Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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234 Minimally Invasive Dentistry with Dan Fischer : Dentistry Uncensored with Howard Farran

234 Minimally Invasive Dentistry with Dan Fischer : Dentistry Uncensored with Howard Farran

11/21/2015 2:00:00 AM   |   Comments: 0   |   Views: 572

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VIDEO - HSP #234 - Dan Fischer

Dr. Dan Fischer, founder and president of Ultradent Products, Inc., shares the minimally invasive approach that surrounds everything he does.



Dr. Dan E. Fischer graduated from Loma Linda University in 1974. Following graduation, Dr. Fischer maintained a full-time private practice for 15 years. Since 1990 he has been practicing dentistry part time while working extensively in the research and development of many products used in the dental profession. He is president and CEO of Ultradent Products, Inc., an international dental manufacturer that owns and operates offices in nine countries throughout the world in addition to its U.S. headquarters. In 2013, the Utah Governor’s Office for Economic Development named Dr. Fischer International Man of the Year for Ultradent’s success in establishing and sustaining economic and cultural relations throughout the world. The Loma Linda University School of Dentistry named Dr. Fischer Alumnus of the Year in 1994 and bestowed upon him its prestigious Distinguished Alumnus Award in 2002. Additionally, Dr. Fischer has received several nominations for the Ernst & Young Entrepreneur of the Year Award. He was also awarded the Lifetime Achievement Award from the AACD in 2005, and he was inducted into the American College of Dentists in October 2011. He currently serves as an adjunct professor at Loma Linda University and the University of Texas at San Antonio. He enjoys maintaining a rigorous lecturing schedule where he presents to students and fellow clinicians around the world every year


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Howard: It is a huge honor today to be interviewing one of my absolute idols, Dan Fischer, the CEO and founder of Ultradent, who needs no introduction. Dan graduated from Loma Linda University in 1974, where I actually took my boards, Dan, in 1987. Following graduation, Dr. Fischer maintained a full time practice for 15 years since 1990. He has been practicing dentistry part time while working extensively in the research and development of many products used in the dental profession, many of which I have been using for 28 years. He is president and CEO of Ultradent Products Inc, an international dental manufacturer that owns and operates offices in 9 countries throughout the world in addition to its US headquarters.

In 2013, the Utah governor's office for economic development named at Dr. Fischer international man of the year [inaudible 00:00:54] Ultradent success in establishing sustaining economic and cultural relations throughout the world. The Loma Linda University school of dentistry named Dr. Fischer alumnus of the year in 1994 and bestowed upon him its prestigious distinguished alumnus award in 2002. Additionally, Dr. Fischer has received several nominations for the earnest and young entrepreneur of the year. He was also awarded a lifetime achievement award for the AACD in 2005 and was inducted into the American College of Dentists in October in 2011.

He currently serves as an adjunct professor at Loma Linda University and the University of Texas at San Antonio. He enjoys maintaining a rigorous lecturing schedule where he presents to students and fellow clinicians around the world. Dan, it's an honor to have you today. First question I want to ask you is, I'm not ever going to compare myself to you, that would be like a, that's just going to happen. You're just amazing. You were always a father figure to me. You've been giving advice from family to personal to raising children. I have 4 kids, you got a bunch of kids. My son Ryan, come here. I am so lucky, can you see Ryan? I got 4 boys, 20 ...

Dan: Absolutely, good looking young man by the way.

Howard: Yeah, their mother was good looking, they lucked out. I got 4 boys, 20, 22 24, 26. 3 of the 4 work for me. How many of your children work for you?

Dan: There's about 4 direct kids and 3 son in laws.

Howard: 4 direct kids and 3 son in laws?

Dan: Yeah.

Howard: What advice would you give to my son Ryan here, and to me, what advice would you give us when your son works for your old man?

Dan: I'm going to say it depends on what point in time. My kids helped to start Ultradent. They worked when they were 6, 7, 8, up through teenage years helping make the samples, stuffing the envelopes and the like. In that age, yeah, you have to tell them in nice ways what they need to be doing. Then when they start to get up into adulthood, you have to shift gears a little. The advice to your son at his age and your older sons is, have patience with us guys as we get a little older.

The advice to Howard that I found that least is important for me is that I should listen a little better and listen a little longer. Not jump in, never cut them off, wait until they're done talking and then process in a good way. To show respect for their intellect and for even demonstrating our own intellect that each person is so important. It's so important that they be heard and that they get their entire message out. I think back to my younger years as a father. I would bet that I could have learned more from my kids if I wouldn't have cut them off so fast. I've really worked with myself to make sure that I never start talking until they are totally done talking.

Howard: Same goes with patience too.

Dan: Absolutely. It's across the board and in the company with every employee, with every manager. Even on the manufacturing floor/ we especially need not only their hands but we need their brains. Certainly they will see and know of problems that we can't even hope to know. That's it.

Howard: It's funny, the only time I think my 4 boys have ever seen me cry is the day my dad died 16 years ago. I cried like a baby and I moped around. It took me a little bit of time and I realized, you know what, I'm crying for myself. I realized at that point that the circle of life that dad's gone, and I want to turn around and I want to make sure that my boys cried like that when I died. What's funny is our generation, 90% of all the memories I have of my father, or at least 80%, probably 80% of all the memories I have of my father was going to his restaurant and working with him. A lot of people always thought, oh man, you work a lot. It's like, I never considered it work when you're going to work with your hero, your idol, your best friend. I would rather be sitting there at the restaurant peeling onions making onion rings and cooking hamburgers and fries at a Sonic drive in than sitting at home doing what. 

Dan: Yeah, absolutely. Doing that at a young age helps us develop on a path for adulthood responsibility like nothing else can. In fact I strongly believe that our laws against child labor have gone a little too extreme in some cases. It's so healthy for kids at an early age to take on the responsibility of work, and even working around quality adults as that helps prep them, if you will, for their own adulthood.

Howard: Not letting a child work until 16 is absolute racism. If your father owns your own business, I'm in Arizona where a lot of Hispanics own their own landscaping and stuff. They bring kids into my yard every Saturday and they're with their dads and uncles and brothers. I always worked with my dad and we got paid and we had money. If your dad doesn't own their own business and the government says you can't work until 16, what do they do for money and leadership and mentors? That is just a horrible law.

Dan: It's totally wacko, it's totally wacko. If kids don't learn the value and an appreciation for hard work in their young years, it's much more difficult for them to pick that attitude, that mentality characteristic if you will after 16, after 18, after 20. I often tell dentists when I'm lecturing to them that if you can teach your children no more than 2 things, they can become anything they wish become on planet Earth. Number one is teach them quality values, but number two is teach them a work ethic with the love of work by working with them by keeping the work fun and enjoyable, enabling them to discover that good feeling of accomplishment, of virtually immediate reward with what they can do themselves. It's great.

Like you, I would say at least 80% of my memories with my dad is the same, be it in his excavating business, when he was a carpenter, electrician you name it. Yeah, as a young boy when you're working with men, when you sit down to lunch you feel like you're one of the men. When you've finished the job, you feel like you're one of the men that help make it happen. Learning how to feel like a man in teenage years, especially for boys, that's a big deal.

Howard: When older people would come into Sonic drive in, and my little baby sister Shelley was 8 years old trying to make change and she getting it wrong, the customers were helping her and showing her no, you don't put the change in, you lay it on the top so you remember what they gave you. The customers loved it. If you go into McDonald's and you're offended that a 12 year old poor kid in the inner cities got a job and wearing a uniform and being with managers and role, if you got a problem with that then you're just not right in the head.

Dan: Absolutely. It does worry me however. Every generation that goes by that precludes these kids from not working until they're 16, yeah, it warps the head and makes these problem-type people when they see someone younger working.

Howard: What's the substitute, they're going to sit home and play video games and get into drugs and sex and alcohol because they can't go get a job and make some money and buy the clothes or shoes or whatever it is they want, whatever's motivating them to want to work? I want to start with a macro question, because you graduated in 74. How long you been doing dentistry?

Dan: Oh my goodness, that means I've been doing dentistry for, shoot, 40 years.

Howard: Let's see, 2015 minus 1974. I'm going to defer this to Ryan because I can't remember my algebra. Let's see, 2015 minus 1974, 41 years. Why does 74 ring a bell to me? I graduated in high school in 80. Dan, I want to start with macro, macroeconomics. You've seen in this industry for 40 years. Is it a healthier dental industry in 2015 than it was in 1974? Has it gone down a wrong path, a good path, is it better, worse, the same, anything different? We've lived through a lot of monsters. I remember when I got out of school in 87, everybody capitation was going to rule the world and we're all going to get paid 9 dollars a month per person whether they had 20 cavities or none.

I remember when I got out of school, orthodontic centers of America had made it to the New York Stock Exchange with a billion dollar cap. Every orthodontist I knew thought they'd be working at Walgreens or orthodontics in a box. That exploded, there were a dozen publicly traded on NASDAQ, they're gone. Now you see the heartland dentals, the Pacific dentals. Is the sky falling? Is the sun rising, is the sun setting? What would you say to a kid who's just finished BYU and saying, "I think I want to go to dental school." What would you tell that kid?

Dan: I'd tell them go for it, absolutely. In fact you're going to do better at what you enjoy than forcing yourself to do something you don't want to do. Yes, it has changed. Yes, some of the change I think is for the better. Depending on which generation you are, it might be considered not as good. For example, one of the greatest changes you pointed out, the DSOs if you will, the large group practices, this has made a major impact. Shoot, within the next 15, 20 years we could see possibly 60 to 80% of dentists working in such an organization.

That can be good, that can be bad. If your mentality is that you want to be your own boss, that's not good. If your mentality is that you want to have a good quality of life that you don't want to hassle the business aspects, the HR aspects, you just want to perform your dentistry, that can be good. Certainly the large money tycoons, if you will, are driving this the most. Their model as a rule and the model of the smaller groups is to build a group, get it up to say 8 to 12 docs, and then sell it to a heartland, a larger organization. This trend is continuing and will continue whether we like it or not. Certainly the cost of education that young people incur now going through dental school can make it pretty challenging for them to go out and start a solo practice.

That being said, I think that can be overcome if they could put more attention on yes, working part time through dental school when and where possible, living frugal, not having fancy cars, learn how to suck it in and live with your belt tightened a bit going through your school years and additionally when you come out of dental school. Don't go outlandish and feel you have to have a 6 chair office and all the fancy latest equipment and the like. Start with 1 or 2 chairs if you like and grow into it as the money will allow. I think when young people get DR in front of their name, they can too often feel like okay, it's all easy street from here on. Take on as much debt as you want. This can get them in trouble. They need to learn when to live on a tight shoestring and then loosen is up little by little as they gather and glean patients around them and build their base.

Howard: Speaking of working during dental school, I think that's great. Living frugal, that's advice for every single human on earth. Humans almost never figure out in their entire life journey that every time they spend money they increase the stress in their life. Back to setting up a dental office, you say you don't need all the bells and whistles. It's 2015, for a young kid getting out of school, $300,000 in debt, do they need $140,000 Sirona, Dentsply CAD/CAM CEREC machine, a $100,000 CBCT laser from iCAD or Carestream or a $75,000 laser or these oral scanners? What would you say to a young kids opening up an office with $350,000, they just rented 1800 square foot, they plumbed it 4, they're opening 1 chair and they're saying, Dan, for me to market and be a high-tech 2015 modern dentist, do I need all those bells and whistles? That's another student loan debt.

Dan: Yeah, I would say absolutely not. It would be foolish, as that equipment is going to be setting 90% of the time, maybe more if they've managed to buy a practice with an existing pool of patients and they feel they need a CEREC. Okay, the rest of the stuff is already there, go for it. It's foolish to buy all of this expensive equipment when there's no patients to use it on. That payment comes due every month whether the patients come in the door or not. 

Howard: Dan, you personally, how many dentists do you know personally that have a million dollar practice and take home 3 or $400,000 a year and they do not have a CAD/CAM, a CBCT, a laser, or an oral scanner?

Dan: I know of a number of them.

Howard: What percentage don't have any of those toys?

Dan: I'm shooting from the hip, but I would bet that 40 to 50% don't have all those toys.

Howard: Yeah. My circle, I'd say 85%.

Dan: 85%, okay.

Howard: We're saying between 50 and 80%. Is that what your number was, 50? What did you say?

Dan: Yeah, 50.

Howard: You're saying half of them don't have one of those things and I'm saying 80% don't have. 4 out of 5. Why would a kid with $300,000 in debt think they need to go add another $300,000 for all that stuff? Did P. Dawson ever practice with a CBT or a CAD/CAM?

Dan: Sure. That makes total sense. Certainly CAD/CAM is one of the least interesting devices to me in my mentality, as I've come to really embrace and love the virtue of minimal invasive dentistry of not cutting away tooth structure simply for the need of a material, but rather to be as conservative as you can, simply excising the lesion and then using technology that enables you to bond to the tooth, dentin and enamel. CAD/CAM is not conducive to that type of dentistry.

Howard: In case that flew over a young kid's had, what you mean by that is that a lot of times after you get [inaudible 00:18:17] decay, you got to open up the axial walls, you have to prepare it. Explain in detail what you meant in case that went over someone's head.

Dan: If you're looking at an inlay, an onlay, yeah. You've got to create craft, you've got to have the walls in the case of an inlay. They got to be diverging so that the restoration can be put in and out in the case of a crown. You have to cut in for the same reason so you can put that crown in and out. With the new modern materials versus the metals we were using, you're very often having to reduce circumferentially a greater amount of the tooth structure and occlusally a greater amount for these lithium disilicates, zirconiums, and the like. There's many reasons that I'm not a fan of CAD/CAM dentistry.

That being said, we both know that CAD/CAM dentistry is growing. One of the hottest items of a consumable for the supply houses today are these blocks, if you will. There's a strong competition for who is going to be able to offer the greatest and best blocks. That generates expensive dentistry. I also feel that we have such a large segment of our fellow Americans who are underserved simply because they can't afford that kind of dentistry. When you can eliminate wherever possible the need of laboratory work or a CAD/CAM, you can bring more affordable dentistry to those patients. You still feed your family well, you've eliminated the need for, in the case of CAD/CAM, that expensive machine and the like.

In the case of laboratory, eliminated the need for the second appointment, the provisionals, the impressions, and the laboratory costs at the next appointment. Yeah, every time you have a different patient in the chair, all of the costs of preparing that room for the next patient, all of the disinfection, you can eliminate all of that and feed your family well and you're charging your patients less. The patient wins, you win. That's the type of dentistry that excites me.

Howard: I tell my boys and all my employees every time I get a chance, you got a brain and 2 eyes. You keep one eye on the customer, the patient, and you keep one eye on cost, and you use your 3 pound walnut brain to figure out how you can drive down costs. When you drive down costs, the only secret to lower prices is lower costs. When you drive down costs, we can have lower prices, and then we give our patients the freedom to afford to save their teeth. Once we're using our brain to drive down costs and we take our eye off costs, now our patients can't afford to keep their teeth. Losing teeth, I've seen women bawl like they just lost a family member when you inserted their denture.

Dan: Absolutely. It's an emotional castration to them when those teeth are removed. I've seen women, you just take their denture out and they are virtually and panic attack. Having your teeth is a big deal. In fact, teeth, they're multifunctional organs. They're not just for chewing. They are there for maintaining the lips, they are the picture in the body language articulation of the lips. The lips are the frame, the teeth are the picture. A little upturn here, downturn there, a thousand words communicated in an instant. When you don't have teeth, think about kissing someone you love. You come to a nice warm kiss embrace, and your upper centrals move a centimeter distally. Not a pleasant thought. Teeth are multifunctional organs. They are emotionally critically part of our anatomy. To lose them, it is an emotional castration.

Howard: You know Dan, I'm single and live with a cat so I don't even know what you're talking about. That was a joke.

Dan: You're still a young guy. That could change, Howard.

Howard: Back to, you're talking about the blocks. Do you think the block business had to do with Dentsply while merging with Sirona?

Dan: Absolutely, just the whole overall trend of increasing CAD/CAM. Boy, yeah. I could see with Dentsply behind that and the technology of Sirona. That was a pretty smart business decision.

Howard: Go into detail, why was that a smart business decision? When it comes to mergers and acquisitions, I know firsthand that you and Ultradent are one of the hottest targets in the industry. What do you think of the details of that merger? What was the overall strategy?

Dan: I think they get the multiplying benefit of the sales force, power, distribution channels globally of Dentsply. With the technology that is developed reasonably well to this point in time of the CAD/CAM, and certainly, yeah. The more dentists they can get aligned on that, the more they can zero in on the block business, which is that consumable item that will continue as long as they're using CAD/CAM.

Howard: Does Dentsply have a good block, do you like their block? Do you think it's a good block?

Dan: I'm not an expert on blocks. I will tell you that the rigid materials like a zirconia, there's times and places for it. It gets overused. For example, zirconium is twice as rigid as enamel, twice as rigid as feldspathic porcelain or lithium disilicate. It is the absolute most resistant to flex of any material we've ever used in the oral cavity. It can be as strong as stainless steel, but it gets overused. One of the more important subjects that's not taught as well in our dental schools as it should be is teaching students, dentists to align the flex modulus, align the flex modulus to that tissue that's supporting it. Meaning that yes, if you're doing a ceramic veneer, try and keep as much of that preparation and enamel as you can simply so that you've got a similar flex moduli of ceramic coming and being part bonded to a similar flex moduli enamel.

When you have a large restoration, be it an onlay posteriorly, 80%, 90% of the support is in dentin, to put a very rigid material on a flexible foundation is not good. In that case, they're better off using a resin block or maybe one of these new hybrids that's partially resin, partially ceramic if you will. Certainly any kind that any block is used to create an onlay that ends up having the margin end on the occlusal, they've got to be thinking hydrophobic [leading 00:26:11] composite, not these goofy self edge resin cements and the rest as these CAD/CAM margins, versus what you and I grew up with, which with a gold onlayer inlay, you could burnish that to where you had a few micron gap. It's very ordinary for the CAD/CAM onlay to have a 70 to 150 micron gap. Now you've got to look at that if it's on the occlusal as though it's a class 2 composite and use a material that can withstand the forces of mastication and the like.

I know I extended a bit beyond the blocks here, but I'll tell you Howard, one of the biggest problems that we see is, let me back up. When I graduated out of dental school of my first years of practice, probably the same for you. We could address 95% of our restorative needs with approximately 6 materials. You had Copalite amalgam, you had zinc phosphate cement one brand only, Flex, you had ZOE, you had gold, you had ceramic, feldspathic porcelain. You could address 95% of those needs. In today's world, oh my goodness. There's over 100 brands of bonding agents.

There's probably a like number of composites. You've got how many categories of cements now? The more recent one, calcium phosphate, steel zinc phosphate viable if used correctly, but it's not used much today. Glass ionomer, resin modified glass ionomer, self-edge resin cements. How many brands in all of those categories, versus just the metals that we dealt with earlier? Lithium disilicate, how does one prepare the surface before they cement or bond or loop? Zirconia, how does one prepare the surface before they cement, loop, bond, whatever? There's so many different combinations, permutations, if you will, of all the scads of brands and materials that it can be tough for the dentist in the trenches to keep track of all of it.

Yeah, at the end of the day if it's not addressed right the patient pays the price. They don't even know what the problem is. Sad to say they will even take the blame onto themselves when something fails in a year, 2 years, and look up the doctor with the big doughy eyes, say, "Don't feel bad doc, I just have soft teeth." It's gotten much more complicated in dentistry. It underscores the need to become an eternal student. Once you graduate, just make the commitment, you're a student for life. Change is great, but change means you got to change what's up here as well to stay on top of it all.

Howard: Dan, when I look at those 6 materials, Copalite amalgam, amalgam is extremely antibacterial. Half of it's mercury, the other half silver, zinc, copper, and tin. Every one of those ingredients, [inaudible 00:29:42] don't like teeth, zinc phosphate, the zinc was very antibacterial and very resistant to water absorption. Zinc oxide and eugenol, God, eugenol is antibacterial. Gold, it's high energy level. I see gold foils on 80 year old ladies where you can see the gaps between them and there's no recurrent decay. Then they had a root surface cavity filled with an inert plastic composite, and 3 1/2 years later it's got root surface decay. The gold foil is still as beautiful.

Do you think the aesthetic health compromise of getting rid of all these bacteriostatic things that we used to use 28 years ago and replace it with a bunch of inert plastics because we want to be cosmetic dentists has really shortened the lifetimes of restorations? Whenever I see amalgams in my patients, a lot of them are 40, 50, 60 years old. The other thing, Dan, is when you take out these amalgams, yeah, there may be some black scuzz, there might be a little bit this or that. When you take out some of these composites, it's oatmeal. It's number 4 round bur. Obviously the bugs, do you think the aesthetic health compromise, do you think going to all natural tooth colored restorations in the last two decades shortened the lives of all these restorations?

Dan: I'm going to answer in a way a little bit different than what you may think. What you just explained in my mind, more important than the material is, did that dentist get the education they needed to learn how to handle these new materials? For example, okay. The amalgams, I see them 40, 50 years. Very often however what fails is the tooth, the buccal cusp fracturing off of the upper or than mesial buccal fracturing off of the upper molar. With that expansion, contraction, with the sharp internal line angles, with the retentive grooves, that weakens the tooth. From my point of view, the tooth has to be prepared to meet the needs of the material, namely the amalgam, versus with a bonded composite it can be the reverse.

What is a little hard on my brain is when dentists simply compare composite versus amalgam. A composite is not a composite is not a composite. For example, when that dentist prepared, did that dentist use a caries indicator to make sure that every bit of the soft stuff was removed on the reality that you wouldn't be placing a composite except for using a quality bonding agent. Yes, there's only about 6 bonding agents of the 100 brands that I consider truly non-compromising. To break dentin from itself, it requires approximately 100 mega pascals. A non-compromising adhesive can bond to mineral mother dentin at a level of about 70 to 80 megapascals. That's a phenomenal strength, but you're going to have virtually zero adhesion if there is any stuff left in.

Some of our students are even taught in some schools that you should leave affected dentin, only take the infected. That's impossible to know as a dentist. It's goofy to be using a plastic round bur to try and keep more of that affected dentin intact. At the end of the day, you have to remove every bit of the soft stuff and be adjacent to mineral mother dentin, mineral mother enamel, then use a non-compromising adhesive. Then that first increment of composite, adapting it perfectly to every square millimeter. any place you entrap an air void between the composite and that adhesive layer, you've got zero adhesion once again. This is one of my the concerns of a bulk fill is not adapting very well against the bonding adhesive.

When you consider what is the most important aspect of that composite that needs to be totally polymerized to the greatest level possible, it's that composite immediately adjacent to the adhesive. Dentists, they see marketing materials teaching how many megapascal bonding agent A bonds to dentin, to enamel and the like. To have adhesion, it requires a mutual attraction. It requires quality adhesion between the material and the bonding agent, not just between the bonding agent and the tooth structure. Okay, you then construct your restoration, maybe it's 1 or 2 increments after. I myself, I like to have an enamel shape for the last layer. Usually it's taken 3 layers. One that's super adaptive, one to fill in for dentin, then I like the enamel shape.

Another big subject is the curing light. Oh my goodness, when curing lights first came on the market, Howard, we had garbage problems back in the era of halogens. Broken light guides and bulbs that should've been replaced before they blew. There were all sorts of tricks that manufacturers took to try and compensate for garbage curing lights. Today we have a crazy influx of Chinese curing lights. Any little ma and pa shop that figures they can attach LEDs to a board and wrap a handle around it become curing [inaudible 00:36:08] manufacturers. We don't check it adequately at our borders.

One of the worlds authority, I would say Fred Rueggeburg is probably one of the world's authorities in caring right. Another one is Richard Price up in Dalhousie, the dental school of Nova Scotia. He studied about a dozen of these el cheapo curing lights that you can get for 100, 150 bucks, and they're garbage. They do not generate enough energy to adequately cure the composite. He estimates that there is multiple billions of dollars wasted for composites that are under-cured, that break, that fail simply because there wasn't enough energy driven into them to totally convert to the maximum monomer to polymer [inaudible 00:37:07] then to the level at which it is polymerized.

This can be a major problem in our country, yet a dentist can take a little handheld meter, a little demetron meter, put one of these Chinese curing lights on it and they'll peg at say 1100, 1200 milliwatts per centimeter squared. They think, wow, I've got a powerful curing light. Milliwatts per centimeter squared has become a marketing catchall for how to evaluate curing lights. In the first place that little handheld meter, the sensor [inaudible 00:37:50] right in the center and it's designed with a step type of funnel to keep that light guide positioned right so that the center of the beam of that light guide goes right to that sensor.

Dentists should start, instead of just putting it on the meter, they should start sliding that light guide sideways across it and watch how much that needle drops when they hit into the middle portion and the outer portion, as that varies dramatically. Additionally, milliwatts per centimeter squared can be made a large number 2 ways. One is to increase the numerator and the other is to decrease the denominator. You take and funnel those photons down into a small little footprint, put it on the meter, boom, you spike the meter.

Now if you are using it correctly, you may have to cure in 3 to 4 locations for an MOD on a molar if you will, which few dentists do. You need to be looking at a light with a big footprint [inaudible 00:38:57] MOD on a bicuspid in one shot, and that is powerful across the entire footprint and that ideally even has added wavelengths to address some of these proprietary initiators that have been used to a greater degree in the name of aesthetics over the last 15, 18 years if you will.

I often tell dentists, I say there are 2 products that just as per the brand that you choose to purchase have a greater effect on the integrity of your composite restorations more than any other factor. One is the bonding agent you choose to use, as some compromising adhesives, single bottle adhesives will be as low as 15 to 20 megapascals. A far cry from a noncompromising one at 70 to 80 megapascals. One is your bonding agent. The second is your curing light. There's a lot of garbage curing lights being used. It makes me cringe when I think of the number of restorations that are cured with these goofy little el cheapo curing lights.

Yes, it is good for dentists to pay attention to their costs, but there's some places that they shouldn't compromise on. If the dentist has integrity, it's going to cost them more replacing filled restorations that fill prematurely because they didn't use a quality bonding agent or they didn't use a quality curing light. Those are places they shouldn't cut costs. Sad to say for most of the patients out there, it's the patient that too often pays the price.

To come back to your original question, a composite is not a composite is not a composite. We all know we wouldn't be placing composites at least posteriorly without bonding agents. Number one, did that dentist who did that composite before they use their bonding agent, did they use a caries indicator and get all the soft stuff off? I'll confess, I avoided using a caries indicator for years. I thought after the number of years I've been and dentistry, if I couldn't identify caries, something was wrong with me. I finally started using a caries indicator and I was discovered something was wrong with me. You think you got it all out, and you don't. You cannot bond to what you cannot etch, and you can only etch mineral. You can't etch soft stuff, you can't etch collagen. You must be adjacent to mineral in order to etch, be it with a self etch or a phosphoric acid etch.

Yes, did they etch the appropriate amount of time? Did they follow the instructions in using that product? I share a fun little story. Some of our grandkids and my youngest son Austin who helped work with your son Ryan to get us live on Skype, oh my goodness, what a godsend these young people are to us Howard. We'd be toast without them. They're a godsend. Years back when they were in the ages of 8, 10, 12, they like to go with their dad to the lab and bond composite to natural teeth. In a competitive way, who could get the highest bond strength for a set of 5? Little Cambrie, a little redhead like her like her Nana, my bride [lee-nee 00:42:52] She asked her dad, "Dad, how much money would you give me if I can get a higher value than what your technicians get?" He had shared with them that for a set of 5, they got it at an average of 82 MPA. "What will you give me, dad, if I can beat them?"

On her first set of 5 she hit an average of 75, which was higher than what any of the professors had gotten that we'd been bringing into Ultradent for 28 years now, but doing just hands-on bonding with them probably for the last 18 to 20 years. It was higher than any of the groups of dentists that we'd brought in. Why is it that Cambrie beat beat all of them? We find one of the greatest challenges in teaching quality adhesive dentistry is in first un-teaching everything they've been taught with amalgam and the like. In fact, this is one of the greatest challenges I have with us continuing to teach amalgam is it puts confusion in the minds of the dental students, because to do a quality bonding composite, there's so many aspects that are diametrically opposed to a quality amalgam, starting right with the design of the preparation on through. You've got to follow instructions.

Cambrie had nothing she had to be un-taught on. She followed what her father taught her at each step, watching even the sweep hand on the clock to get that 20 second etch, making sure that after she aired thinned the adhesive, she air dried for 8 to 10 seconds to get the ethyl alcohol out, to get the booze out. If you polymerize with booze in your bonding agent it'll be drunk, it'll be weak. Then using a powerful curing light with safety glasses so to keep the head of that light right over what's to be cured, not drifting, wandering so that energy doesn't go in. She paid attention at each one of those steps and well adapting that first increment. She beat everybody else. It's the un-teaching that can be a challenge.

You take guys that have just been doing amalgam a long time and just turn them loose without any education on how to do a quality bonding composite, there's a lot of places they can screw up. A composite is not a composite is not a composite. If you look at reports, and it's hard to generate enough numbers with just a couple dentists. If you look at reports of levels of success with well trained dentists in composites, they go much longer than is the norm. I have bonded composites that have been in the oral cavity for, shoot, since 1990. My daughter Dr. Jessica, she's graduated 13 years ago. She's never placed an amalgam, but she's got these composites that have been in from when she first came out, and no problem. A composite is not a composite is not a composite.

I will confess that a bad amalgam is better than a bad composite, for some of the reasons you just pointed out. The antibacterial effect, the ability to corrode to fill in to compensate for gaps with a bonded composite. It is more technic sensitive. You have to pay attention to detail. You can't afford little voids at the margin and the like. There's more places to screw up. That is the story that we started from, just with the hundreds of brands of all the different materials and all the types of materials. How does a dentist keep track of all of that? For sure they need to focus on materials that they know are the best they can find for those critical ones. Yes, they should zero in on a few options.

If they're doing CAD/CAM for example, and that restoration is supported principally in dentin, use a resin block. Use something that's going to flex more, and bond it in well. If it's a tooth that's mutilated that's a molar maybe with a root canal, okay, you're going to bond in some pre-stress fiberglass post and build your core. Yeah, a zirconia crown can be very good there. Yes, avoid the self etch resin cements. I call them Trojan horses. I often say that our materials that we use, they come about either from history or from science or from marketing mentalities. Marketing mentalities have the capability of creating a fashion.

Laser can be over-promoted as a fashionable need for a dentist to appear high-tech in the dental office. For a general dentist to have a 60 to $70,000 CO2 laser makes no sense. They'll never be able to justify that just for cutting soft tissue. Yeah, you look at the segment of self etch resin cements. Wow, the dentists, they hear self etch, that means fast. They hear resin, that means strong. What they fail to realize is now you've got an acid component with a resin. Acid and resin aren't good for each other together. In fact with a number of self etch bonding agents, the bond strength will decrease significantly in the bottle, the sealed bottle, never opened within that container shelf life as that acid and resin are reacting if you will and breaking it down.

Additionally as a general rule, the more hydrophilic a resin is, the more it's going to absorb water as a polymer. As a general rule, a more hydrophobic resin when polymerized is going to be more resistant to water degradation than a more hydrophilic one is, if you will. These sets cements of self etch resin cement absorbing water can cause that to actually swell and actually displace that restoration. This has become a major challenge in modern dentistry. I'm part of a long string blog that has been orchestrated by Dr. Bruce Leblanc down in the Bayou.

Howard: I love Bruce.

Dan: Isn't he a quality guy? I think he's wonderful. He's only been placing composites for what, 25, 26 years? He's got scads that are out for that length of time. He works in control, he's controlled the saliva, he's controlled the bleeding. That's another place that dentists can screw up. If they're addressing say a sub-gingival or near-gingival margin, if they're addressing that and there's bleeding around it and they're attempting to use a bonding agent, it's going to fail without question. You've got to work in total control. Another example of where composite is not a composite is not a composite. Amalgam is going to be more forgiving in that instance. That goes without question. It still does compromise that amalgam to be placing it in the presence of bleeding and/or saliva, if you will.

Bruce threw out a picture. I think it was 2 Thanksgivings ago on this blog. It was a zirconia restoration onlay. It had failed after 2, 3 years. He says, "Guys, tell me if you're seeing what I'm seeing or not. I'm seeing an increased incidence of these type of failures." It was amazing as the gurus chimed in, some had some good suggestions of what would have prevented it to fail, others didn't have good ones. A fabulous prominent aesthetic dentist who lectures a lot chimed in that a company had encouraged him to use their self etch resin cement. After a short time, every one of the 65 crowns he had submitted with it he had to redo.

Howard: Dan, I think a lot of people might not know the technical self etch resin cement. Do you have any name brands you can name? Can you name names?

Dan: Yeah, those that are noncompromising?

Howard: No, you said you don't like self etch resin cements. What are brand names of that category?

Dan: I don't like any of them.

Howard: Can you name any brands?

Dan: The one with the highest bond strength I think, don't quote me, I'd have to look at my chart. I think it's a 3M one. I can tell you that a prominent guy from University of Texas let me know a couple years ago that they had banned all the self etch resin cements from their clinic floor just because of the large number of failures. I can tell you we were given strong guidance in a caring way some 7, 8 years ago that we really needed to develop a self etch resin cement or we wouldn't be in the marketplace. Wow, we got a self etch resin cement that was about 3/4 as strong as the strongest one. We came in I think around 7, 8 MPA. The best was getting around 8 MPA.

We shot the sucker in the head and we buried it. Why? When you can use a quality resin modified glass ionomer, especially powdered liquid format that gets a higher percentage of the glass ionomer silicate into the formulation, yeah. If you have the tooth surface prepared right, the zirconia prepared right, you can get in the neighborhood of 24, 25 MPA. Why would you want to compromise and go down to a measly 8 at the strongest down to as low as 1 that we measured at the weakest? Additionally, you don't have any fluoride release on the margins. Why would you want to do that?

Howard: What are these 6 noncompromising adhesives?

Dan: I will pound my chest on this, but even as determined by clinical research, our Peak came in at the highest. Another quality one is Solo, and as well XTR. The 3M universal is pretty darn good. The Clearfield SE is pretty darn good. I tell dentists if they don't want to use our Peak, that those would be bonding agents that I would suggest to use.

Howard: That was 5, Peak, solo, XTR ...

Dan: Then I'm off on my count. I'd have to look at my chart again.

Howard: I thought what you said about affected, effected dentin was amazing. Have you ever heard of the product Seek?

Dan: Yes. Lo and behold, how about it?

Howard: Caries indicator. You taught me that. Did you teach me that, when did you come out with that product?

Dan: We came out with the first Seek, the red version somewhere around 20 years ago. We came out with Sable seek Somewhere around 16 years ago. The logic of the Sable Seek is we found that dentists would be challenged from time to time when there was a red stain in the area of where a pulp horn might be exposed should they scoop it out. We decided we needed something that really contrasted with red or with that purplish color even when you're close to the pulp. The Sable Seek was created.

Howard: Sable Seek is purple?

Dan: It's a green, a dark green.

Howard: Oh, that's the dark green. Okay. Seek is red?

Dan: Yes.

Howard: Yeah, you taught me that, God. I thought you taught me that in 87. I always thought, I've gone down to Salt Lake to watch you probably every 5 years. In the last 28 years I think I've made that pilgrimage to your place ...

Dan: I always enjoy when you come, by the way.

Howard: You're the Vince Lombardi of dentistry. Not only are you just down to earth and humble, not only are you always the smartest person in the room, but I always thought it was amazing that after this long exhausting all day lecture, you always invite everybody to your house with your family and cook a big shindig and a meal. I just think you're just the greatest guy in the world. I want to backtrack on some of this stuff, because I think you might have flown over some people's heads. My job is to guess questions that people, there's about 7000 dentists listening to us. What is the difference between affected and effected dentin?

Dan: Yes. This is really something that's more of a subject for academicians. In a practical sense we dentists can never differentiate just macroscopically or with our loops. The claim is that affected dentin is that leading-edge of vicarious breakdown in which the acidity that's generated from the bacterial waste product has soften the dentin, but there's not actually bacteria in it. It's not infected. The affected versus infected is that description. Again, you can't dissolve collagen with acid, you certainly can't etch it.

In fact, probably the second oldest profession in the world would be the tanning of leather. Wow, you took that raw skin, the dermis, the skin, and you immersed it in a moderately strong acid. Today we used tannic acid as just a certain concentration of sulfuric. Ancient humans, they used uric acid, they used their own urine and let it sit until it went to uric acid and soak the hides in it. It didn't dissolve the collagen, the acid doesn't dissolve the collagen. It does eliminate the rubbery-ness, the elasticity, it's more manageable and certainly superior to use for the human. You don't dissolve protein with acid. Protein is dissolved with alkaline pH, hence why the very very low alkaline pH for Drano and other liquids that you buy to try and dissolve hair protein out of your drainpipes and the like. Acid won't break down that soft stuff, that collagen.

You must be adjacent to mineral mother dentin, meaning metal round burs, metal excavators, and a caries indicator more appropriately should be called a mineral indicator. To give you an example of how important it is, every tray set up in our office, whenever we're doing a bonded restoration, it has a syringe of that Sable Seek on it. When I work in the office, my daughter Dr. [Jessup 00:59:44] She's my boss and that's fun for me. Yeah, that assistant knows without me even asking that before I get the etch, I'm handed the Sable Seek. Yes, once I've eliminated all of the stained green, then I etch.

Howard: How long has Peak been out now?

Dan: Boy, Peak has been out for about I think around 5 years, thereabouts.

Howard: Tell us the Peak story. What made that all come about and how did that all come about?

Dan: Yeah. The Peak story has been on evolution of adhesives. Our first adhesive was like an all bond to, let me think. I want to say Permabond, it's slipping me. We then had a Permaquik. We then had a PQ1. The PQ1 performs just as high in bond strength as what Peak does today. The reason for that is the Peak is the same chemistry, but it is a thinner, lower viscosity material so that dentists can more easily thin it appropriately. We evolved in a lot of development. The number one thing, the most important thing that enabled us to create the strongest bonding agent was testing. I often share with dentists, when you're inventing, it's like following the scent of the hunt. You've got to close the loop quickly. In the case of a chemist working on a bonding agent, it's important for them to know today what were the effects of the changes they made yesterday on the formula. If it takes too long for that to occur, they lose the scent of the hunt. To get back into it is a challenge.

Neil Jessup and his team over about a 12 year period developed an exquisite, precise way of testing the adhesion to dentin so to close that loop with a device, a system at which one technician could bond 200 samples in a day themselves so that you've got a highly statistical significant number that really tells you something concrete that next day. It involved us using a high precision machine that grinds to a 1 micron accuracy. We were told when we purchased it that it was the only machine west of the Mississippi, and about a million and a half bucks for this machine. In fact, you might have recalled some years ago, 16, 17, 18 years ago when our US government became royally mad at the company that makes this, because they had sold one to the Russians. Prior to that time, our submarines ran silent. You couldn't pick them up on solar.

Howard: The propellers.

Dan: Yeah, theirs you could. Theirs run silent now too. It's so important when you're bonding that you not use a straight knife blade. A straight knife blade like what had been used for years in many instances was testing how much the composite compressed more than what the actual adhesion to the tooth was. As with that point contact, that tangential point where that straight line hits, it starts pushing and it compresses the composite and could peel it off. We weren't truly measuring sheer testing. Micro tensile is a good way to test, but it's very technic sensitive, it's very laborious.

At any rate, this system was so good, it's called the Ultradent tester by the way, the testing jig is the Ultradent testing jig. So good that a professor Lorenzo Breschi out of Bologna, Italy nominated it to the world standards committee, the ISO standards committee as the way to test. There was a lot of debate on what sort of tests should be that standard. After 12 years they focused in on our Ultradent tester. It's probably in about 40% of the schools now. All of our competitors have it. When we sell it to schools we sell it at cost. When we sell to our competitors we make a profit. Unless you've got a reproducible quality way of determining what that adhesion actually is, you don't know which way you're going when you make changes to your formulation. That was the single most important factor in creating Peak.

Howard: Okay. I get a lot of trouble a lot of times because people want more details. Go through the actual steps of, let's say you have something easy, an MOD. Let's go to the most common restoration, an MOD on the first molar. The first molar is most likely to be missing, implant, crown. Walk through the exact steps. You have an MOD, it's prepped, fill it. Fill the filling.

Dan: Yeah. Especially if it's a lower molar, ideally you've got a rubber dam in place, not that there is not other ways to control contamination. In fact I'm going to back up just one step from what you asked, because it will help fill in as we do this filling, if you will. The number one enemy to adhesive dentistry is contamination. My definition of contamination goes like this. Any substance, any substance accidentally left, accidentally placed, purposely placed, that is a contaminant if it comes between mineral mother dentin and your adhesive. Any of those substances between mineral mother dentin and your adhesive, it's a contaminant. It will preclude or reduce the ability to bond to dentin at that non-compromised 70 to 80 MPA value, if you will.

Now let's go through the prep and MO on a lower molar. Okay, you're in control of saliva ideally or a rubber dam. Bruce LeBlanc won't operate without a rubber dam, an example of a very caring dentist. Now your preparation first of all was excising the lesion. You're not making it wide to go out into free cleansing, you're just addressing the lesion. You might even have some unsupported enamel here and there, but you're coming in with your caries indicator, in our case the Sable Seek. If you've got any caries up underneath that unsupported enamel, you're going to go to the backside with your excavator and scrape and peel that off and stain again and make sure you got it all off, and for all of the rest of the preparation, if you will.

At that juncture, we're going to etch it. I tell dentists if they've had good success with a phosphoric acid etch, don't change. It's still a gold standard. My choice is phosphoric acid, so I'll come in with our ultra etch and make sure all the surfaces are coated, leaving it for a minimum of 20 seconds. If I've got 2 or 3 restorations in a row, I might etch all of them meaning that Ultra-Etch might be sitting there for a minute on one and 20 seconds on the other. That's because of the design of Ultra-Etch. It uses a fume silica as the thickener. That gently binds the hydronium ion, the H3O positive, the acid ion so it's not etching deeper, deeper, deeper near to the level that a liquid or polymer thickened etching is.

That's a minimum of 20 second etch. Then with a vacuum pulse we're going to wash all of that out, and it'll quickly go away. That's because of what has always been a surfactant in it from when it was first created around 1982, 83. Then we're going to make sure that we leave the surface slightly moist. As Neil Jessup told his daughter Cambrie, love, if you're to err, err on the side of leaving it what looks like it's a little bit too wet. We can compensate in the next step by using a thick puddle coat of adhesive. If there's too much water there, it's going to absorb, remove and pull that water away.

Now as we apply that Peak universal to that etched slightly moister surface, we're going to scrub it against the dentin. We're going to scrub it so hard that that little orange, red and spiral tip bends. We're going to scrub it aggressively against that etched dentin. Little Cambrie, she scrubbed the bajeebies out of it. We get some 12 to 15% higher bond strength if we aggressively scrub that adhesive in, virtually infusing if you will into that dentin. You avoid scrubbing on etched enamel. It can reduce the bond strength a tiny bit, but you scrub the bajeebies out of it on dentin.

Now we're going to come in and give some blasts of air for the different walls, little bursts of air, but making sure that we keep all of the walls shiny, as Cambrie's father told her. Keep it so it looks like stretched saran wrap, if you will. With a bit of mask, no puddles, but shiny. Now we're going to air dry 8 to 10 seconds. A very important step, and one that many clinicians aren't even aware of, or if they're in a hurry, that 10 second need might become a 2 second do, if you will. Now with a high energy light and with a hopefully good sized footprint on it for this MO on the molar, and with our safety glasses on, so that we can look right at it and make sure that head stays where it belongs. Maybe even supporting that head with our non-dominant hand so it's not drifting and waving.

The engineering team up at Dalhousie where Richard Price is, they created this mark system. Instead of a handheld meter that was never designed for measuring the output of a light, it was just to determine if you needed to replace your bulb on your halogen light, they have sensors imposed to your teeth. You quickly see that curing lights vary dramatically when curing posterior as compared to anterior based on their design. Ideally you've got a curing light that has a very low profile.

Howard: What's the name? Name your curing light.

Dan: Our curing light is VALO. We believe it's the gold standard for curing lights. It puts out energy over a large footprint, a large enough release on MOD on a bicuspid.

Howard: Sorry to interrupt, but you were saying 2 important things. The light was one of them. Do you think you could get Richard Price to build us an online CE course on Dentaltown on curing lights and this? We put up 350 1 hour classes on Dentaltown. They've been viewed over half a million times. These new age dentists, they don't like to shut down their office and fly to Salt Lake like guys like me did. I went to saw you and Gordon and all those people. They just love to watch these courses on their iPad. Dan, we've passed 550,000 course views. If this is so important, I'd like to have an online CE course. Do you think you can get Richard Price, who was the other guy you said?

Dan: I'm virtually certain we could get Richard Price to do that.

Howard: Who's the Fred guy, Fred who?

Dan: Fred Rueggeburg.

Howard: How do you spell Rueggeburg?

Dan: Boy, don't ask me that one.

Howard: Is it German or German?

Dan: I think it's German, yeah.

Howard: Is he in Germany?

Dan: He's at I'd say Medical College of Georgia. It was Medical College of Georgia. It's had 2 name changes since. I still call that.

Howard: If that's one of the most important, if bonding agent and curing light, if you could get Richard Price to build us an online CE course, that would be amazing. Dan, I've been begging you since 1998 to put a course on Dentaltown. You're a townie, you've posted a lot, you've had some of the most phenomenal answers, but God dang, everybody needs to see this in a presentation. When I go see you, your lecture is several hours. I also love your Ultradent story. Someday you've got to break down and find the time and put the whole day lecture.

Dan: I've got to. How long do you usually run your courses on that?

Howard: It's interesting. When Carl Misch a course, it was 4 hours. They vary all over, it depends on subject. I think the longer the course is better. I think dentists are hungry for information. They'll give you 6 hours, 8 hours. We put up an endo curriculum that was 13 hours by Richard Trope out of South Africa. They loved it. It was 13 hours long and they loved it. They love Misch's at 4 hours. We've got some legends on there. We've never got the legend. Martin Trope, I can't believe I just called him Richard Trope.

Dan: Those are great [regiments 01:14:41] that you named 

Howard: Martin Trope and Endo. I would love to see the complete Dan Fischer story going over the details of this light, the details of the bonding, everything. Even your Drano example is genius. No one can talk to Dan Fischer, that's another thing about you. I've never met a single dentist in my life that met you that just, when you say Dan Fischer they just start smiling, and they always punch my shoulder. You're known for gesturing ...

Dan: I'm a touchy-feely guy, aren't I?

Howard: You're a touchy-feely guy.

Dan: I love hugging and ...

Howard: The other thing Dan, I was doing some charity dentistry in a [Tanzanita 01:15:22] orphanage. Every dentist I meet in Africa and Asia and South America, I say, "Where do you learn? They just give me a big hug, because we have our app on the iPhone. 40,000 dentists have downloaded the app. 205,000 have registered on the website. I've walked into dental schools where the Dean started crying because she said Dentaltown was their entire curriculum augmented by dental books that were 10 to 20 years old.

Dan: Oh, wow. What a fabulous contribution.

Howard: There is one little girl I met, her full-time job at the dental school is just translating Dentaltown into their native language. Then when they're watching the online CE courses, she's narrating in their language.

Dan: Oh, what a contribution. Imagine, wow, fabulous.

Howard: All because Al Gore invented the Internet.

Dan: There you go.

Howard: Dan, there's 2 million dentists around the world. A million of them are never going to meet you in person. You've got to capture this digitally. It's too damn good, Dan.

Dan: Tell you what, let's figure on something like a 7 to 9 hour program in 016.

Howard: You know what they like? It should be a continuum or a curriculum. The adhesive dentistry curriculum. I'm sorry to interrupt, continue. You're  at the VALO light. You talked about the bonding.

Dan: With the safety glasses on, not only to protect your eyes which is important, because a high-energy light can damage your eyes.

Howard: Dan, not to interrupt again, I'm sorry. My ophthalmologist said, "Dude, you're getting 10 times more light when you go snow skiing at Vail." They say, "You're 14,000 feet, all the snow is white." He goes, "You do that all day?"

Dan: I think you wear some protective goggles there too I would bet, and probably even of a ...

Howard: You're right, I do have goggles on.

Dan: Of the light to protect.

Howard: Okay, I didn't [know 01:17:22] that.

Dan: This story that I'll tell you is an extreme story. First, let's remember this. The curing lights that generate adequate energy to assure as much polymerization as possible, they are powerful high energy devices. They're designed to be put just right over that restoration. If you don't have your safety glasses on, how can you be sure it's staying right where it belongs when you're on a second molar especially? It's analogous to how you use your handpiece. Would you ever take your high speed handpiece, go in there, touch it to the tooth and then turn your head and push on the foot control? That's how you should think about a curing light.

Yeah, a couple extreme stories. One was back when we had our Ultra Lume 5. Very weak in energy compared to the VALO. There was a case report in AGD Journal a few years back on a dental student down in Louisiana that caused a bad welt, burn on the lip with our Ultra Lume 5. I'm still struggling as to why that dental student tried to cure the lip on a patient, if you will. They are intended to be used right on the composite itself. Here's the other extreme story. This occurred a few years back and with our VALO. A dentist in Japan sent his light, no, he said at first, "My curing light isn't putting out as much light energy as when I bought it."

We asked him to send it. Not to our surprise it was putting out the same amount of energy as when it was new. What we're using, these ultra high-energy LEDs out of a fabulous high tech company in North Carolina. We are only driving these LEDs at 1/3 to 1/2 their power in the highest setting. Those things should go for years. At any rate, we asked him how he ascertained that his light wasn't putting out as much light energy. His response was, "When I looked into that light when it was new, it is not as bright when I do that now." He burned out his cones, his red cones. It's tragic. The reason that we're using red orange is because that's on the opposite side of the color wheel from the blue. Basically it's absorbing that blue energy especially. Red blood cells will absorb it to.

Another story of a dentist many years back who, being a very caring dentist and knowing that like your luting composite would not change color as much as dual care with chemical activation, decided he was just going to use light cure even on [more-oh-pay-cious 01:20:50] onlays and those going sub-gingival and interproximal. He felt he could compensate by having 3 to 5 minute cure on the buccal and a 3 to 5 minute cure on the lingual. He cooked the gums, and they sloughed. Red blood cells are going to absorb now just going on a class 5 that's sub-gingival at 20 second cure on a standard setting or maybe 2 times 3 on our VALO high-energy setting, you don't have to worry about that. These are powerful devices. There are powerful instruments and they have to be treated and handled and used appropriately nonetheless.

Howard: I love your VALO, it's an amazing light. How do I know when it needs to be replaced? How do I check it, how do I measure it?

Dan: That is a good question. What we suggest you do is you take your red orange shield or your red orange glasses and you just shine and look at it through that red orange, or you shine it on a black surface so it doesn't just reflect right back into your eyes. You make sure that each of those four LEDs are functioning. If they're functioning, you're good. They aren't like the halogen that it goes down like this, plunk.

Howard: To me, it either works or doesn't work.

Dan: It works or it doesn't work.

Howard: You just put it through your shield and if you see all 4 lights, it works?

Dan: Yeah, and/or on a black surface. Do remember that there will be one of those 4 that will appear to your eye to be not strong enough. It will not be near as bright as the other 3. That's because it's the 405 wavelength. It's the ultraviolet wavelength. That brings an advantage, even though the UV doesn't cure to such a great depth as the blue, it brings an advantage in that it's a super energized wavelength that can polymerize that outer surface a little more completely than just a blue and give you a greater wear resistance on your composite.

Howard: Okay. Back to that MO composite, what composite are you going to put in there, and how deep is the increment that can be cured? Are you concerned about putting a little bit on this wall and letting it shrink towards the wall and then some on the other wall? Talk about name brand specific, what composite are you going to put in there? How many increments because of curing, and do you add increments anyway because of shrinkage?

Dan: There's a lot of good composites out there. That's even why I did the name composite as one of the two critical, the light and the bonding agent's the biggie. If I was doing it, I'd be using our vital essence aesthetics as a good material. Shoot, Heliomolar is not that bad and it's been out, what, 30 years maybe. Not great for marginal integrity as it's simply a micro fill, but still great wear resistance if you will.

Howard: Explain vital essence. Is it a micro fill, is it a hybrid?

Dan: It's a micro hybrid.

Howard: Dan the man, you've been my idol, my role model, my mentor. You've got to get that guy to do the light deal from Dalhousie in Canada. If you could give us a 7, 9, 10, 2 day, I've listened to you for 2 days half a dozen times. If you could give us everything you know on an adhesive curriculum or whatever, and also cover, in fact maybe we should do another podcast [inaudible 01:24:57] A lot of dentists have asked me to ask you when they found out I was interviewing the other day. They use ViscoStat on their pulpotomies because they think formocresol and Cresophane in is carcinogenic. Do you agree with that?

Dan: That is one of the main reasons that back in the mid-80s we had the first studies done, which back in the 80s was a primate study. You wouldn't be doing that today. Then we had 2 human studies done. Yes, following instructions, the results are equivalent to formocresol. Yes, formaldehyde is listed as a carcinogen. It's something that would never be approved today. It's one of those materials that comes from history grandfathered in, if you will. It's not from science.

Howard: Can you give us a curriculum that explains the whole Dan Fischer's Ultradent story, go through all your products and your infinite wisdom on why you did everything you did?

Dan: Do you think dentists could put up with that many hours of bull shit?

Howard: Dan, every time I've gone to Salt Lake and taken your 2 day course, everybody in the class was a repeat. In fact when I walked in the last time, I think I knew damn near everyone in the room. Everybody idolizes you. What do you work, about 100 hours a week for 40 years?

Dan: I'm not afraid of hard work. I grew up working with my dad as we ...

Howard: When you do one thing, and you just do one thing 100 hours a week decade after decade, 4 decades, of course you're at the top. When kids are listening to this, when you're 20 or 30 or 40, and you wonder, don't sit there and listen to Dan and say God, I wish I was that smart. No dude, he's got a decade or two on you of just 100 hour weeks for decades. You're just a machine.

Dan: I'm a lucky guy who has a lot of good people around me that help keep me looking good. When I come to work I feel like a kid going to a toy shop. I feel like the luckiest guy in the world.

Howard: I feel the exact same way. You do look like it, you're still sporting all that good looking hair. You look like a Calvin Klein model.

Dan: It's obviously changed color immensely, but I'm a lucky guy. We both are lucky guys, we certainly are Howard.

Howard: You can get me that ...

Dan: They admire you immensely. You were the first person with your knowledge, your background, your training to really push me hard to just start talking trench talk, talk about the dentist needs in Kansas and Wyoming and wherever else and talk about patching tires as you called it and the like. That was a good recommend, great advice. It's something that becomes more and more important to me the older I get.

Howard: Coming from Kansas with my entire, I remember going to some of these institutes and talking about you want to treat the right type of people and build the right type of practice. They'd describe the right people and the wrong people. My entire [feran 01:28:10] family was the wrong people. If you come to me with an idea about how to make dentistry slower, more expensive for richer people, I'm not interested. Show me how to do dentistry faster, higher quality, lower cost, and you can serve more people like Mother Teresa of Calcutta, then you're my new best friend. You've always been my best friend.

Dan: You've got to put an emphasis on reaching the masses. That's why at Ultradent we have zero interest in spending our research dollars to develop exotic ceramics that only 5% of the world can afford. We're driven for preventive models, we're driven for the minimal invasive, the direct place restoration, but that can deliver quality and aesthetics.

Howard: You know what, I have more fun and have more giggling when I'm in dental schools in Africa, South America and Asia than I do in these rich countries where everybody's so anal and crazy and uptight. It's like, gosh.

Dan: And extreme.

Howard: Yeah. Everybody from Germany, Japan, Korea, the United States, Canada, they all need to go to Africa, Asian, South American dental schools and just learn how to have fun. That's why I do these podcasts, these online CE courses. They don't cost a penny in the poorer countries. All the podcasts are free, but my online CE is free in the poor countries. My job is to find the smartest people like you in the most advanced richest countries and transfer that information for zero price. My analogy is when you get off the elevator on the top floor you should send it back down to the bottom floor and bring the next load up. You've been bringing the next load up. Dan, thanks for all you do. You've got an important meeting. When will that curriculum be on Dentaltown? 7000 dentists listening to you right now want to know.

Dan: I'll get Chalice here working with my assistant. Let's see if we can identify a time or two in the first quarter of 016.

Howard: Don't worry about time, just get all the information out. Dentists are just, they love information.

Dan: Sure, absolutely.

Howard: All right, take care, bye-bye.

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