Modern Dentistry Discussion: Crowns, CAD/CAM Tech, and Finding the Right Dentist

[00:00:00] Entertainment Insights Don't Take Life Too Seriously Welcome to Brainsky Unleashed. Welcome to the program. Thank you, Tom. I really appreciate it. It's known you a long time. It's a pleasure talking to you, and I'm glad you're having me on your little podcast today.

[00:00:57] Little... This is... This is big, man. This is huge. Sorry. Nationwide podcast. Let's not... Forget... Forget... Let's not be insulting, Ron. Don't ever insult the guest. Oh, I'm terribly sorry. I actually said don't ever insult the guest. I meant don't ever insult the host.

[00:01:12] So that was my mistake. There it is. That's okay. There it is. Okay. So, Ron, I wanted to share something with you. And this is... This is personal. So why not let the whole universe know? Okay. I had a bad dream last night. Oh, no?

[00:01:29] Yeah. And in this dream, I was having to have dental work on 8 and 9. For those of you who are non-dental people, 8 and 9 are your front two upper teeth. Your two front teeth, yep. Yeah, your two front teeth. And my dentist wanted to put PFMs there.

[00:01:49] And I'm arguing with my dentist in my dream. And Jim, my dentist, if you are watching this, this argument should never take place because I know you know better. Anyway, I'm arguing with him because I don't want PFMs. And I want Zirconia, right? Right.

[00:02:08] Because Zirconia is so much better, but there was some BS with... I had to have some sort of strength in the back and the lingual side, the tongue side. And this just became so vivid. And it started scaring the living crap out of me, Ron.

[00:02:24] And I thought, you know what? I'm going to go ahead and tell this ridiculous story because you're a guy that actually knows about these materials. So for the audience, many of them who have no idea what a PFM is, can you tell that to the audience?

[00:02:40] Because I think people who, you know, they just think, I'm going to go to the dentist. And the dentist says I need to get a crown. And they go, okay. And they're just going to listen to one of the dentists says, why would you not want a PFM?

[00:02:51] Why would we not want a PFM? Okay. Well, first of all, that's a two-sided question because in some situations a PFM is warranted and in some situations a PFM is not warranted. So in this particular situation, in the anterior specifically, I would not want a PFM.

[00:03:09] And the reason I would not is because depending on how good your dentist is and how well he does a preparation line where the crown actually seats and finishes too, that line could theoretically be visible or cause a gray halo or a halo effect in your gum line.

[00:03:28] And it might not be as attractive as an all ceramic restoration in the anterior. It might not. It won't be. Okay. No, no, no, no, because there are some technicians out there that can create some pretty nice things even if there's metal involved.

[00:03:46] So they can, I've seen some pretty nice things. But all in all, I'm just going to say an all ceramic restoration by far will be a PFM in the anterior any day. Right. All ceramic being a zirconia or a material known as lithium-dysilicate,

[00:04:02] Emax is like, you know, I guess the Coca-Cola brand of that. But those look more natural because what a lot of people don't realize is, you know, when people smile and you sort of see like that graying around the tissue there and they get those big smiles,

[00:04:16] that's metal in there. That metal shows through that tissue. It's ugly. Yes it does. Yes it is. It's terrible. And you don't see it as much anymore, which is wonderful. I'm like so anti-PFM. Like I'm just, oh, I hate them.

[00:04:31] But you know, one of the reasons Ron, why I hate PFMs is because you'll never be really accurate with a PFM as far as fit goes and usually clean and natural as far as finish goes. And you certainly can't have translucency

[00:04:48] with them like you can with an all porcelain or an all ceramic because you've got to hide metal and you can't see through metal obviously, right? Obviously. So you've spent most of your career at this point working in a CAD-CAM environment, right? I have.

[00:05:06] For the last 16 years now I've been in the CAD-CAM environment. Right. And so dealing with purely digital. Purely digital. Now, can you have a purely digital PFM crown? Yes, you can now. No, you cannot. Yes, you can. No, you cannot. How do you say purely digital?

[00:05:26] Purely digital meaning that, I mean I suppose the only way that you really can do it would be if it's a full contour crown in metal. Right. Or doing a metal substructure and then pressing porcelain to it, which it's not the most efficient way

[00:05:51] to do it by any stretch of imagination. It's not the efficient way. It's not a great workflow at all. To answer your question, yes, you can have a digital PFM. Yes. All right. You can. It's just not great. Now the all metal Scott Mappin throwing this out there,

[00:06:07] I am bringing Scott Mappin into this. He's not here. You bring Scott Mappin. He's a good friend of ours. Prior guest on my show, that guy is what it means to be full digital all metal. Straight up. I mean that's the greatest finish, the greatest.

[00:06:22] And the reason I was saying PFM and I don't mean to interrupt you. He does that. You have PFM alloys available from Scott Mappin at strategy Millen. And it is so much better than anything else that's out there.

[00:06:35] But okay, so let's talk though about the stuff and let's do it in a way where anyone who's listening to this who may have to get a crown who knows nothing about this. I mean for any of you who says,

[00:06:48] well, you know, I went to my dentist and I got a cap. First of all, it's crap. I'm just throwing that out. Yes. The one vernacular we're going to use here today is it is a crown, right? Absolutely.

[00:07:00] And so if you are on deck to have a dentist grind some teeth out there so you can get a cap or a crown. This may be a really ideal podcast to listen to. It's going to be educational. So Ron, at this point in time,

[00:07:15] is it fair to say that there is at least a growing sizeable amount of dentists that can make these things in their office instead of sending to a lab? Yes, there are. That's actually a market that is growing today in a considerable fashion and rate.

[00:07:32] There's a lot of doctors who want to perform same day crowns and crowns that are milled internally with their team, with their assistants helping the doctor every step of the way and basically getting the equipment necessary in the office to produce these crowns on a daily basis. Right.

[00:07:51] So the backbone of this, and I mean you and I know it really well but let's boil it down so people who don't know anything about it can fully understand it. When we talk about CAD-CAM, what that means is it is CAD being computer aided design

[00:08:07] and then CAM being computer aided manufacturing. In other words, how do you take that design and get it to be made by a piece of equipment be it a 3D printer or a milling machine or something like that. How does that thing get fabricated?

[00:08:21] And even in the doctor's office they have CAD-CAM equipment depending on the doctor whether they have it or not. Is there a benefit to a same day crown and are there negatives to a same day crown?

[00:08:35] I think there are some benefits to the same day crowns, especially for single units. When I say single units for the average person understanding that means one crown or one tooth, it means that it will save them some appointment time.

[00:08:49] It will allow the doctor to complete a same day crown in the office and it is a benefit because they don't have to send anything off. The customer can get service right away and they can leave with a completed crown

[00:09:01] instead of a temporary taking its position in there while they wait for another manufacturer to make it and the doctor can do it step by step with his team. So yes, there are benefits to it because they get the product back faster. What are the downsides?

[00:09:16] The downsides could be shape, could be color, could be fit or the form. There could be mistakes, there could be little drawbacks here and there all depending on how the office is trained.

[00:09:32] If the office is trained really really well and the doctor and its auxiliary staff work well it could be a great success. If they don't, it could be a hindrance and it might not fit properly or it might not work properly.

[00:09:43] So therefore having the file format that if they do a scan intraoral leaf so for the lay person, the CAD portion we need information in the way the doctor or the office takes that information is with an intraoral scanner.

[00:09:57] That information gets transmitted over to the laboratory or to their CAD design system and either way they can produce a crown from that information. So when we talk about that just to really make it simple

[00:10:12] you have two ways of capturing this right so someone can make a crown. So in other words, the doctor is going to take your tooth, they're going to grind it down. You're going to have basic post, everyone knows about the post.

[00:10:23] For those of us in the dental field we call that a prep. For the lay person they've got the post and cap. Well this is actually a prep and crown. So in order to be able to make a crown you have to have an impression

[00:10:40] and you can either do that one of two ways, one of them would be literally sticking the gummy impression in the mouth and it sits there for X amount of time while it sits and they pull it out

[00:10:50] and they throw it disinfected doctors, they throw it in a box and then it goes off to a laboratory and the laboratory then pours it up in stone

[00:10:58] so it goes from a negative to a positive and then that's something that could get scanned in a lab using a lab scanner and then designed for their or in the offices in the dentist offices they have those wands now these intraoral scanners

[00:11:11] and that is essentially a digital impression and so they just run that wand around the patient's mouth and the prep there and then from there the office or the laboratory if they decide to send the file out

[00:11:25] can then fabricate the crown. Now you mentioned that there may be some negatives in the office one could argue that you may still also have the same negatives from a laboratory

[00:11:43] but the likelihood of having those exact same negatives more often from a laboratory I believe in my mind are lower because this is what these people do for a living versus the office so let's talk about that at least on the office side

[00:11:57] where can doctors go wrong if they get themselves CADCAM and how do they prevent it or improve the situation? Well I think the most important part of fixing or improving the situation if they run into a mistake

[00:12:15] is not knowing the workflow or the protocol well and what I mean by that is not knowing the necessary steps from start to finish how to produce the necessary parts to get where they need to go

[00:12:28] so workflow is the most important and following the right steps along the way and training your staff and your team to work with you in conjunction to get the right information is extremely important

[00:12:42] so you rely upon your auxiliary staff to get that information and sometimes they for example the first way which is the impression way they let the assistants take the impression and then the doctor checks it to make sure it's okay

[00:12:55] they do the same thing digitally but sometimes digitally they might not have the background necessary to do that so how do we do that? We offer training and we teach them to improve that situation

[00:13:06] So give me a really good example of that going wrong like it's one thing to say they didn't do it right but what does that look like? How would someone even know if they didn't do that right?

[00:13:21] Well there are ways to notice that on the actual screen and there are different I would say fashions for them digitally to notice that there's something wrong there could be like all kinds of artifacts on the screen that you're looking at that shouldn't be there

[00:13:35] Artifacts like dinosaur bones? No, artifacts like missing pieces to the actual files so that you have holes and large holes or you have let's say artifacts what I mean like extra pieces added on that should not be there

[00:13:52] because things are being meshed together on a regular basis the information is coming in from a camera and if it's not being moved properly it can cause all kinds of additional information that doesn't need to be there

[00:14:03] so it's all kinds of scattered and that's scattered can cause problems where the lab or the person at the dental office can't see what they're scanning or what they need so that they can produce the crown necessary to fit on top of that preparation

[00:14:18] so if it's not clean and if it's not visible properly you're not going to get a good result so these are kind of things flag points you got to pay attention to when you're dealing with digital

[00:14:30] and you have to be taught to pay attention to these things and when you're dealing with an intro scanner there's a pattern in a way to move the scanner and the camera in order to capture all the information

[00:14:41] because a lot of you don't know that the camera itself is a mechanical piece but there are algorithms in the software that control everything for the desired outcome so moving it in a specific way and repetitive consistent proper motion of that camera will give you the best result

[00:15:02] So I'm going to ask you, I think this is kind of a crappy question but I'm going to ask it anyway There's no such thing Tom Oh no this is kind of a crappy question

[00:15:11] But if somebody out there who's listening maybe having dental problems may be afraid of taking impressions I know I for one am a gigantic gagger It's a lot of us out there A lot of us out there

[00:15:27] We could probably have like groups like AA for all of us gaggers to just get together and talk all about that and help each other come down from that fear of A workshop? Yes, we could actually have a gagging workshop which would be great

[00:15:44] As a matter of fact I think that's going to be my new thing But how would someone know whether they should go to their current dentist or should they choose because their current dentist may not have a wand Should they be calling offices? Should they be calling around?

[00:16:01] How does someone figure out what's best for them? It's kind of not a great question because some people may just simply have insurance that dictates where they go That's actually a very valid question Of course it's valid because I asked it

[00:16:15] Well no, it's not because you asked it It's a valid question in the industry So most educated people rely on asking questions or being guided by the professional that they're going to see Some people don't know the questions that they need to ask especially in dental

[00:16:32] What are they? Yeah, what are they? Go ahead Some of the questions are straightforward I usually if I go in and I'm having my teeth cleaned by my hygienists The first question is has doctor gotten into any digital or is there new equipment

[00:16:48] or new things available in the treatment plan? So the hygienist starts talking about it and filling you in on what's available and some of the possibilities that are available Not every office is digitally inclined

[00:17:00] Some of them still want to do the impression technique and send it off to the laboratory So these are questions that you want to ask possibly

[00:17:08] Or find out, hey do you have any modern way of doing this so I don't have to have the impression material in my mouth and go through that goopy situation? Do you do CAD-CAM or do you do same day crowns or what do you offer?

[00:17:21] And even looking at their website as most offices now have a website because of the modern day and age with computers You can see this information because the doctors are sharing it proudly

[00:17:33] to actually bring in more customers and say hey we can offer you this, this, this and this So not only can you educate yourself online but you can ask the questions to the staff when you're there for your regular appointment

[00:17:45] Are there any red flags that people should be looking out for when looking for a dentist It may not even be you know you're sitting in the chair and the hygienist is working on you But it may be you know my tooth hurts

[00:17:59] And I haven't been to a dentist in 45 years because I'm afraid of gagging again Part of the club, card carrying member What are some red flags people should be looking for if they're even calling around looking for a dentist? Red flags that's a hard one

[00:18:16] Ah there's the tough question then That's a very tough question because one we don't want to offend any of the practicing dentists out there But they have to be aware that people are looking at how modern your office is

[00:18:29] How up-to-date your office is, some of the equipment that you carry or things that they see when they walk in Is the waiting room modernized You know do you walk into a friendly environment where everything is kind of up-to-date

[00:18:44] If you're walking into a practice that seems like it's from 1970 and hasn't changed You're walking into a practice that you can probably expect, okay I'm going to get an impression in the doctors like status quo

[00:18:55] And there's nothing wrong with some of those offices and they meet the need But if you want modern and you want people that are moving with the times Or some of the let's say more recent graduates let's say from 2010 and higher

[00:19:10] Those doctors are looking at digital and looking at moving things and shaking things and moving things into the future So these are the kind of doctors you want to look for that will give you an advantage in proper dental care But also state-of-the-art

[00:19:26] Okay, I'm just asking your opinion on this. I have my own Just having dealt with the, never had it done, never had it used on me before But it certainly intrigues me What's your opinion on laser versus drill when it comes to prep work?

[00:19:45] Laser versus drill when it comes to prep work You've never seen the laser? I've never seen a laser drill But I've seen a laser used for tissue maintenance, for troughing and things like that They have lasers that can replace a drill I know something you don't

[00:20:05] Yes you do I've not seen that so that's pretty neat When I owned a lab, I had a dentist who used her laser instead of a drill and would laser off tissue Now my understanding is that it does take a little bit longer than a drill

[00:20:22] A drill will cut away tooth faster But the laser does it painlessly without heat And so you could basically do this without any novocaine at all I mean people may want novocaine for comfort Interesting Yeah it's apparently a lot better in some respects

[00:20:45] From a technician standpoint, it did not provide a clean finish on the prep Which could either help you for cementation and retention Or hurt you for clarity of where's the margin But I was curious if you had an opinion on that one because that's at least a

[00:21:06] I would actually, to be honest with you, I'd probably prefer the old school method Which is actually with diamond burrs and cutting And having the injection to do it because I think like you said, you get a cleaner preparation A finer preparation, more detailed preparation

[00:21:23] And maybe that technology has not come along enough yet to give the desired results That we've been getting for years with diamond burrs So I'm kind of old school on that because I want not only the doctor

[00:21:37] And let's say the internal staff seeing the margin and the finish lines I want the lab to see the finish lines So the details are very important Because if the details are good and you have good details You're going to have a successful outcome

[00:21:51] And the patient is going to be happy And usually the restoration is going to last a long time And then everybody's happy So speaking of everyone being happy One of the things that I know from years of experience is Shade of a crown is important

[00:22:06] Getting the shade right is so critical I mean, the funny thing is patients may not even give a crap about the fit As much as they care about the shade Whereas the dentist cares very deeply about the fit For the long-term health of the tooth below it

[00:22:23] But the shade obviously is important to them Because they want the patient to shut the F up and leave And never contact except for future use of course But where can shade be... How can shade be more accurate? What can be done to improve the situation

[00:22:44] Where the shade is more accurate right out of the gate? Shade is more accurate right out of the gate I'm just trying This is fun stuff Well, it's fun stuff but the question is again

[00:22:54] You know, Vita was the first I would say to come out with the Vita shade guide And shade tomography system So taking a shade electronically So where it would actually put a light in And get a reading back from the tooth

[00:23:09] So that it can actually give you a base shade or base color to work from But I don't think there's anything more accurate than the human eye In the right color environment And I think doctor and laboratory both have to be trained on how to see color

[00:23:26] And understand color And how it changes, how it resonates in what you're looking at And try to achieve base tones and shades that are closer to what the patient has Now I've seen a lot of doctors that don't care anything that happens from the second bicuspid back

[00:23:43] And I've seen a lot of doctors that do It depends on the situation because they're saying anything in the posterior behind that second bicuspid And for those of you who don't understand You have a tooth here that's a smaller tooth than you have your first molar

[00:23:57] And as you move back it gets darker So normally you can't tell as much if the shade is off If you're moving towards the front where you're smiling and you have a big smile line like I do Or like Tom does

[00:24:11] Visibly we can see the shade and see the differences And that's where having an accurate color is extremely important So how do we do that? It's training, I mean I've been doing it for 30 years And color, I was the lead ceramist in my laboratory

[00:24:30] So taking a shade depending on the color effects that are going on around you You have color inside from neon lights You have color from natural sunlight You have color that's affected by the clouds Everything affects the overall outcome of the shade

[00:24:46] So I would get like two or three different views from different directions And I would take pictures And we would use either an intraoral camera to take a picture Or we would use a Nikon camera with light diffusion

[00:25:01] To get the proper color or at least a picture so that we can see this So the dental office if they're working with the laboratory should provide these pictures in file format to the lab

[00:25:14] So that they have something coming that they can actually visually see with the case Now does that happen all the time? No But for a large case in the anterior where people are smiling

[00:25:27] I would say 90% of the time the doctor will send you the right piece of information I'm nodding my head because no it's nowhere near 90% But I think anyone who has an upcoming case to me this is actually somewhat of a red flag

[00:25:43] Not emergency, shut the whole thing down, go to different dentist, pull the fire alarm and run Or if you're in Congress the fire alarm someone may just believe it's like a unlock button Which I'll figure But they're brilliant, totally brilliant people

[00:25:59] Best people on earth in Washington, smartest people ever But let's not go But one thing that I think is if you're a patient and your doctor has this gigantic picture window Right there in the operatory, that may be great for you to look out over the peaceful serene

[00:26:19] Or maybe the traffic on the bridge that's right outside the window or whatever it is But that's not actually a great thing for shade taking Because that light actually conflicts with the light that they may have above their heads It may conflict with the lights in the room

[00:26:35] So getting shade is not always the easiest thing on earth And I agree with you completely Sending pictures is really important so I would encourage patients to actually step up and speak up And say hey listen, can we get pictures sent

[00:26:51] And that will probably get the patient a better outcome I agree Of course you do I absolutely agree You should, if you didn't, you and I would have words We're not having rules when we agree with each other We're actually being quiet which is really funny

[00:27:05] I would not buy you sake anymore No you would not I would buy you sake, come on Alright So Ron, we're kind of running a little bit low on time I would love to have you back as a guest

[00:27:18] As a matter of fact I would even like to take this show live at some point And just banter because I happen to love you and you're so dashingly handsome Well I appreciate that, I would love to also

[00:27:28] And you know the fun thing in this conversation is we never got into material And there's a lot of material choices out there And I help and work with a company called America's Smiles Network That happens to sell a lot of great material Also equipment

[00:27:42] And I want to put my little plug-in for America's Smiles Network Because they're a great team and a great bunch of people And I associate with them on a daily basis And I answer questions as well as sell service and support

[00:27:57] So I can carry this on for them But for those doctors out there I was getting to the plug For those doctors out there I am putting on a wonderful seminar in Las Vegas with Daniel Portal Who is an exocad expert

[00:28:12] And I am doing the machining side and material side And we are doing a two and a half day seminar in Vegas That we would like to promote And say that if you come to Vegas Your auxiliary staff as well as yourself

[00:28:27] Will learn great workflow from inter-oral scanning Through design, two milling and material choice In two and a half days and it's a very all-encompassing program Where in Vegas? We are doing it in Vegas at an educational building That is not on the strip

[00:28:44] And all the information is provided to you on our QR code That is on Facebook, LinkedIn, Instagram And you just have to look for it And you can register for it there And we look forward to educating you And enlightening you and hopefully sharing some good times

[00:29:02] And bringing you guys up to speed In a digital world that is changing on a daily basis Alright so we are also going to have to get that link And put that link in the bottom of the Whether you're watching this on YouTube or Facebook

[00:29:16] Or Instagram or what it is And all of our amazing distribution channels for the show So we have to make sure that we have that link for everyone In addition to going to their... Thank you again Ron so much Thank you for jumping in and plugging

[00:29:29] Even before I gave you the opportunity Because you know me so well and knew exactly where I was going to go And that by the way ladies and gentlemen That friendship is about... And Saki And Saki Yes Doctor Thank you Doctor Thank you Doctor