiency is important for a lot of different reasons. Number one, patients don't want to be in our chairs. They want the restorations to go as quickly and seamlessly as possible. We need them to go as quickly and seamlessly as possible with as few as post-op as possible from a profitability standpoint. So it's really a win-win for everybody when we can work efficiently in our practices. Yeah. And so, you know, we all went to dental school. We learned a lot of things in dental school and some of us still practice some of the things we learn there. We can refer to it as the old school restorative dogmas of the past. Now, how have those dogmas changed over the years? for that matter, how many of those dogmas no longer apply to our real life clinical experiences and how does that affect efficiency? Yeah, for sure. That's a great question. You know, when I think back to my dental school experience, like most people who have gone to dental school in the last 30 years, you know, I was taught that if you used anything other than a fourth generation bonding agent, not only were you going to go to hell, but like your kids would go to hell and your children's children would go to hell. because i was just like that was the gold standard and that's what we used right um and since then like obviously we've had fifth generation bonding agents sixth generation bonding agents and now arguably with the universal bonding agents we're either on seventh or eighth depending on who you listen to um and and you know we always felt like hey we would never surpass the results that we got from the traditional fourth generation applying a primer, scrubbing the primer into the dentin, lightly air drying that, applying a separate adhesive, the two-bottle system, which really becomes a three-bottle system when you talk about phosphoric acid etch. On top of that, that just seemed like, well, that's how this is going to be forever and ever and ever. And what we have found is that this generation of universal bonding agents... are really really good and they work very well they are less technique sensitive and they give you a lot of options as far as how you etch and they give you much more leeway as far as kind of how much moisture needs to be in the dentin when we apply these these adhesives so you know i never thought i would see the day that the dental school that i went to and then subsequently taught at for for five years after i graduated would go away from um a fourth generation bonding agent and and now they have actually they're they've now started using about three years ago they switched to a universal bonding agent that kind of tells me like hey the time has passed you know fourth generation bonding agents are done it's time to move on to universal so i think that's that's a huge step forward in changing the old dogma and then the other one is is hey when we do when we do composites they have to be small increments or we're going to introduce so much polymerization shrinkage and c factor into a tooth that we're going to have you know everything from post-op sensitivity to introducing cracks and failing restorations and all that um and and and that dogma has shifted as well because we've had the introduction of these low shrinkage materials um that we can place in increments of up to four or five millimeters or so And these do really, really well. So these are things that make our steps less, make our sensitivity or our technique less sensitive and, you know, perform equally as well as the previous generations of restorations that we did. So, you know, I think it's great for us as clinicians and it's great for patients as well. Yeah. And talking about technique sensitive, that was my next question. From a procedural standpoint, is simplifying. our processes, something we should be doing on an ongoing basis, you know, as these new materials develop. In other words, do we tend to get stuck in a rut with technique sensitive and cumbersome procedures when there may be easier and faster ways to do things that will ultimately achieve as good or better clinical outcomes? But we have this, you know, I don't know what it is. It's a hang up or a guilt factor where, like you said, it's a dogma from the past where if things get simpler. maybe they won't perform as well because they're just, this is too easy or it's so much easier than what I used to do. How should a dentist evaluate that in their practice over time? Yeah, for sure. So you're an endodontist, I believe, correct? Yes. Yeah. So you probably trained in the day of like lateral condensation, right? And lateral condensation works, but it's a lot of time and it's not easy to do. And, you know, it also... you know, probably makes it harder in the situation where we're going to place a post in the tooth and all of that. As time moves on, you know, you start changing what you do because it is the right thing to do for the patient. It's the right thing to do for the tooth that we're working on. And that's how restorative dentistry is, is that change is hard. Change is hard in a practice. We get our systems. We do what we do. You know, we don't have, like to me, a successful procedure is when I don't have to talk to my assistant at all. And I don't mean that like pejoratively towards my assistant. I love my assistant, but the less times we have to interact and the more seamless our procedures are, you know, the easier it is for everybody. And when we change something, we have to retrain and we have to go over stuff and it just, it's a heavy lift, right? And so a lot of times we can stuck, we can get stuck in the idea of doing something that's more cumbersome just because of the idea of changing is such a heavy lift. for us. And so I think having an open mind into the expansion of things, yeah, in the short term, we're paying a little price of maybe not being as slick as we were in our handoffs with our assistant, maybe having to go over it a few times in a team huddle or something like that. At the end of the day, once we get those systems down, we become more efficient and everything gets better. So I think it's absolutely human nature to be resistant to change because change is hard. But again, if we were doing things the way that we were taught in dental school, a lot of us would still be plugging holes with amalgam and doing gold inlays and onlays, and we wouldn't be using. adhesive dentistry at all. And dentistry would stagnate and not change. And that's just not the world. And so I think when dentists decide to open up their minds to trying some of these new things, yeah, they're going to find the change is hard, but the result of it is so beneficial in the long run. And it reinvigorates us. No one wants to sit there and do these tiny little two millimeter increments of composite. In my opinion, every increment that we place of composite. is a chance for something to go wrong, right? For every little bit that we have to stack, there's a chance for contamination, there's a chance to get an air bubble, things like that. So as many of those little steps that I can eliminate where there introduces an opportunity for something to go wrong, the fewer things can go wrong. And so that's why I think simplifying some of these procedures behooves any dentist, any restorative dentist in the long run from a patient care perspective and from an increasing outcome perspective. Yeah, no doubt. And there was a time where all we heard about was polymerization, shrinkage, C factor, and, you know, bulk fills were a bad word, two bad words, I should say. You explained that very well. So where are we now with R&D, with some of these materials that can help us increase efficiency and maintain the clinical outcomes that we're looking for? Absolutely. Yeah. You know, we're at the point where we know we have data, right? When these materials first come out, we don't necessarily have the longevity of data that we'd love to have. And so we have to kind of make some calculated risks and things like that. But now we've got good data that shows that, hey, bulk fill resins and universal adhesives. work just as well as their previous generation's counterparts, if not, you know, a little bit better in some situations. So the data is there that tells us that, hey, these restorations last just as long. They do just as well. Any favorites that you could recommend to our audience or was looking to find out what KOL clinical experts are using? When looking at a bulk fill composite, I want to look at a couple of different things. For a posterior tooth, I want something that's honestly probably a single shade system because I don't want to have to take. uh you know to do shade taking type procedures if i'm doing you know an occlusal lingual composite on tooth number 14 having a perfect layered composite shade match in that situation is not is not important to me as long as it's white i'm happy and the patient's happy this isn't like doing a class 4 restoration on number eight where we really have to layer and match and all that kind of stuff so i want a system that has single shading I want a system that allows me to place increments at around four or five millimeters. And so, you know, we have several of those systems on the market. We have Admira Fusion Extra by Voco is a really nice choice. It is a single shade system. It's actually a nano Ormister, which is a little bit different than our traditional methacrylate based resin composite systems. And Ormisters do really well in reducing polymerization shrinkage. And so that eliminates a lot of those concerns that we have. with shrinkage. So I think that's a great choice. 3M's Filtec One is a great choice. And Ivoclar's Tetric Evo Ceram Power Fill and Power Flow work really well as well. So we have a lot of great options out there. Again, from a restorative standpoint, I want single shade and I want something that I can do four and five millimeter increments on because that's going to be most of my restorative procedures with direct composite. As far as adhesives go, again, lots of great options. We have a lot of great universal adhesives out there. I want a universal adhesive that gives me the option to do selective etch, total etch, or self etch. And I want an adhesive system. that has a little sensitivity as possible. And so again, a lot of great options out there, Futura Bond U by Voco, Scotch Bond Universal Plus, Adhese Universal, All Bond Universal, all really great choices. And I'm the firm belief that as far as bonding agents go, there's no magic pixie dust in any of these. At the end of the day, if you have good bonding technique, any adhesive system will work. If you have sloppy bonding technique, there's not an adhesive system that will work well for you. So I would much rather, Dennis, as far as bonding systems go, focus on your technique as opposed to just deciding to switch systems. You know, I think there are different things that some practices may want. Some practices may want a unit dose. Some may not want a unit dose. And so those are all sort of factors that come in, just the usability of the product. But again, anytime we're talking about bonding agents, if someone's having a problem with a bonding agent, I say, go back to fundamentals, read your instructions for use, go over all those steps. You know, I know this is dogma for you, but sometimes placing a rubber dam, you know, as an endodontist, that's all you're used to. As a restorative dentist, only about... 15% of restorative dentists use a rubber dam even occasionally. So those are all things that can really help as well. So, you know, looking at any universal bonding agent, I think will work well, provided you have good technique and good isolation. Right. But as far as efficiency goes on restorative dentistry, direct restorative dentistry, that bulk fill, the development of these advanced bulk fill products really make a difference with time. Like you were talking about in the beginning of the podcast, how important it is. Yeah, reimbursement is not holding up to where it should be with our costs. So you certainly, our dental practice needs to look at these materials. And I know at my refusion from VOCO has been very well received by a lot of top experts in clinical dentistry over the years. So to wrap up this podcast. And it's BPA-free. Yes. I know you're in Austin, which I'm a Texas person as well. And we all know that Austin is the hippiest city of all the Texas cities. And so if you're in kind of a hippie, granola, crunchy city, you know, you're probably getting questions from patients about BPA. And a Neurofusion Extra is a BPA-free restorative material. And so, you know, if you have that type of patient population. Really great choice for that. Yeah, that's a great point, Dr. Austin. It is really a great point. And yeah, and that's a practice builder because patients, especially like you said, here in Austin, Texas, they're very aware of it. And I think anywhere, once you make it a point to your patients to say that it's BPA free, I think they'll appreciate that fact that you care and you're using products that adhere to those safety measures. With so many class two restorations being done as we wrap up this podcast, why do you think interproximal contacts are so important to direct restorations? It sounds like an obvious question, but there's obvious nuances to all this. Absolutely. Yeah, I think interproximal contact is so underrated. as far as the important part, because if we leave a light or even open or even light in a proximal contact, the patient's going to pack food there. And when they get recurrent decay around that area, which they will, it's not going to be in that traditional contact area that we're used to restoring. It's going to be well below that, and it's going to be down near the gingival area, down into the sulcus and below. And as an endodontist, as we move down that direction, the pulp is so much closer. uh to to that area than it is up in the traditional contact area and so we have these people i have tons of photos of this of people that have had class two restorations done small to moderate class that had a crummy interproximal contact that then led to recurrent decay deep down on the tooth. And so now we started with what should have been a relatively easy class two. Now the patient is set up to have to have endodontic therapy and potentially crown lengthening surgery done to have a tooth restored. And so that's all because we got a crummy contact. And so, you know, I think the days of Toffelmeyer matrix systems are just done. Toffelmeyers were designed for amalgam. that's how they that's where they work the best and most of us aren't doing amalgam we're doing composite so it's time to be looking at segmental matrices as really the choice for direct resin composite and really focusing on getting really good tight broad interproximal contact areas instead of those tiny little contact points that sometimes we get with uh toffelmeyer matrix systems yes any as we wrap up any good recommendations a lot of good ones uh garrison uh 3d xr fusion paladin plus treatant v3 all of these are really great systems that have a really nice ring a really nice matrix selection and then wedge selections as well and so any of those work really well and uh just just getting used to them using them learning how to apply them well will make a huge difference in and how nice of an interproximal contact you can generate for patients, which will definitely help them stay away from more invasive type of interventions. So Dr. Austin, I think you covered this very well in your webinar, as I mentioned in the introduction. So anybody interested in seeing some of the details of what Dr. Austin is talking about today in this podcast, you can go to vivolearning.com and watch the on-demand webinar. that he gave. And it covers a lot of these topics with visuals to support it. So thank you very much, Dr. Austin. I appreciate your time. I know how busy you are and we look forward to having you on our show in the future. Thank you. I appreciate it.