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VIDEO - DUwHF #938 - George Tysowsky
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AUDIO - DUwHF #938 - George Tysowsky
Dr. Tysowsky serves as Senior Vice President of Technology and Professional Relations for Ivoclar Vivadent, Inc. In his capacity, Dr. Tysowsky is responsible for Research & Development activities for all North American operations. He also serves as a Clinical Assistant Professor at the State University of New York at Buffalo, School of Dental Medicine, and is a Fellow of the Greater New York Academy of Prosthodontics and the American College of Dentistry.
Dr. Tysowsky has served as a board member of the American College of Prosthodontics Foundation for the past nine years and is Chairman of the Board Elect for the Oral Health America Foundation.
Dr. Tysowsky earned a DDS degree from the University of Minnesota, School of Dentistry, and a Masters of Public Health from Minnesota’s School of Public Health.
Howard: It's just a huge, huge honor for me today to be podcast interviewing my buddy for thirty years, Dr. George Tysowsky, DDS, MPH. He serves as Senior Vice President Technology and Professional Relations for Ivoclar Vivadent in this capacity. Dr. Tysowsky is responsible for research and development activities for all North American operations. He also serves as a Clinical Assistant professor at the State University of New York at Buffalo School of Dental Medicine, and is a fellow of the Greater New York Academy of Prosthodontics and the American College of Dentistry. George has served as a board member of the American College of Prosthodontics Foundation for the past nine years, and is Chairman of the Board elect for Oral Health America Foundation. Dr. Tysowsky earned a DDS degree from the University of Minnesota School of Dentistry and a Master's of Public Health from Minnesota School of Public Health. George, it is my experience that every dentist I know who ever got their master's in public health, did it so that someday they may hold out the option of being a Dean of a dental school. Is that is that going to be your next move? Are you are you going to do that DDS, MPH so you can be the Dean of Buffalo or somewhere?
George: Well, I'll play the corporate line. I'm very happy here by far and I have a beautiful career here So, I'll pass on that one.
Howard: Okay, I'll call that a dodge. I'll call that a dodge. I'll bet you when George is seventy years old, I'll hear someday that he's the Dean of Buffalo. But George, we've known each other for thirty years. What are you passionate about today? The way I look at you and I relationship, we got out of school, first there was the the materials revolution which took us from amalgam and gold, to all this composite stuff. And then we went into the computer digital revolution which is the CBCT's and all that stuff. What's the revolution of today? What's got you passionate today?
George: It's all changing, Howard. As you said, it's been an exciting era and from our thirty years, dentistry has changed so much. And the young clinicians coming out today, they have whole new opportunities, new skill sets, new avenues to pursue dentistry. And as you mentioned back in thirty years ago, we focused on four materials - we had gold, composite, amalgam, and PFM's. Today, the options of the digital workflow, computerization, digital access of information from the patients is completely different. And so the young clinicians today have to incorporate all those new technologies and understand their patients in a different way, and introduce technologies in order to enhance their productivity in the workplace. So it's completely changing. I think we focused much more on materials back then whereas today, we're focusing not only materials but the materials are an adjunct to the processes and how we fabricate and streamline our workflow in the dental practice.
Howard: Going back thirty years ago, I remember when they came out with the first laser, it was a fifty thousand dollar machine and a thousand dentists bought it. And then they went out of business. I've kind of always believed that a thousand dentists would buy anything. But it's really not mainstream until at least a quarter the dentists can. A quarter, mainstream practice management computer systems, everybody's got that, digital x-rays, everybody's got that. But it seems like CAD/CAM, to me it seems like it's still only sitting at about 15%. Is that about the number that you think in the United States? And what percent of the dentists do you think, have CAD/CAM?
George: Yeah, you're right. You're right about that Howard. It's a good number. The thing is, CAD/CAM has been around for how long, from the original serve days to where we are today. It's really still at an infancy but growing rapidly and only about 15, depends who we talk to, 15-20% maybe as far as penetration. But now, with the price point coming down, dentists are getting more involved with just getting scanners to try to introduce themselves into the digital workflow. And then will incorporate as far as the full chairside milling process and as needed accordingly. But it'll continue to grow, projections are that Digital chairside scanning will plateau somewhere around 50%. So there's a long way to go relative to penetrating that marketplace. It's moving fast but still at an infancy, but a big opportunity and people are getting into it more and more as we go along.
Howard: I think it's 15%, you're saying it'll saturate at 50%. What percent do you think have digital radiography? Let's go back to the most technology, practice management computer systems as opposed to paper charts. What percent that dentists you think have a practice management system? At least 80%, wouldn't you say?
George: I would say so for sure. That's a given today. If you had your workflows relative to your office system, it's relative to the leading systems out there, it's got to be it. I don't have the number but it's 75-80% of the majority.
Howard: You're in the great state of New York and they just took an 85-year-old woman physician's license away because she wasn't digital. She was on the computer, and so she was writing prescriptions which were all lawful. But you have to do it a special way, and they just took her license (inaudible 05:31). What percent do you think have digital x-rays?
George: It's got to be at least in the 70% I think coming up as well for that matter. So the integration is really high relative to what we've seen as far as a from practice management, digital workflow. The big new growth will be CBCT scans also. Today, from placing implants, people are still doing manually but why wouldn't you? You have a whole guided process of incorporating the whole procedure. It's predictable, the outcome is guaranteed on that. So that's a big influx going through. But Howard, coming back, I think relative the clinicians today, it's a new era. There's our generation which is learning digital technology and the young generation we're living every day from social media, integration, communication methods. We didn't have any of that before so the adaptability is going to be at a quick ramp up and moving very quickly.
Howard: On my digital workflow, can I just take a Snapchat picture of the prep and send that to the lab? Do I need anything other than Snapchat?
George: It's going that way.
Howard: Ivoclar is in dental lab and dental offices. In fact, you guys really actually started heavily in the lab business. When I used to talk to you guys thirty years ago, you had big lab divisions. What's the future of the lab and the digital workflow? When you and I graduate from school, the numbers I heard, there were fifteen thousand dental labs in America. And now I hear that numbers have been cut in half. So what is digital workflow and what does that mean for the future of dental laboratories, CAD/CAM dentistry?
George: We see all of dentistry segmenting out. There will be the high-end, the comprehensive approach, and you need the expertise in that particular area. And then you have volume production and streamlining of single tooth restorations. And so there will always be an expertise and a needed for complex cases, basically for a laboratory to be the coach or the advisor out to the clinician of how to provide those complex cases. We see a lot of high-end laboratories succeeding, growing rapidly. On the other hand, we see a lot of assimilation, a consolidation of laboratories today. There are big groups that we have - from DSG, National Dentex and others - that emerge laboratories and centralized production, facilitating those type of restorative procedures. And so from a lab standpoint, I think the common we always make is differentiate ourselves. There's always room for excellence and if you you're at the top end, there will always be a need for that. But if you're just routinely manufacturing a single tooth restoration, there are new efficient production methods that can enhance that and produce it in a rapid fashion that will come out of size. That's why we have the consolidation or we have the laboratory business. We're very much involved a laboratory business but it's a different model today. People centralize our production facilities so you may have a digital workflow where all the data comes in from different clinicians. It may go to a centralized production facility for creating milling centers and other factors, for that matter. They then go back to the individual laboratories. The laboratories then can customize the restoration but they're not necessarily fabricating the restoration. They're just characterizing it to the final prescription and then sending it out from the laboratory. But you know, complex implant cases, removable work, full mouth rehabilitations, combination cases between ortho and restorative, that's where the laboratory really plays a key role in being an advisor to the clinician and guiding them and being a partner in that restorative process. That's what we see the future going for the lab business.
Howard: Well said and I agree. When you're doing a full mouth comprehensive case, nobody is chairside milling or anything like that. It's full impressions. It's with the high-end lab all that kind of stuff. But the vast majority of the market, when I talked to Jim Glidewell (inaudible 09:45), he says that something like 94% of the crowns come in one unit at a time. Is that the numbers you're hearing?
George: We were on the '80s but it depends on laboratories and he's got great, of course.
Howard: Let's focus on my homies on that sending it one at a time, the mass-market single unit. One of the problems is that dental insurance started in 1948 when the Longshoremen's Union demanded dental benefits and a couple companies sprouted up later, you might have turned into a Delta Dental. But in 1948, the maximum was a thousand bucks to keep that total real in constant dollars. It's in 2017, it's now past ten thousand dollars. When I got out of school, a crown was a thousand. I submit that to Delta, they paid half. Now the model's changed - they send me the fee schedule, it's six hundred. These dentists out there, prices have come down 40% on a crown. So you have to compensate for that by doing the dentistry faster, easier, higher quality, lower price. But you've mentioned digital workflow, so the majority of people listen to you. I think 95% of that has take a Delta which gives them a fee schedule. So basically, factually, 95% of dentists participate in PPOs. If you're getting paid $600 for a crown, you talked about this digital workflow. Give us some tips on how to do that faster, easier, higher quality, lower cost when you got to work back from a $600 budget on a crown.
George: Some people, depending on their practice philosophy and their standards, will utilize laboratories that provide more cost-efficient crowns. And it's a Shoppers market today to try to find a commodity of what they can afford at a particular fee schedule. But many people move chairside and usually there is that to produce that kind of crown, you have to be fast and effective as you just mentioned. So one appointment crowns is really critical. The ability of speeding up that process faster, faster crystallization, we now have zirconias that can be fired chairside to minimize the second appointment for that fabrication. The times of firing, for example, are E-max restorations have shrunk down considerably and there are millable materials for class tools, large class tools or fillings. We even have composite blocks that are available where you can mill them out, cement them in and you don't have to fire them and go through laboratory process accordingly. So I think the milling processes and the one appointment visits have helped us control those costs and dentists are continuously looking for materials that are fast, chairside easy and can facilitate and minimize that appointment time. So it's a big, big factor for us. Alright, I'm going to come back to you and ask you about that. You know the data better than I do but I hear the reimbursement levels vary from provider to provider and some provide up to twelve hundred and some are at six hundred. Is that correct? It does vary across the country.
Howard: Yeah. Six hundred to six fifty is the norm for a crown, for the majority. It's tough to say Delta because if I said McDonald's, every McDonald's is owned by one company. But when you say Delta Dental, there's actually nineteen different Delta Dentals so it's very different. The trend is definitely-- they're not raising the max of thousands, not going to just have for inflation at ten grand and the fee schedules seem to be drifting downward. There's just no question about that. But I'm going to back up, George. You and I forget that we've been out of school thirty years and I always tell my homies, "E-mail me. Please e-mail me email@example.com and tell me who you are, something about yourself, your age, what country." But George, 25% of the e-mails coming in, they're still in dental school. And I only get, like, one e-mail a month of anyone over fifty and they'll say, "Hey dude! I'm as old as you." So podcasting is a thirty and under deal. I mean, really. Do you even listen to podcast, truthfully?
George: This is my first one.
Howard: Exactly! I remember when I called up Gordon Gerson to do a podcast two years ago, first thing he said is, "What is it?" So it's a Millennial thing and they're in dental school. So I want you to go back to dental kindergarten and what is the difference between zirconia and E-max?
George: New materials are evolving as you mentioned today and I think it's one of the most confusing things for young clinicians or experienced ones is to select the different materials. There's different categories of glass products. We've had (inaudible 14:43) courses that are used on PFM. They were really weak below one hundred megapascals which is the breaking strength or fracture strength of these types of porcelains. We then moved into lucite-reinforced like products, like Empress, which people won't even remember or some people utilize still but was the first glass light last ceramics that had better reinforcement and strength to them and they are about one sixty - one eighty megapascals. We're jumping up the ladder and strength. Then we got into the lithium disilicate products and aluminum (inaudible 15:18) oxide products for about the four to five hundred range. And now around five hundred. And then the big breakthrough was the zirconia--
Howard: But wait, lithium disilicate, that was your E-max, right?
George: Right. I'll come back to that.
Howard: Okay, I'm sorry.
George: And then the new generation products that we have for high strength, they're about twelve hundred which is the zirconia products. These things are durable, can use them bridge situations. It's really tough to break these types of materials. But we've always had a balance of optics with strength. And so, the nice thing about the E-max or the intermediate strength products at five hundred, the lithium disilicates, was that it had tooth-like properties of aesthetics. You could cement or bond it into place and it had very robust, durable properties and can be used in the anterior-posterior. And it was the first material that really superseded and allowed us to do an all-ceramic option versus a PFM or a metal support a type of restoration. That was the first generation. They really dominated the profession and you could fabricate it chairside, you can do it in the laboratory. And the dentist with the versatility could put it in anywhere and have a tooth-like pleasing restoration that really enhanced the quality of the restoration. And they could cement it or bond it, and reinforce it accordingly. They could use it for inlays and onlays or very versatile material. But today when people are looking for a high-strength or moving into zirconia. Both products exist, both our dominance and utilization but the market is moving very heavily into zirconia because with its toughness and edge strength, you can do a typical PFM prep, you can feather it out, you can have thinner preparations at 0.5 and the posterior. It's not ideal aesthetically but it's a white tooth-looking type of material and it's not going to break. And so it's really taking a place of substituting for metal today and that's where we have the zirconia. It's a new breed and young dentists are being educated on that quite a bit right now.
Howard: So basically, if it's a short, fat, bald grandpa, you'd put the zirconia on the teeth? And if there was a beautiful lady, you'd use E-max?
George: It depends. Yeah, good analogy. But I mean, E-max for beauty, it can be used everywhere but you got to have the preps and the definition. But if you want the optimum beauty definitely, if you got thin clearance of the poster and you want that thing to last, then it's zirconia.
Howard: Let me just hold your feet to the fire on the specific. When you look at the thirty-two teeth, and you look at hundreds of millions of insurance claims, it's all the six-year molars. It's the teeth most likely be, have filling, a crown, a root canal, an extraction. It's just you see a line, boom! That's number three over here. Fourteen then nineteen. You're in dental school and you have a crown on a six-year molar.
Howard: What would you use? E-max? Zirconia? Talk him through what they should be thinking about deciding on the most common crown in the world. A crown of a single unit crown on a six-year molar.
George: Sure. I'm big on E-max lithium disilicate because we now have the ZirCAD which is the zirconia and that E-max family also. But if it came down, I got to do a prep, I typically would use E-max. Because the thing is, why would I would want the optimum aesthetics, it's got a better translucency, better natural tooth qualities and the durability is really unsurpassed. We've got ten year clinical data with it that has high 90% success rate, a survival rates in those type of situations. So a very durable type of material.
Howard: What's the ten-year survival rate?
George: 98.5 or something in that category. It's above 95% for the lithium disilicate type of products. But the thing is, for forgiveness, the zirconia is a little bit more forgivable. So if your prep's not ideal, you've got a feather edge margin, your clearance isn't quite a millimeter in that type of category, you don't want to bond it in place, then the zirconia is a little bit more forgiving. Me, I walk in an operatory, first of all, I'm going to prep it for E-max. But if I have any compromise situation, I'm going to zirconia.
Howard: Are going to cement it or bond it?
George: Ideally, the best is always bonding but many clinicians prefer not to bond because the multiple steps so I may use a self-adhesive cement, like our SpeedCEM or others.
Howard: Repeat the name, SpeedCEM?
George: SpeedCEM Plus.
Howard: SpeedCEM Plus.
George: Yes. SpeedCEM Plus is our self-adhesive cement. It's utilized particularly for zirconia or for E-max type of restorations.
Howard: And is that a--?
George: A self-adhesive.
Howard: So go through the steps on cementing it, then.
George: Yeah sure. So the bonding agent is basically the adhesive properties are built into the cement. It's got the monomers which can react with the city, which can react with the dentin structure and provide an intermediate bond. If I wanted the full higher bond, then I would use Barelink aesthetic, for example, which I can use with the adhesives, cements. Or the Multilink, which is our self-adhesive type of cement with a primer system. We either have total adhesive systems or we have self-adhesive systems. Those are some of the variables that we can use for the cementation.
Howard: And which one would you use?
George: I like Multilink a lot. Multilink provides rocket bonds. This thing locks things on, it's not going anywhere. So Multilink, you scrub the tooth for fifteen to twenty seconds with the A & B primer, and then seat the crown and those bonds are over forty megapascals. It's not breaking, it's not going anywhere. It really locks into that lithium disilicate very, very well and provides basically replicating the natural tooth structure. That's the ideal.
Howard: I want to say one thing the kids is because when George said twenty seconds, that number just didn't fall out of his ear or his nose or his hand. It's so cool to go to these work benches, on extracted teeth and you scrub it for five seconds and do it. And then scrub for ten seconds and do it. And then twenty seconds and do it, and see the massive difference in strength. When you see really elite clinicians, they always have a stopwatch back there. You know who turned me on to that first was Michael Miller in downtown Houston. He'd say, "Okay this goes on twenty seconds." He says it hits a deal and he'd scrub for twenty seconds. When you're looking at a clock for twenty seconds, it's it seems like forty days and forty nights. And you see these dentists and really Christian always tells me. She says, "Dentists don't read the instructions. They don't read the instructions." So kids, when he said twenty seconds, I mean it's twenty seconds. Be serious about that. When you do the instructions correctly, it's amazing technology.
George: Yeah, Howard. You've been through the process and Michael was an expert at it. But we have our applied testing center here and we invite clinicians and invite your audience to come in and visit us. We run open houses all the time for clinicians coming through and you can see that basically you're scrubbing that tooth, you cut down a half-time and you have like a bell curve. Half-time, half-time, then it shoots up to the peak and then degrades after that as far as coming through. So we try to optimize those and provide a window forgiveness where we can optimize those instructions. The numbers aren't just made up; They're all validated to the use that you're talking about.
Howard: You would prep it for E-max and you cement it with Multilink.
George: That would be the ideal. But the fact is, a lot of clinicians are just reality taped from usage standpoint. Simplicity and convenience-- some people just want a simpler process. They don't want a monkey with the bonding agent or whatever. That's where we see the growth of these self-adhesive cements is taking off.
Howard: What kind of compromise is that on strength and efficiency? Is it a 5%? 10%? Half?
Howard: 50%. So how would you like to be getting your prostate surgery? And the doctor said, "Well you know, I'm going to shave off 50% success rate because I want to do this procedure in one minute instead of three." Could you imagine getting a bypass, and that's how the cardiovascular surgeons. They're giving you $600 for a crown, you're not going to take an extra minute or two?
George: That's what happens. People want to optimize that time so the thing is, people will shave down the times out of convenience and productivity. It's just a fact. We get a durable crown still with the result but true, I agree with you fully. Why wouldn't you go for the optimum if you can? But the issue is that people demand simple processes and convenience. So it's splitting purity of the best to the practicality of the fabrication technique, the insertion techniques. It's part of our dental world today.
Howard: Okay. Well, she just got out of the University of Buffalo School of Medicine which just celebrated, what, their one hundred and twenty-fifth year anniversary?
George: Yeah, I was honored. I was the commencement speaker.
Howard: I know you are. Congratulations on that buddy! Now she's got three hundred thousand dollars in student loans so she's going to go set up her office. You talking about digital workflow, would you recommend that she invests another one fifty in CBs and CAD/CAM? Or do you recommend that she to oral scan that, send it to a digital workflow lab? Or just good ol' impression material polyether polyvinyl siloxane and a triple tray instead of running numbers? Or still focus on just that single unit six-year molar crown?
George: I would recommend the individual to tread slowly getting involved in the technologies. First of all, invest your office, set up your workflow. But as soon as you can, I would least start with digital scanning. So I would buy a scanner, start that process, learn what you can accomplish with it. It's going to take over dentistry. It really was the new trend for communication, efficiency, opportunity, speed of process. Also as a patient builder, today versus sticking who and impression material and choke your patient half to death as far as it's different things, scanning is the new trend and new incorporation. It will make dentistry more fun, more pleasing, more efficient, and more productive for the patient. I think is a great patient builder as well as streamlining our productive workflow.
Howard: But go through my four finger test. Is scanning over an impression material - polyether, polyvinyl - is scanning faster, easier, higher quality, lower cost? Does it meet all four fingers?
George: I think it's equal quality because studies have shown that you get the same margins basically now with digital scanners as you do with PVS, for that matter. Cost, with a scanner, there are economic scanners coming out today. With the reduction in lab fees, 'cause a lot of labs today will charge less, will charge 25% less for a digital input versus a Polyvinyl impression coming in. So there are some save lab savings in that particular direction. What were the other two points?
Howard: Faster, easier, higher quality, lower costs. You said the quality is the same. The cost, you're correct in the fact that a lot of labs say, "I don't have to pay a human to pour this up in stone and trim it." So they give a discount. But is it faster?
George: I believe so. I think it's easier and easier for the patient too. You still have to retract them, you're taking a picture or not having stuff set up for several minutes and going through the uncomfort type of thing. So I think it is easier once you can become proficient at it.
Howard: I know that you and I know all these companies sell scanners so I know you don't want to piss off any of your friends but what scanner would you recommend? Piss off everyone but one company. If you were going to buy a scanner just for George, what would you buy?
George: There's a number of them out there and they've all got their traits. Three shapes certainly booming in their technology today, we have the CEREC which is out there, and E4D's coming on strong. They have a new economical scanner out there. The Emerald, I believe, it's called. Carestream's got one, 3M's got one. There's a number of brands out there and they all have different packages. One has a user fee, one has an upfront cost, so I think you got to work with your dealer and kind of flush those things out.
Howard: They're all great points. (inaudible 28:47) out of Denmark, they're crushed it. E4D had at Dallas, 3M true def at Minnesota. Where's Carestream out of right now?
George: Carestream, I believe their headquarter's in Atlanta. Carestream's the old Kodak Company. When they diversified but now I know that their headquarter's in Atlanta. So that's where they're coming out of. Every facility has different manufacture. I think its manufacture in France actually.
Howard: And what's Carestream's scanner called?
George: I don't know Howard. I don't know if there's a trade name to it or not.
Howard: I want you to go back to that six-year molar. Because when you're in dental school, you're working on one tooth out of time. We're not doing full mouth rehabs. When you come out of school, the first four, it's kind of like when you play football. You first need to learn just a tackle, a block, a pass and a catch. You're not going to go out there and teach you some flea-flicker play. Let's go back to that six-year molar and now it needs an MOD composite. What would you recommend? She's hearing all these things, incremental layers all the way to bulk fill. It's very confusing when one instructor saying, "Put down two millimeters cure, layer it against the wall," all this stuff. And then the next instructor is doing a bulk fill. If she has an MOD composite on a six-year molar, how should she do it? What should she use?
George: There's tremendous innovations in that type of area. When from previous technologies, we used to be curing forty seconds per increment. We had our initial composites that were heavily loaded with fillers, and large boulders, and things like that. We had to build them up in very small increments and cure each layer so as you said, it felt like it was taking a career to finish waffle and restorations. You're curing-placing, curing-placing, curing, it's ridiculous. The lights have gotten tremendously better. First of all, we have stronger curing lights. Thirty years ago, the milliwatt output is about five hundred. Today, we have two thousand-milliwatt lights available. Most of them around twelve hundred, roughly. We've doubled to quadrupled the light output on these curing lights and so there are like hot flamethrowers. We can cure these increments in five to ten seconds depending on what the need is of the material and how it's matched up. So that's faster. And then the new technology composites with these bulk fill materials have higher reactivity of initiators in them, so they're faster curing. We can cure these increments in deeper depths. Four is a very reproducible number today.
Howard: Four millimeters?
George: Four millimeter increments, so we're reducing our time. The speed up process on producing a filling is much more advanced. If you have a large filling, you can usually do it in two increments and get a very viable restoration. What's unique about these materials, first of all, the initiators have changed. And then the other factor is that they actually have monomers that have relaxers in them. They minimize the shrinkage and they have a stress relief. So you're not taking like a big volume of concrete and trying to shrink it inside the filling. It's basically relaxing that type of area so allowing the margins to seal and maintain themselves overall. They're really nice trend. For a six-year molar like you're saying, a bulk fill is really the way to go. There's a variety of materials out there, they cure faster, they adapt better, they polymerize deeper. It's the new direction for us to move into.
Howard: So you'd recommend a bulk fill and two four millimeter increments?
George: If it's a large filling, yes.
Howard: Okay, and what's the brand name of the material you'd use?
George: We have Tetric EvoCeram Bulk Fills, our brand.
Howard: Say it slower.
George: Tetric EvoCeram Bulk Fill. Tetric EvoCeram our brand name but we have a bulk fill version. It's very, very popular today and it's a great material. And we also have a flowable material that's quite unique, available for it also. What's nice about it, let me step back. A lot of the bulk fills achieve their depth of cure by increasing the translucency. What happens is that sometimes these materials are so translucent, your fillings can gray out on you a little bit. But we have a flowable bulk fill flowable that you can coat the dentin underneath and actually has an opacifier. So blocks out the dentin, makes a more natural restoration. That's Tetric EvoCeram Bulk Fills flowable are the two of brands that we carry for that matter.
Howard: And what about the bonding agent?
George: We use Adhese Universal, it's our flagship.
Howard: Adhese Universal?
George: Very high bond strains, again in these studies that you've talked about when you come in the labs, we're getting thirty megapascals routinely which is, you got to break the tooth before you break the restoration.
Howard: Go through the steps of using Adhese. It's not a self-etching?
George: It is self-etching. You can use it as a self-etch or you can use it as a total etch, it's got versatility in all different directions. You can use it for partial etching or a total etching or self-etching accordingly. So you scrub the tooth, as I mentioned for the twenty seconds, and then precure it. You fit it out with the air and light cure it, and then place your restorative material right onto it. It can be used for directs and indirects as well. And it's got great, great sealing ability also. The post-op sensitivity really drops down because it really penetrates and locks in your hybrid layer so you get much more decreased post-op sensitivity with these types of materials.
Howard: I heard number one complaint on MOD composite is the contact. Any tips for her there?
George: We have a new matrix seal bands that are available. Not direct from us but in general, from Garrison and some of the other people that help out a lot on those type of areas. And then we have to learn the manipulation techniques of making sure that we wedge properly and enforce the material into that contact area. A lot of people if they use a smoother, more flexible composite, they just syringe it in and let the band take control of that area, and then we get loose contact areas. So the ability of taking a plunger and forcing that material in the contact area while we're curing is really important to establish that contact. The matrix seal bands help also by increasing the wet space and providing some compensation for that. You know, Howard, the other thing you mentioned is that proximal contacts are definitely something that are critical but post-op sensitivity is something that still comes up often. I don't know if you agree or not from your viewers and users for that matter, but nobody wants to place an ice three surface filling and then Mr. Jones is calling him back at night on a Friday and saying, "My tooth hurts." and you're chasing it down and what are your repercussions on trying to handle that accordingly. But it all comes down to that bonding process. I would say, clinicians have to focus on those details and really just stop and focus on that tooth structure and pay attention to that dentin bonding process. So they want to make sure that isolate the field properly, control the field. If you're using a total etch, that they rinse that off. Minimally total etch, fifteen seconds, maximum. Rinse off and then saturate, saturate, saturate. Get that dentin bonding agent penetrating to that hybrid zone because once they seal it, they got basically a band-aid there that will hold and protect that tooth structure and not get any penetration. So the dentin body step is really critical as well and direct restoratives to minimize that post-op sensitivity.
Howard: A couple things to the kids out there. We talked about you want to go faster, easier, higher-quality and talk about how SpeedCEM is a lot faster or simpler, but the bond string's only about as half as Multilink. You kind of get jaded after you've been in dentists for thirty years because it's the 80/20 rule when you practice. 80% of Americans don't take care of their teeth. They only floss twice a year and you do it both times. They come in and they don't take care of it. Sometimes it's hard to strive for perfection when you know this patient's not going to brush it, floss it, take care of their health. In my office, they come in with a mountain dew. I'm like, "Dude, you take their bong to church? Really? Really brought a sixty-four-ounce mountain dew into the operatory?" So I get it and I do tend to do far better dentistry on the 20% who actually care than the 80% who the only thing they ask is, "My insurance pay for it, do whatever the insurance will cover." That's different but the point I was going with that is, we do all this great amazing dentistry. I feel like dentists go out there and build this amazing Ivoclar Vivadent barn, and then six and a half years later, the whole thing's eaten by termites. I'm wondering how close we are for these fillings and crowns and cements to be antibacterial. Because, George, you and I know for a fact that when we got out of school, the majority of fillings were amalgams. And they lasted twice as long as composites because amalgam, it's half-mercury. You're not going to find that in a multivitamin. The other half, silver. You see that in silver diamine fluoride with pediatricians. Tin, you see that in stannous fluoride. Every ingredient in an amalgam is not helpful for streptococcus mutans to thrive and now, we're replacing them. Amalgams are dead. They're dead to me for two reasons - the market doesn't want them and the last straw for me was when I was reading the atmospheric mercury contamination fifty. When you and I were born, the ocean was one part per billion mercury. Now it's four part per million. It's from burning coal. But when you study the mercury contamination, 6% of it is from cremating humans that have amalgams in their teeth. 6%. So amalgam's really dead but will we ever have a tooth-colored restoration that had the antibacterial properties of amalgam?
George: Interesting you brought that up, Howard, I know you have a passion for that 'cause I remember a conversation. We were having lunch and one of the ADAs, I think it was Orlando several years ago, and we had a new Chief Technical Officer join us. You were yelling at him for that matter of "help me provide a material that can prevent caries, especially in geriatric populations, root caries."
Howard: Oh yeah. What a plague.
George: Yeah it's a plague thing. Coming back to that point, we've addressed that very heavily through our R&D initiative. And as you mentioned, the World Health Organization has made a call-out initiating and requesting manufacturers to find an amalgam substitute to fulfill this need that we're looking at today. So amalgam has been easy, it's been economical and it's been rather foolproof from placement and longevity. That's the benefits of it. But for all the environmental reasons that you provided, highlighted, it's time to move on. Several companies, and we just introduced a new product called Cention N. It's not available in the U.S. yet but coming to Europe in the North America, maybe the next year hopefully for that matter. But evolving in a direction but basically it's a highly bioactive type of material and utilizes a reactivity. Basically, it adjusts on acidity so releasing calcium phosphate-fluoride and adjusting to the pH situations. We've been doing extensive evaluations here in U.S. with universities like Kevin Donnelly at University of Texas, and with John Burgess in Birmingham, Alabama, and others. We're looking at the long-term clinical trials but what's interesting, these materials that are pH sensitive and adjust and basically react to the environment, adjust themselves so there are ion adjusting type of filling materials that adjust to the acidity of the environment. So if you have a heavy bacterial attack, they adjust, release more, neutralize the acidity and can combat that type of field. It's a different chemistry than amalgam but they're self-adjusting composites that react to the acidity and the attack and the different environment. If somebody has a lower pH and has a clean hygiene and minimal type of need for that matter, it's just a stable composite type of materials, composite-based. It's not a composite essentially but it is composite resin-based. And it adjusts accordingly and it can adapt to the challenges in the different environments. If you have somebody who has high acidity, a lot of back plaque and bacteria, it'll just warn release more ions to try to combat that type of area. It's a new direction and growth, and ourselves and other manufacturers will be going in that direction. The product I mentioned is called Cention N and we're looking into introducing some sort of that technology in North America next year, possibly.
Howard: Where you saw in and out?
George: We went to underserved countries because the need has been so extensive so it's in a primitive delivery format right now. A powder, liquid type of format and so it's sold in India, Malaysia, China introductions right now and doing very, very successfully. But the clinical trials have been based in Europe and also North America are doing very, very well.
Howard: So George, in America, about 4 1/2% will end up in a nursing home. It's about one out of twenty. When you go into a nursing home, they're getting one root surface cavity a month. Grandma's been in there a year, she's got twelve of them. Now she shows up on your door and these young dentists are confused. They hear things, "Maybe you should use a glass ionomer." Obviously, an inert composite. Amalgam would be better, but even though she has Alzheimers, her daughter doesn't want her to have an amalgam class five's on all of her teeth. So if grandma showed up at your door, by the way, when you go to a nursing home, they're all women. There's only one guy in the whole nursing home and his name's "Lucky". So what would you tell her to fill if grandma comes in from the nursing home, she's got rheumatism, she's got dementia. She's obviously not brushing, flossing and she's got a bunch of root surface cavities. What would you fill them with today?
George: Coming back to your biggest point today, treatment of the elderly is one of the biggest concerns because they're most underserved population available. If you have appropriate retirement plan, you have a family takes care of you, you can get access to proper clinical treatment accordingly. But if you're left alone and nursing home type of situation, not blaming them, but you have a visiting dentist comes in once periodically. And so, getting access to care is a real critical crisis that we have in this country for all the elderly. So we talked a lot about children and we have a lot of programs, we have the national program, school programs, other factors try to bring kids to a dental home. For the elderly, many times that doesn't exist so you've nailed that topic quite critically. On the restorative needs, it's a real critical factor. The root caries factor like mushrooms growing around on the cervical areas and they never stop for that matter. That's why we're looking at these bioactive materials that can be placed, user-friendly and active, so those are under development today. But you've got the glass ionomers are really the only standard of care that we have in that area where you can basically patch them in, release the floor, at least stabilize the situation. But they're not going to reinforce the tooth overall because they have weak properties and the more you go around cervically around the entire tooth, they're not going to reinforce the tooth. They're just going to seal and provide that antibacterial property through the floor and release associated with it. Unfortunately right now, we're limited. There are products like (inaudible 45:35), the new Octavia's coming in different areas that we're moving into, our Cention N and others. But it's a huge need and we have to develop more materials and techniques that are more user-friendly. You're not going to isolate that for a classified composite on an elderly patient and nursing home. It's not ideal and you have to have materials that stick, they have bonding capability, ion release capability and reinforcement capability, and can be placed efficiently and easily in those type of areas.
Howard: I think it's back to active ingredients. One of the biggest debates on Dentaltown is you take a two-year-old and she needs a bunch of pulpotomy zinc chrome steel crowns and she's obviously not cooperating so you take her to an OR and put her under. But that's a highly dangerous procedure and at least every three months, somebody's posting on Facebook some little girl died, and I'm getting (inaudible 46:31). Now there's a big movement, it made the cover of the New York Times with pediatric dentist Janine McLean treating it with silver diamine fluoride. And she's like, "Look." And there's a lot of research says that if a two or three or four-year-old needs a bunch of pulpotomy zinc chrome steel crowns, when you get done treating it, there's going to be no change in the child's diet and home care. They'll still have the same parents, given a Mountain Dew and Cheez-Its. So two or three years later, the failure rate of that stuff is very high. And now you're seeing a big movement is saying, "Just come in every six months and I'm just going to paint them with silver diamine fluoride." The problem with that though, turns to teeth black and I was wondering if you think Ivoclar will, I mean I've seen your research facilities. I've seen Lichtenstein. You guys are unicorn freaks. How many PhD research scientists do you guys have on your team?
George: We have a hundred seventy in R&T. I don't know the breakdown the PhDs. We got a one hundred and seventy in there.
Howard: Do you think they can ever make a tooth-colored silver diamine fluoride? Silver diamine fluoride is the bomb, clinically. But it turns the teeth black. Why don't you guys make one in a white version?
George: Well being worked on. If you had a portfolio, it's a different direction. We're working on all these type of avenues. Howard, I'm not avoiding that question, I just want to come back. I think coming back to that elderly, I just want to make a point that it's the biggest need that we have in dentistry and one of the biggest public health problems is treatment of the elderly. You dedicated an issue to it, if several issues ago, you had a whole issue dedicated serving the underprivileged and the elderly in that type of area. You mentioned before with Oral Health America right now and we have a big initiative called the Wisdom Tooth Project. Again, trying to create awareness and some sort of a reimbursement and an ability of those people to find dental care. Finding a dental home for the elderly, they can be screened or whatever but they have no homes and no access to get to, and that's a big, big need today we have in social dentistry.
Howard: Yeah and it's very stressful for my patients too. Just the decision to find a nursing home for your mom. Even that is just gut-wrenching. I got to go back to that six-year molar on a filling. You said when you and I were little, the lights were five hundred and now there's lights up to two thousand. What light would you recommend she buy if she just got out of school?
George: We have our Bluephase Style which is fantastic. It's ergonomic--
George: Bluephase Style.
George: B-L-U-E P-H-A-S-E. And then second word is style. S-T-Y-L-E. Bluephase Style. It's rated the number one light by the marketplace by Dental Advisor. I think, in the fifth year already so we're in the fifth year.
Howard: So where is it on the five hundred to two thousand?
George: It's about twelve hundred. The benefit of the twelve hundred, it's pencil grip so it's ergonomic, easy to use. It's got all dimensions of timers and the five, ten second cures, versatility. And it's fairly priced at mid-level. If you're doing a lot of E-max and shooting full mouth restorative all day, then you'd move up to the 20i. The Blue Phase 20i would be the two thousand-milliwatt and that's a hot light that runs very, very powerful. If you're curing through ceramics all day long, then that's a good light as well. The difference is, the Blue Phase 20i is more gun-style and so it's a little bit more bulkier but the Blue Phase Style is our our flagship and workhorse and again it has the highest ratings.
Howard: How much does that cost?
George: I believe, in the mid twelve hundred, somewhere in there.
Howard: I just found your toothwisdom.org. Ryan just texted me. Toothwisdom.org is a project at Oral Health America that serves seniors and their caregivers by teaching about oral health and aging, and by connecting individuals with affordable dental class. Who's in charge of that?
George: I'm the Chairman of the Board right now, but Beth Truitt is our President and CEO. And so we have a whole staff in Chicago, it's dedicated that in establishing partnerships with dentistry to try to communicate and develop the informational links to it. They have website that's run where we try to link patients and try to provide advice on how to provide a dental home so patients can reach out to it, clinicians can reach out to it, and provide those resources accordingly.
Howard: On Twitter, they're @smileforhealth. That's Oral Health America and I'm just going to retweet their last tweet to my twenty-two thousand homies following me on Twitter. Thank you so much for following me @HowardFarran. That is amazing. But you said Beth Truitt's in charge?
George: Beth Truitt is our CEO, yes.
Howard: You want to send her on the show and talk about it for an hour?
George: Sure, she'd be thrilled! Absolutely.
Howard: Fix us up and Ryan's the one who schedules. I'm a big fan of Oral Health America and let me tell you how much I love it. Chicago is like the greatest city in the world. In April and May, and September, October, November. But Oral Health America, the Chicago midwinter meeting, they hold it in February. I'm from Phoenix. To me, I have to put on a jacket if it gets below sixty and they hold that damn meeting in the middle of February. And that Oral Health America Convention is like next to the water. You have like this minus twenty degree windchill and every time I go to it, I know it's just going to be a death march getting into that place. Is there any chance they can move that meeting to April or October? I think the greatest meeting is the Greater New York meeting because it's the perfect time to go to Manhattan. The Macy's Day Parade, it's right after Thanksgiving. The weather. You just want to walk around the whole city 'till your feet hurt.
George: It's fantastic, I know. But the Oral Health America thing is tied to Chicago midwinter, so we do it in sequence. But this year, it'll be at the Marriott so be a little bit more inland, so it won't be on the waterfront this year.
Howard: All these are meetings like Yankee and Chicago, they always say, "What do you think we should do to make the attendance better?" Change the time of the year! Nobody wants go to Boston or Chicago in February. I want to ask you another thing. We're talking about Ivoclar's products and you're talking to Millennials now. Are you a grandpa yet?
George: Not yet. No marriages yet.
Howard: No marriages yet? I can't wait 'till you're a grandpa because it's the only thing that might be better than being a dentist. But yesterday, December 6, Morgan Stanley warned dental investors at Amazon is here sending shares of dental supply distributors Henry Schein and Patterson tumbling those companies both close more than 4% lower Wednesday by accessing dental's place directly for manufacturer. But you're you're talking to Millennials. We're grandpas and they're Millennials, they buy everything on Amazon Prime. What is your prediction of one day being able to buy her Tetric EvoCeram Bulk Fill on Amazon Prime, where she buys basically 80% of all the other stuff she uses?
George: Yeah it's a tough question. First of all, we as Ivoclar, have a very strong viewer partnership and I've been working with them for years, and are committed to our distribution partners. On a social culture as you mentioned, just with Facebook and social media and everything else, internet buying is a factor reality today and they will come into play in some sort of fashion for that matter. We'll see to what level they come into but we did see them in New York. They had a small footprint there, they have some partnerships with some companies. So we're watching the trend right now, Howard, that matter. But it'll be a different world as we seen at the laboratory business today. Consolidation, integration is something that's happening and as we see with retail models that exist in this country overall. Look at shopping malls in different directions or buying habits.
Howard: Things change. You and I are old school. We used to read books. Now you got on an airplane, I'm the only old fart reading a book. Everyone else is reading a Kindle or something digital and I look at him next to me and the reason it'll make me change is because I got to work readers with my book and I'm sitting next to grandpas and grandmas who just changed the font on the text. And that's what's going to get me to start reading digital. But it's just a change of text but I guarantee you, these Millennials listening to you right now, they're going to buy through Amazon Prime. That's just what they do. That's how they roll.
George: Yeah I was saying before, their buying habits have changed and utilizing Internet and the mall pressures that we saw. We see model reduction, so the models change, the dealers will always be here and play a very critical role especially depending on the partnership that they establish with the with the dealer rep and the dealer service. From equipment service and providing as a resource in different areas. As the models change, we'll see where that pans out accordingly.
Howard: You know George, the one thing you and I have so much in common is that both of our commitment to continued education, and that's another thing where Millennials are changing. We put four hundred courses up on Dentaltown and they're coming up on a million views. And these Millennials say, "I just go to the Dentaltown app on my iPhone, I throw it up on Apple TV. And I'd rather sit in my front room and take a course than getting in my car, driving down to the local state dental meeting and registering and signing in and all that stuff." They and they also prefer learning and hour increments which is the research is showing. The research is showing that when you're teaching someone, they'll probably only listen for about fifteen to twenty minutes, so going to an eight hour course is kind of an overkill. But what do you think about the future of continuing education and Ivoclar's commitment to continue education?
George: We still offer traditional analog courses where people come in and meet face-to-face and have the hands-on. I think there will be tiers of education but we live in a learn now society with rapid access and so, the ability of getting information now is very, very critical. So whether you want to look up a procedure on YouTube, you can look up how to cement or veneer, how to do bonding or whatever in different areas. You've done an outstanding job, Howard. You've created as far as through Dentaltown the access of the different videos that are available and that type of resource. But we see that people don't want to sit down for an hour. They don't want to sit down for eight-hour courses. If you look at the trends of general meetings in general, they're dropping. They're lowering as far as attendance. But what's happening is that people are coming in the model of doing short snippets. The AGD used to require that you had to have an hour or forty-five minutes to an hour of C.E. to get an hour of our lectures to get a C.E. course credit. Now I think they've reduced it down to fifteen-minute increments. So there's different increments available for getting C.E. but many people are taking a lecture, a topic. So let's say, it could be on how to do appropriate dentin bonding. People are cutting into snippets of videos and information in fifteen-minute segments that add up to an hour to get the full picture. Because people just don't have the time and the resources and the attention span to accomplish that. So quicker information, faster sectional or broken up different areas of expertise will be brought up. But it's got to be fast, effective and reachable by masses on a very rapid basis. We're looking at that very rapidly website designs, online education, interaction, chat rooms. And I'm not trying to patronize you but you are pioneer and established the whole value of the Dentaltown community accordingly.
Howard: That was the fastest hour in the world, George. I love you, I could talk to you forever but I got one overtime question. It will be my final question. Sometimes they get sad, there's some big threads on Dentaltown. They come out of school and they say, "George, Howard, you guys were lucky, you graduated in the golden years, indemnity insurance, you submitted your own fees, dental school was cheap. I just got to ask you, I got three hundred and fifty thousand dollars of student loans, I got all these PPOs." and they actually they say, "Do you think she messed up becoming a dentist in 2017?" Do you think you and I got out in the glory days? Do you think the glory days are behind dentistry? What would you say to her if she said, "Did I mess up choosing dentistry? Now I'm twenty-five, I'm a quarter million dollars in debt." What would you say to that girl?
George: No, very, very openly I think it's the most exciting time to be in dentistry and as you saw the rankings by USA Today, it's still ranked number one profession several years in a row. And the benefit is the reward of the patient care as far as what you can provide for your patients. Two, economically, it's still a very rewarding profession. Sure you're in debt, but if you build a successful practice, you can pay that off in a very feasible fashion. Speaking to numbers of Dean's, these people are coming out at three hundred grand as far as in debt in different areas. But they're paying it off in a few years for that matter. So the reward is there as far as pulling in, and then the technology and the opportunities. You're a healthcare practitioner and a leading profession providing great care, providing great benefits to mankind overall. You're restoring quality of life, you're removing disease, you're controlling, maintaining healthcare. It's one of the best professions in the world as being recognized accordingly. I know we were in the glory, it was tough and hard in '85, it was very tough starting out. We have too many dental schools and the saturation. And people are looking at getting hygiene jobs and trying to survive in different areas. I think we're in the glory years now, it's a great profession and continue to prosper in the future.
Howard: Now I couldn't agree more and whenever they whine to me about their $250,000 of student loans, I always say, "Dude, your first divorce will cost you a million." Thank you so much for coming on the show with me for an hour. Thank you seriously to you personally. You really have shaped my career. I remember you'd hear me saying crazy stuff on the lecture circuit and you didn't fight me down, and you'd fight other speakers down. You guys knew who was out there lecturing the most and you always made sure we always had great information. I can't even think how many times you flew me into a Amherst, New York or someplace and give us two days of just intense training. You guys really, you personally really, really shaped my career. And your old buddy back in the day, remember Gary Severance back in the day?
Howard: And your boss. I really like the way you took educating the speakers, making sure we had the right information, correcting us when we were wrong. I just think you've been really, really good for dentistry. I think Ivoclar has been very, very good for dentistry.
George: Well great, Howard. Thanks a lot. It's always a pleasure and great seeing you.
Howard: Alright! And set me that lady from wisdomtooth.org.
George: Oral Health America, Wisdom Tooth Project. I'll set you up.
Howard: Okay buddy! Have a rockin hot day!