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AUDIO - HSP #280 - Carla Cohn
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VIDEO - HSP #280 - Carla Cohn
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What’s hot and what’s not in pediatric dentistry?
Dr. Cohn graduated from the Faculty of Dentistry at the University of Manitoba in 1991. She furthered her education, completing a post graduate internship in Children's Dentistry at Health Science Centre, Children's Hospital. Dr Cohn regularly attends continuing education programs to stay current in the latest advances in modern Dentistry. While practicing at Kids Dental, Carla continues to support “hospital dentistry” - treating children under general anaesthetic in the operating room.
www.drcarlacohn.com
Howard: It is a huge honor today to be podcasting with Carla Cohn who graduated in 1991 and I have to tell you not to be offensive or anything. You like working on children and a lot of us older guys the one thing we don’t want to do is we’re going to … I love root canals, extractions but you love working on kids. How did that happen?
Carla: I hear you Farran well thank you for podcasting with me it’s a great honor to podcast with you. How did that happen? It happened like many things in my life I got on to a path of maybe not exactly my choice but my destiny let’s call it. I did a year’s internship at children’s hospital right after dental school.
Howard: In Winnipeg Manitoba Canada?
Carla: A great mentor Howard Cross fantastic dentist. I did that and after I left that internship I went and I did a couple of years of general practice dentistry. It didn’t take me too long to realize that the adults were not a lot of fun but the kids were. I was fortunate enough to be able to be in a practice and in a position where I could just limit my practice to seeing kids. Which is what I love to do and I never looked back.
Howard: You’re not a specialist you’re a general dentist who limits her practice to children?
Carla: Absolutely.
Howard: Does the whole practice only do children or just you do only children in your practice?
Carla: Good question. I’m in a large practice, I’m in a group practice we’ve got about 14 dentists and there are 3 dentists that I work with over on my side at the clinic. Which is called Kids Dental and we only see kids there. We have an orthodontist that comes in and does the ortho thing for us.
That’s become our niche and let me tell you it is something that is defiantly necessary because as you know there are maybe 200,000 and change general dentists. Out of that we’ve got about 6,000 and so pediatric dentists. There is no way all of the pediatric dentists can service all of the kids that need to have help. Most of the kids that are being seen for care are being seen in general practice offices.
It’s a great thing to be able to offer these kids a service that they need and to offer it well and to do it well.
Howard: I also think that one of the things a lot of general dentist don’t think about is that some of the greatest endodontist in the world never went to Endo School. They just said, “I’m going to limit my prac to endo. I’m John McSpen in Chattanooga Tennessee, we have Ben Johnson in Tulsa Oklahoma who started Tulsa Dental Products.
In my years I have seen many dentist who are in a small town of like say 6 or 8 dentists and they only wanted to see the children or they only wanted to do the endo and they went to all their friends and say, “I will limit my practice to just endo and I won’t do the crown or the extraction or [inaudible 00:03:06].” They just didn’t go to Endo School.
A lot endodontist will say, “Well that’s not right you should go to Endo School.” It’s like these guys have done more endo than anyone who ever got out of Endo School. You got out in 91 and this is 2015. I’m sure you’ve treated five times as many children as anyone who ever gradated with a pediatric dental residency.
Carla: I’ve seen a lot of kids and I’ve seen a lot of things and it’s important to keep up on what’s current and literature, but it’s really important to see your kids and to see them well. Treat your kids like you’d want to be treated or like you’d want your own children to be treated. That’s what we go for and do the very best that we can.
Howard: What’s hot and what’s not in pediatric dentistry?
Carla: I would say there’s a few things that are hot and up and coming. If I had to pick a few to talk about because we only have a limited amount of time here. I would have to say that the most advanced in pediatric dentistry are zirconia crowns. You’ve been using zirconia crowns in general dentistry for a lot longer than we have, but about 4 years ago, 5 years ago zirconia crowns came on the scene in a very strong way.
We have pre-fabricated zirconia crowns pre-sized as if you would find your stainless steel crown kits. We have zirconia crowns that are sized in a similar fashion and we can offer our aesthetic full coverage restorations which is huge. Back in the day when I was doing my internship and we would see a lot of decays and we still see a lot of decay but anterior decay on kid’s primary teeth, we didn’t have a lot of options.
We saw those four anterior teeth decays we used to call them four little ugly ones, take the kid down to the quiet room and it wasn’t very quiet. We’d need to remove these four anterior teeth. Now if these teeth are salvageable, we don’t have infection, we just have some decay that can be fixed we can save these teeth for these kids in the anterior it’s a huge thing.
Because it helps these kids to develop confidence, it helps them to be able to smile, it helps them with their speech, it helps them with so many things on so many levels to be able to save these anterior teeth and posterior teeth. The demands for aesthetics that you see in your adult practice they are coming on just as strong in the pediatric practice. Parents are coming and they’re asking for white fillings and you know very to do a white filling on too large of carious lesion you’re asking for failure.
We needed to have an option to do full coverage for these kids and so these zirconia pre-fabricated crowns that we’re using are a fantastic option. In my practice I’ve used all of the ones that are available in the United States and Canada and they’re a great thing to use definitely.
Howard: These guys practice alone and my whole motto is that with Dental Town no one has to practice alone. Talk about name brands, the technique, what do you cement it with, do you cement, are you’re bonding?
Carla: You know what, I’m glad you asked, I really am. As I said I’ve used all the ones that are available. We’ve got about four brands that are available in North America but by far the ones that I’ve used farthest and widest and done, I can’t even tell you how many thousands I’ve done of these or the Nusmile crowns. Nusmile is a company.
Howard: It’s called Nusmile.
Carla: Yeah.
Howard: Is the website nusmile.com.
Carla: It’s N-U-S-M-I-L-E, Nusmile
Howard: N-U-S-M-I-L-E.
Carla: You got it nusmile.com and that’s out of Houston.
Howard: Ryan come over here and while she’s talking see if you can pull up nusmile.com, nusmile.com out of Houston?
Carla: Yeah, it’s out of Houston so it’s an American company and they really have a fantastic product. In my opinion it’s a superior product both functionally and esthetically?
Howard: These are zirconium?
Carla: These are zirconia, it’s a new paradigm shift for us practicing pediatric dentistry because we now need to learn how to use these material. We’re used to using stainless steel crowns and by no means are those out of the picture, we’re still doing a tone of stainless steel crowns. I heard you refer to them as chrome steel crowns. That’s what we would call them in Canada stainless steel crowns.
Still need to do a tone of those but the whole cementation is completely different. When we’re talking zirconia or talking stainless steel because now we’re talking zirconia we start thinking about things like contamination. We don’t want to have any blood contamination, we don’t want to have any saliva contamination when we’re cementing these because you know that your cements are not going to cement properly if you’ve got blood and saliva. Blood and saliva is a fact of life in pediatric dentistry.
We’re not cutting the crown and sending the patient away and bringing it back and cementing it when the tissue is healed. We’re cutting the crown and we’re cementing it within a minute of cutting it and finishing that prep. There’s blood, there’s saliva and we need to start thinking about that.
Howard: Nusmile crowns and is this company started by like a pediatric dentist?
Carla: No the founder and CEO Dianne Johnson is actually a lab technician and she had seen the need from one of her friends was asking for an aesthetic crown. The way she started this company was to answer that need for that aesthetic crown for the pediatric dentist.
Howard: What’s her name?
Carla: Dianne Johnson.
Howard: Do you know her?
Carla: I do know her. She started the company to …
Howard: In Houston?
Carla: In Houston. To meet the demand that we needed for aesthetic crowns. It didn’t start off with zirconia crowns for her. I’ll let her tell you the story but the first generation of aesthetic crowns for pediatrics was a pre-veneered stainless steel crown. I’m sure you’ve seen them a stainless Steel crown with a white facing.
That was the first generation and it was a good option, it was a great option for anterior, posterior as well but the zirconia has far surpassed in my opinion the aesthetics of these pre-veneered stainless steel crowns and we’ve got durability that’s fantastic with them. I’ve been placing them and like I said the majority of them that I’m placing are Nusmile.
Howard: The homies want to know what’s the price of a standard chrome steel crown and what’s the price of the Nusmile zirconium Crown?
Carla: My prices are probably going to be a little off because I’m telling you in Canadian dollars, but I’ll pay somewhere around $6 per stainless steel crown. The zirconia crowns are closer to between $18 to $20. You can do your conversation with that.
Howard: Between 12 for chrome steel crown and 20 probably for zirconium.
Carla: No I think it’s less 6 for stainless steel.
Howard: 6 then 12 to 20?
Carla: Yeah and then 18 to 20 for a zirconia crown so you’re definitely paying the cost.
Howard: But how much is the price for a chrome?
Carla: The procedure then is much higher. You definitely gain your investment back again.
Howard: How much do you charge for a chrome steel crown?
Speaker 3: Again it’s going to depend on where you are. If we’re in Manitoba it’s going to be different than when we’re in Alberta or if we’re Ontario.
Howard: What would the range be?
Carla: You’re probably looking at charging maybe somewhere around $80 more for a zirconia crown than you would. This would be my charge to the patient than I would for a stainless steel crown. You’re looking at somewhere hundred and something dollar range for a stainless steel crown and then you’re somewhere two hundred and something for zirconia crown. About an $80 span.
Howard: I also think a lot of parents have guilt that they did something wrong then their kid has a bunch of silver crown in their teeth. That’s why women don’t care if there’s gold all over their body but they don’t want a gold crown. Because the gold earring doesn’t say, “I did something,” but a gold tooth says, “I had a cavity and I’m broke.”
Carla: It’s okay if the parents look in the kids and there’s a little bunch of little brown or green teeth that’s okay but not okay if they look and there’s a bunch of stainless steel. They want to have white teeth, the want their kids to have white teeth and they’ll stick it out.
Howard: I also only noticed that moms will buy braces on their children for 5 grand long before they’d get a $5,000 face job, face lift or a boob job or a tummy tuck. I always see moms 9 times out of 10 the self-sacrificing for the child. She’s going to buy cosmetic dentistry for a child 10 times before she’d buy it for grandfather and herself.
Carla: It’s true and the cost differential that we’re looking at between the stainless steel crown and a zirconia crown for a kid is not that big. It’s not like we’re asking thousands of dollars.
Howard: What are you cementing them with?
Carla: There’s a couple of things that we can cement them with, we can cement them with BioCem which is an ionic resin cement that’s sold by Nusmile as well.
Howard: An ionic resin.
Carla: Ionic resin cement it’s got ions that flows through the resin as well. It’s just going to release calcium, phosphate and all kinds of great things for the tooth. Now like I said we need to be careful that we’re not contaminating our crowns which is an issue with our resin cements. To get around that what Nusmile has done is they’ve developed a pink try-in crown.
We don’t actually take the crown that we’re going to cement until it’s time to cement it. We do all of our prep in our try-ins with these try-ins crowns. We can contaminate them as much as we want and then we re-sterilize them. When it comes time to cement we take a fresh crown from our box and we cement it with that. BioCem is one option that’s’ been great. Another option is Ceramir from Doxa we don’t need to worry at all.
Howard: Doxa, what’s Doxa spell that.
Carla: Doxa D-O-X-A.
Howard: D-O-X-A.
Carla: That’s a company out of and I hope I’m going to get this right, I think it’s out of Sweden. That’s a calcium aluminate cement and Doxa has developed this cement we don’t need to worry about contamination because it works in a different way than our resin cements. The Ceramir has been a great thing to cement these zirconia crown with. Then our final option is just resin modified glass ionomer cement which we use far and wide in pediatric dentistry.
Howard: doxa.com do you know the person there too?
Carla: I have contacts for you I’ll put you in touch.
Howard: Send me them. In Ceramir you have someone who is that?
Carla: That’s doxa it’s sold by, they had it at the show today Bisco is selling it in Canada for us.
Howard: Really but you know someone there that you can get me in contact with?
Carla: I know them all.
Howard: You know them all? The way you’re talking about it let’s talk to them about it. Let’s get back to some real questions. When I’m doing a crown on adult I want it to last for a long time. When you do your average well I keep saying chrome steel crown but these aren’t chrome steel. What is the crown?
Carla: Zirconia crowns.
Howard: If you take out the stainless steel are there zirconium.
Carla: Pre-fabricated crown.
Howard: Pre-fabricated crown?
Carla: For sure.
Howard: How old is the average child when they get a pre-fabricated crown and how old are they going to be when that tooth falls. Are we looking at a window of about four years?
Carla: Yes or no, it depends what we’re restoring, it depends how old the kid is, we’re doing anterior teeth?
Howard: Aren’t they mostly A and B.
Carla: Yeah so A and B in the United States are your first and second molars. We have certain tooth scenarios. Let’s talk about our anterior teeth first so let’s say …
Howard: Is that going to be mostly baby bottle tooth decay?
Carla: Yeah.
Howard: All the time?
Carla: Yeah mostly apple juice, neglect the whole gambit of dental faux pas and people get cavities, cavities are, that’s a fact of unfortunately of life and people aren’t going to stop kissing their babies either.
Howard: Right I know.
Carla: Let’s say we’re restoring anterior teeth. We’d see traditionally lateral to lateral I’m talking of universal way that [crosstalk 00:15:46].
Howard: Four upper incisors?
Carla: Four anterior yeah. When kids come with decay usually we’ll see them come around the age of two with that and sometimes we see them a fair bit earlier with anterior decay. At the latest we’ll start restoring these teeth around the age of 2 give or take. We start exfoliating our central incisors about the age of 6 and then the laterals will start to go maybe age of 7 or 8.
We’ve got a lifespan of those anterior of say 4 to 5 years is what we want these zirconia crowns to last. Keep in mind these are kids they are not going to be careful with their teeth, they’re breaking off Lego, they’re biting into apples, there’s corn on the cob, we’re demanding a lot.
Howard: Their brother’s finger.
Carla: Absolutely, demanding a lot from our restorations, we’re demanding a lot form out cement. The kids are falling and they’re hitting themselves so this is the lifespan of the anterior teeth. Posterior teeth there’s much more variable, by the time we get to the amount of decay where we need to place full coverage on that tooth. Sometimes we have these kids come in at the age of 2, sometimes they’re not until 5, 6 with that amount of decay, sometimes it’s a failed restoration.
We’ll exfoliate our first primary molar around the age of 11 years and second primary molar around the age of 12. Take your pick when you’re restoring them how long do you want it to last for. Then again in posterior we’ve got all kinds of issues to deal with, lots of kids are bracing and grinding their head cut of their restorations that has to hold up to that force as well.
Howard: I wish you on this is so information and you’re so on top of this game. I put up 351 hour courses on Dental Town, they’ve been viewed over half a million times. Do you ever give this lecture in a slide or a PowerPoint?
Carla: I give this lecture all the time.
Howard: Is there any way I could beg you to put this on an online course on Dental Town.
Carla: It depends what do you want, do you want us to just do talk about zirconia there’s resin infiltration that’s hot and coming, there’s bio-activity.
Howard: I’d love to have it all.
Carla: I’ll go around I’ll out and do courses, lectures, hands-on 10, 12 times a year. I have a couple of webinars up there online, a couple that are powered by Viva for different companies I’ve been there, done that. I can develop something if you want to have a specific topic in an hour, pretty much I know what I can …
Howard: It could be longer I think learning how to treat children is very difficult. The most viewed course we ever put up was actually a pediatric dentistry course by Josh Wren and we asked some of the users, “Why this course?” The just sit there and said, “You know I can learn about endo and [pario 00:18:45] from a dozen different places, but there’s not many people teaching pediatric dentistry.”
Carla: There isn’t a lot of [pediatrics 00:18:50].
Howard: It was our most viewed course is pediatric dentistry by Josh Wren. Would you be willing to teach some more?
Carla: We can talk about it.
Howard: I don’t know anybody, I really in my backyard all my friends none of my friends in Ahwatukee are doing white zirconium on children, I’m not doing them.
Carla: It’s something that the pediatric dentists have really embraced. It is slower to take with the general.
Howard: They haven’t really embrace them?
Carla: They have really embraced.
Howard: They have really embraced.
Carla: Slower with the general dentist but I can tell you when I go and I teach hands-on courses, hands-on workshops and I teach mostly general dentist. There’s always one or two pediatric dentist come in because my title for my course is Pediatric Dentistry for The General Dentist. It’s the general dentists that can do the zirconia preparations with their eyes closed because they’re used to doing a traditional prep.
When we’re doing a zirconia prep we’re taking more tooth structure than we do for a stainless steel crown. You’re not cutting with that little inverted pair that we cut with, we’re cutting with diamonds and the restoration procedure seems to be something that the general dentist can catch on to really, really quickly.
Yet the majority I think and you can ask this to the CEO of the Nusmile Company. The majority of their sales goes out to pediatric dentists for sure. There’s a whole other factor that goes into this and the general dentists are often shy to be able to treat the patient with the behavior management that takes place and you’re doing anterior crowns.
We’re doing this on 2 year olds and 3 year olds they’re not the easiest people in the world to get to sit still for us. We got to be quick, we got to be efficient, we got to be calm and all the rest of it. A whole laundry list of what we need to be. There’s more that mixes into it than just the procedure.
Howard: Let’s talk about a couple more things. Give us some verbal skills I’m the dad and I want to come back with my child. Is that good or bad?
Carla: You want to come back into the room with your child?
Howard: Yeah, my kid is 3 he needs to come in there, he’s crying, he’s got a toothache. When I say I want to come back with my child.
Carla: There’s a lot of strong opinions both ways on this. My stance the way that I practice my dentistry is that parents can be back there with the kids. If I have a kid that I know is going to play on the empathy of the parent and that is going to stop me from getting the procedure completed. I will tell the parent, “Look it’s best for little Hayden, Caten, Braden if you’re down in the waiting room waiting for us to finish. We’re going to get the job done a lot faster,” and he’s going to corporate with me better.
We have that conversation not the time that we’re about to go into the room with Hayden, Braden, Caten but when we are discussing, “This needs to be done and this is how we’re going to get it done.” For the most part parents come back to the room with me and that’s fine. My routine with the kids is the same whether the parent is there or whether the parent is not there.
If I need somebody to hold a hand, I’m going to have the dad hold the kid’s hand. I want my assistant to be able to pass me instruments not to be holding a kid’s hand. We have the parent in there, I use that opportunity to teach the parent what I’m doing and what’s going to happen, why we’re doing this, how we can prevent it. There’s a whole realm that goes on and I don’t want that parent to be in there seeing how I am with that kid.
I want the parent to know that nothing bad has happened to your kid because sometimes you have a kid in your operatory, send the kid back out to the parent and everything had been in the operatory and the kids starts balling and what’s the mother or father thinking? “What happened to you up there, what did they did to you?” Really what did we do? Just what we always do to treat our kids the best that we can.
Howard: I like to ask all the uncomfortable conversations. Papoose board is there still a place for Papoose board or is that cruel and unusual punishment?
Carla: Papoose board so actually that’s politically incorrect we’re supposed to be calling them immobilization devices.
Howard: Papoose is a.
Carla: That’s an immobilization device.
Howard: That’s politically incorrect?
Carla: Apparently it is, another pediatric dentist had said that to me so we call them immobilization devices. I don’t like to practice like that. I will use my Papoose board in an emergency situation. If I have a kid that’s come in with trauma and we need to get something done quickly and safely, if I have a kid that absolutely cannot be treated in any other way.
I don’t want to be doing anything that is long and involved with the papoose board. I wouldn’t want to be treated that way. We use it when we have to, we pull the thing out maybe a handful times a year.
Howard: Every other month?
Carla: Yeah maybe.
Howard: It’s tough because a lot of times if it’s not papoose board it’s going to be in the hospital general sedation. In your practice how often are you taking the kid to general sedation? Do you do that in the dental office or do you go to the hospital?
Carla: I have a surgical center that I go to so I work with an anesthetist. I have the anesthetist sedate the child under general anesthetics. I go in, I take in 10, 15 kids a month but that’s my average per year.
Howard: On one day?
Carla: No, no, no that’s over a few days.
Howard: 10 to 15 kids a months. You go to a general surgical center with a board certified anesthesiologist provide [anesthetics 00:24:48]?
Carla: I do that because first of all I don’t think that sedation unless it’s a deep sedation on a child works. I think the kids has to be pretty deeply sedated if they’re an uncooperative child. I never wanted to be in a situation where I had to resuscitate a kid, I’m a dentist I am not wanting to have a kid in that situation in my office so I just don’t do it and I never have and I never will.
If a parent wants some sedation that’s not a general anesthetic and I can’t do what I need to do with just local anesthetic and the sweetness of my voice then they can go somewhere where somebody else can help them.
Howard: Well you know a dentist always want to shelter their own and I’m the first guy to throw the dentist under the bridge because I call it the way I see it. In all the hospitals in the United States you’re not legally allowed to do the anesthesia and the procedure. According if you ask a surgeon you can’t be running your IV and doing your bypass.
It was the British who showed me the first time 10 years ago that when the physician doe the anesthesia and the procedure their death rates are higher and they were talking about their own oral surgeons. In the United States the oral surgeons have twice the mortality rate because they do their own IVs.
The bottom line is, the question is real simple how many Americans have to die before the dentist adopt the same standard of care that the physicians adopted 50 years ago. That one person does the anesthesia, one person the procedure and the person to do the anesthesia just that’s all they do, they’re staring at the monitors and they get it done about with half the mortality of when the doctor is trying to do both things. Do you agree with that statement or disagree?
Carla: I do agree with you and until the time until it’s regulated in your particular jurisdiction you need to be responsible and treat your patient.
Howard: I’ve also heard this many times, when you’re a doctor and you do your anesthesia and someone dies and they take you to trial and they bring in a board certified anesthesiologist to cross examine everything you know about anesthesiology that they make you look like an idiot on trial.
You’re a dentist you do root canals, you do pediatric dentistry you can’t hang with an emergency room anesthesiologist on trial and then there’s a dead kid over there. It’s one of the most under-utilized things in dentistry. When calls come in I would say about half the calls are saying, “Well how much is it, how much does is it cost, my insurance?”
Money is half but once you leave money then it goes to, “When I get a shot is it going to hurt, can you knock me out, can you put me to sleep?” Then all the dentist the only they heard was, “Same day crown, same day crown. I just want my crown on the same day.” I hear that like once every six month and everything else is, “How much does it cost, how much is it going to hurt?”
Another controversial question. Some of these young kids come out of school and they go work with some old fad and he’s using for pulpotomy he’s using Formocresol [crescedent 00:28:01] and these young are on Dental Town saying, “Hey isn’t that carcinogenic is that a bad?” What would you say to some old guy who’s using Formocresol or [cresedent 00:28:13] or are there any other ones form back in the day?
Carla: Those are basically the two.
Howard: Carcinogenic is that cancer causing do you use it?
Carla: It depends who you ask so ferric sulphate which I believe is which time of [cresedent 00:28:29] is that would be a brand name [crosstalk 00:28:32]
Howard: No [cresedent 00:28:33] it was some chemical 30 years old. Something you smell and it’s like but it was the pulpotomy stuff.
Carla: Maybe [crescedent 00:28:43] maybe it’s the cresol.
Howard: Yeah cresol.
Carla: That’s the same thing as Formocresol.
Howard: I think it was a name brand of Formocresol. Cresedent was cresol.
Carla: Let’s talk about Formocresol. The studies have come out and said that it’s carcinogen and in 2011 the American food and drug administration put it on the list of known carcinogens.
Howard: 2011?
Carla: 2011 I believe is the date if I’m wrong on that I’ll correct myself.
Howard: No, I did not know that.
Carla: I think that that was it. Known list not banned yet. It is banned in some states, some states regulatory boards have gone ahead and banned the material from being used so you cannot use Formocresol in certain states. Then there’s a whole lot of other literature that came out from some very good sources that had gone and done, what’s the word I’m looking for, they’ve done plasma tests on these kids that have had Formocresol pulpotomies and blood testing, finding out that in fact there is not any Formocresol running through their veins.
You have to take those both things as knowledge but know that there are better up and coming materials and materials that we’ve been using for a long time. That have been doing that job without any fact of using a carcinogen or a known carcinogen. Whether it is or whether it’s not I’m not educated enough to answer that question.
We now want to use MTA as a pulpotomy material which of course which was a problem in that past because MTA was very expensive, cost prohibitive for doing these procedures Formocresol is pennies. You can do the procedure, you can do it fast, you can go ahead and put your IRM in there and you can be done.
In the last recent years there’ve been a couple of things that have come out so biodentine has come out from Septadont. Biodentine we can use for pulpotomy procedures but it has its limitations as well. It comes in a capsule which some people you know, questionable and a 12 minute set time. We get around that with a procedure and a technique that I use that we don’t have to wait that 12 minutes.
Since then NeoMTA has come on the market and NeoMTA has an even shorter set time and it’s less expensive yet. Whichever product you’re comfortable using. This is what we use for our pulpotomy and then those have a higher success rate using MTA or the biodentine which is an MTA like material than our Formocresol ever did.
That I believe is what we’re looking at as a standard of care for pulpotomies now is to use an MTA or an MTA like material.
Howard: An MTA it’s out of Southern California it was a [Paul Simon 00:31:48] or what?
Carla: That was one product the Neo-MTA I’m not sure where it’s manufactured but it’s sold also by Nusmile. They’ve got the whole pulpotomy, crown, cementation of the crown. They’ve got those steps all nicely packaged together with their products so that’s where you can get that Neo-MTA as well.
Howard: I want to have some more verbiage because this is all you do and I’d say most of us kids might be only 10%, 15% of what we’re doing. I’m just going to be the dad. “Why do I need to fix this because it’s going to fall out anyway? I’m I just wasting my money I mean come on?”
Carla: People ask that a lot and that’s an adjective that you’d see …
Howard: What do you say to me? Even there in Canada too?
Carla: We hear everything that you hear we’re just maybe a little later date, you’re always more advanced in timing than we are but yeah we hear it all. The answer is, we need these teeth to function, we need to be able to chew and we need it to be able to grow, we need to be able to smile.
You want to have child that’s pain free, severely decayed teeth don’t exfoliate normally in a normal pattern. If we had root tips left behind those root tips can stay behind for a long time, they can deflect the eruption of the permanent teeth. Do you want to walk around with a toothache in your mouth for 8 years? I don’t think so why would you let your kid do that too.
Now every time they’re swallowing all of that decay, all of that crap going down every time they’re swallowing, all that bacteria and all that acid it’s not a good thing. We want to help our kids, we want to treat our kids don’t leave them. Even if they’re in there for a year you want to treat these carious lesions.
Howard: I know my job is if you asked what these homies are thinking they wish they could ask you and I know they’re wondering. Do you ever do amalgam are you only posture compositive. What are your thoughts on amalgam versus composite baby teeth?
Carla: Out here an amalgam is still widely used, I don’t use it in my practice. What I use instead if I have a situation where I can’t keep things dry and use my composite restoration so I’ll use glass ionomer. Which is a nice hydrophilic material, very forgiving. I can use it in a wet environment and I use it for those cases that I can’t keep dry whether it’s from a kid.
Howard: What glass ionomer you use?
Carla: There’s a couple out there that I use. I’ll use the GC America products or the Fuji II LC or the Equia which is self-cure glass ionomer system or I’ll use the STI products which are called Riva Lite Cure, Riva Self-Cure. Those are the 2 main glass ionomers that I use, but I can’t practice pediatric dentistry without them. They’re strong, they are able to release fluoride, they’re just absolute must if you’re doing any amount of pediatric dentistry.
Howard: Tell me this I’m an American but I’m only 100 miles from Mexico so I might be more Mexican, you’re up here in Canada. How come when you travel around the world glass ionomer is huge in Japan, Australia, New Zealand? A lot of the international data I look at it’s almost like American dentist use less glass ionomer per thousand units and japan and in Australia, New Zealand would be the most.
What do you think in a flat earth where we all the same iPhone in here, Sydney, japan. Why do you think there’s such a huge variance in glass ionomer?
Carla: What you say is exactly true glass ionomer is used much, much more widely abroad than it is in North America and our material of choice seems to be composite. It’s a great material and they’re strong and they’re aesthetic and they’re better than they ever used to be but they are not the best material on a kid that’s full of spit.
Howard: Explain that in detail why is it not the best material for a kid full of spit?
Carla: Composite is incredibly hydrophobic. We get moisture in there, contamination and you’re going to have a restoration that’s going to fail. If we can do that same restoration with glass ionomer which is more forgiving? It requires water for that acid base reaction of the glass ionomer.
Then we’re going to have much more chance at a successful restoration plus since the glass ionomer is going to release some ions, it’s going to release some fluoride and help that de-mineralization around the margins. We’re going to have a better chance of success because when we have a failed restoration in a kid it’s recurrent decay, it’s residual decay, it’s always around the margins.
There’s studies that they’ve published, there’s literature out there talking about how much more effective glass ionomer is in class 2 situations, then composite then amalgam as well. Why are we not it as widely? I think it’s an education thing, I think that we’re used to the norm of using composites in our practice, we know how to use them we know how to deal with them, we know how to apply them. Glass ionomers require some mixing, it’s a different feel when you’re putting it in, it’s a bit of a learning curve.
Howard: It’s less technique sensitive.
Carla: It is.
Howard: It can handle some moisture contamination?
Carla: Yes.
Howard: It has anti-bacterial static properties.
Carla: Yup.
Howard: All of these posture composites which dentist say last longer than amalgams because they’re insane when they say something like that. When you say a composite last longer than amalgam I mean do you really go to Kentucky Fried Chicken and believe that your plastic fork at KFC last longer than the metal fork at home in your kitchen. If you believe that.
Carla: I like that but it looks better, it’s prettier.
Howard: I don’t even know where to start with that. We know the metal fork at home last longer that the plastic fork at KFC, we know the fillings fail because they’re technically put in wrong and the composite is more technique sensitive than the glass ionomer and the amount amalgam almost has no technique I mean you can. What percent of your tooth colored restorations in pediatric dentistry are resin composite versus glass ionomer?
Carla: I still think that we’re probably doing maybe 20% glass ionomer to 80% composite never minding any of our full coverage stuff. The reason is you got to remember too that glass ionomer is not as strong as the composite is. If we have a deep restoration glass ionomers tend to be more brittle so there is a higher chance of a glass ionomer breaking than a composite breaking.
You got to weight the balance. I’ll use my glass ionomers in situations where I can’t keep things dry, I’ll use them in situations where I’m looking at it as a very short period of time, I’m using it in situations where I’m buying time. If I’ve got an average to large size lesion maybe we’ll do a sandwich take advantage of both of the properties that we want from the composite and the glass ionomer or maybe I’ll go full composite.
Howard: A lot of people don’t understand what a sandwich is in America, that’s a common term in Asia, but explain what you mean by a sandwich.
Carla: If we’re using a sandwich what we’re doing is layering our materials basically and we’re taking advantage of the properties of each material so at the bottom of the sandwich your gingiva floor, the lesion let’s call it the deepest most part. We would be using something like a glass ionomer that could give it anti-bacterial properties so it’s going to be kinder to the tooth than a composite would be, that would be layer one.
Then we would use the composite as a layer on top of that in order to take advantage of the strength of the composite and as well as the aesthetics of the composite. We would layer things, there’s all kinds of different layers. What I’ll do with my glass ionomers too in certain situations a layer glass ionomer and then I’ll put a layer of flow ball over top of it.
It all depends on the location of the lesion, it depends on the occlusive force, it depends on the aesthetics. How long do I want that restoration to last for, how long can my kid sit still for? It’s all based on all of that whole mix all put together.
Howard: I’m going to switch to completely different subject. A lot of times we dentists are stressed, a baby’s tooth has got to come out. What are you thinking when I got to do a space maintainer or not. Do you have any quick rules of thumb or any thoughts?
Carla: Sure.
Howard: You think we can go down that direction?
Carla: Space maintainers in general we look at space maintainers for posterior teeth and there are a couple of cases where we’ve lost space anteriorly. In general a space maintainer for a posterior tooth if I’ve got a second primary molar that’s lost and my six year molar is in or not. I want to have a space maintainer in there because I don’t want that six year molar to drift into the space of the second primary molar.
The first primary molar is a bit of a different story and there’s a little bit of finesse that comes with it. If we have our six year molars and they’re in and they’re in complete occlusion, we’ve got a nice tight occlusion. The literature is telling us if we got that, that first primary molar is gone, prematurely second primary molar is there and the six is there maybe there’s not so much need for a space maintainer.
We’ll do a unilateral space maintainer if the need is there or a distal shoe if we have bilateral space-less we’ll do a nance appliance or a lower lingual holding arch provided that we have the permanent anterior is erupted. It’s a hard question to answer in a few sentences but in the end I’d always rather err on the side of caution and even if we have a space maintainer that’s in there for a matter of months instead of years.
I would rather do that than have to explain to the parent why now we have to make a distalizing appliance that’s going to cost them several hundred dollars versus the space maintainer that would have been a hundred and change. We’ve got some really good products out there too that are chairside space maintainers. We’ve some from space maintainers lab I believe it’s called out in California where it’s a chairside band and loop that you put together and you can cement it immediately after the extraction.
Denovo has the same type of product where you can go ahead and put the band and the loop and fit it at the time of the extraction. If you’re doing a distal shoe that’s often the way that you need to go because you don’t have the luxury of having that patient come back and you don’t want to re-anesthetize and the whole thing.
Howard: Carla the last podcast was [inaudible 00:42:55]. Carla you are an amazing wealth of knowledge. I would give anything for you to do an online T course and also we’ve been. In dental there’s a reservation casino right by our place Talking Stick Resort Casino where we’ve been putting on hands-on lectures.
I would love for you to put on some didactic courses on Dental Town and then build demand for coming down to Phoenix and doing some hands-on. Because I think a lot of dentist that are hearing this on your podcast would want to see more in the slides and the presentations and probably want … you do hands-on courses?
Carla: I do hands-on courses.
Howard: What do you teach in your hands-on courses?
Carla: It depends what you want to learn. There’s always a demand for aesthetic pre-fabricated restoration. Zirconia is pretty much a given in all of them. I’ll go through a lot of the bioactive materials. Things like the [inaudible 00:43:52], the Activa products. We’ll do our basic composite fillings and I love to be able to include glass ionomers in there as well. Whatever the demand may be, however long the course is. I’ve done a day course, I’ve done two day courses, I’ve done half day course all hands-on.
Howard: One of my homies wanted you to speak at their dental society or contact you how do they get a hold of you?
Carla: They can get a hold of me through my personal email and I guess this is probably the best way.
Howard: What’s your personal email?
Carla: It’s drcohn@shaw.ca remember we’re Canadian.
Howard: I see that that dot shaw, I see dot shaw a lot for Canadians shaw is that?
Carla: Just one of our carriers.
Howard: Is that like an internet cable TV?
Carla: It’s like saying.
Howard: Fox?
Carla: Yes exactly.
Howard: Shaw S-H-A-W and then it’s dot CA for Canada?
Carla: Yeah that’s probably the best contact then you’re sure to get a hold of me and not go through any …
Howard: You were born in Winnipeg Manitoba. Does that mean your favorite sport is hockey?
Carla: No absolutely not.
Howard: What’s your favorite sport?
Carla: I don’t know I don’t think I have a favorite sport, we do other things.
Howard: I want my last question to be something totally off the record but I get this question a lot and I am embarrassed to ask it because you’re a woman I am a man. We’ve seen a lot of changes, there’s a lot more women dentist now when you got out of school.
Carla: Yes.
Howard: Would you agree?
Carla: Yeah.
Howard: Would you consider yourself almost a woman pioneer were there a lot less women in your?
Carla: There were a lot less women I was …
Howard: How many women were in your class when you were in dentist school?
Carla: We were 20% of our class. It was a small class, we were like 25 people period. I don’t think I would say pioneer because I think that the women that were 10 years, 20 years earlier were more.
Howard: I wanted to ask this sometimes young little girls in dental school will say, “What advice do you have …” Well I get this all the time they say. My number one complain in my podcast is that when I interview a dentist it’s a man when I interview a woman it’s a dental consultant. They tell me that’s sexism I say, “It’s not sexism I’m trying really hard,” so I call you guys unicorn.
They want to hear young girls in dental school, want to hear from I don’t want to say older women.
Carla: Yeah don’t do that.
Howard: Women who have been out a couple of decades. I guess this is the question the main complain I get is that these young girls get out of school and they say, “I went and worked for Henry and I watched how he managed and I worked for him for a year or two and then I bought the practice for $500,000 and now I say the same damn thing Henry says and those girls don’t obey me like they obey Henry.”
Their question is do women since 98% of the employees in dentistry are women in healthcare and in mining it’s 99% men. In construction in America it’s 96% men. In mining and agriculture and construction it’s all men employees, but in healthcare it’s pretty much all women.
Young women dentist believe that if old man McGregor says it the women jump and then she buys the practice and says that they don’t jump. Do you think that’s because she’s a girl and old man McGregor was a man or do you think that’s her? What advice would you give? What advice do you give to young women on how they can be leaders?
Carla: You become a leader by acting and practicing responsibly and ethically. As corny as this may sound, but I think that that problem comes in because those people don’t have the respect of their staff. If their staff sees them acting on a daily basis in personal interaction with ethics and respect and strength then they will earn that respect. I truly believe that, I don’t think that it’s a man woman boss thing.
Howard: I wanted to say something that I have not credentials to say but I want you to get some firm boundaries because I think women cross the line with employees and being too friendly, too close than boys. One of the reason boys is because I can’t go out with all the women in my office after work for drinks and out when I got a wife with four kid at home.
I had natural barriers so I’m not doing that, but I look back and think that helped me lead them more. Then I see some of these young girls going to happy hour with their staff and doing shots and tequila and getting drunk and being crazy and then the next morning they’re supposed to be your sergeant. Can you lay any hard rules, how friendly can you be with your staff and still lead them? What lines do you draw to say, “No I’m not your friend I’m still your boss.”
Carla: That’s a really hard line to draw and it’s true we do have [inaudible 00:49:19] relationship.
Howard: Is there a line?
Carla: There has to be a line and that probably is different for each person, each individual. You got to keep that in mind exactly what you said you’re going to work the next day and you’re the one leading the group you keep in mind what you do the night before or wherever it is that you’re going.
Howard: How can you do jello shots with Amy at night and the next day you write her up for being 5 minutes late, you know what I mean?
Carla: It is a hard line to cross.
Howard: It’s blurry.
Carla: I see it not necessarily in the dental world but in other worlds men do it too. They go out with their buddies, their employees and then the next day they have the same difficulties. You need to be cognizant of what it is that you need to achieve and there’s nothing wrong with being friends with your employees but as you said you also need to lead the team so.
Howard: Carla I think you’re amazing I really do and you’re with the Catapult Group and that is nothing … Lou Gramm and by the Lou Gramm is my favorite singer I got to play Lou Gramm. I hope he hears this but Lou Gramm as you know sang my favorite song. What is this favorite song? Lou Gram. Brian can you get this on the [inaudible 00:50:52]. This is Lou Gramm Midnight Glory [inaudible 00:51:04] Lou Gramm who started a Catapult. What is it called, Catapult Dental Consultant?
Carla: It’s called Catapult Elite.
Howard: Is that him right there?
Carla: Is it the same guy you know it’s hard to tell it might I’ll have to leave that one to your imagination. He started a group of friends really is how it started and we all go out and we do continue education, we’ll do evaluations for products, companies will come to us and ask us to evaluate a product for our input. It’s a really cool group of dental keeners. I’m always a little surprised that they let me join me I don’t know.
Howard: Tell them what is that website?
Carla: catapultelite.com will have all of the speakers’ bios, they will have courses that we teach and what catapult can do to bring a speaker to your group. That’s another source if you don’t want to email me personally to go to that website because that will have contact information on how to get to our public relations people that book us.
Howard: Name some of the speakers on that group.
Carla: I got first and foremost say Paresh Shah.
Howard: Right here in Manitoba?
Carla: Yeah.
Howard: I did podcast with Paresh.
Carla: He’s a very awesome guy if you want to make sure that you’re going the right places, hang out with the right and Paresh is the right people. Who else is in there? Doug Lambert, Ron Kaminer, Gary Radz, Pablo Brian Novy lots and lots of other great speakers that have been up and coming. John Comisi going to come to Manitoba in January. He’s a very brave man he’s going to come and speak to us about bio-active
Howard: We did a podcast with him too and he’s a big pop [inaudible 00:53:05] lover fan. The reason I have a mutual attraction with him is because we both like silver filling that can kind of retard. I feel like dentist want to talk about they’re engineers, they’re civil engineers who want to build a building.
I always didn’t see dentistry as an engineering field I always thought it’s a biology problem. We’re getting attacked by Streptococcus mutans that eats teeth. I’m from Kansas the problem with barns was termites it wasn’t anything else. It wasn’t the nails, it wasn’t the wood. The barn didn’t come down because we used the wrong wood.
It seems like the dentist don’t treat dentistry as a biological and so me and him we like fillings that kind of retard bacteria growth. All my peers just don’t want to talk about wear rates and bonding strength and flexural strength. It’s like are you building a bridge over a river? Because if you’re building something in this mouth that has a billion bacteria virus and fungus per cc we’re in different language. I think that [Popden 00:54:04] is sort of the future companies.
Carla: Absolutely there’s a lot of bio-active materials.
Howard: Like Fuji for pediatric dentistry.
Carla: Glass ionomer maybe that was the first bioactive material that we had. There’s that and there’s [inaudible 00:54:32] products and the BioCem and even our MTAs and the biodentines they’re all bio-active.
Howard: Every ingredient of an amalgam is antibacterial.
Carla: Absolutely.
Howard: Mercury, silver, zinc, copper, tin every one of those is an antibacterial and we replaced those with plastics. I hope to see you put up some courses on Dental Town I think that would be great. If you ever want to do a hands-on course in phoenix Arizona all you got to do is tell me the date and the time because we put these on at the talking sticks casino.
What’s amazing about phoenix [inaudible 00:55:08] there’s actually 3800 dentist in the metro. That’s like a country.
Carla: Isn’t that more than Canada?
Howard: Canada has more than that but it is a small country. There are many, many countries that don’t have 3000 dentist and we’ve got 3000 dentists in phoenix.
Carla: Awesome.
Howard: Carla thank you so much for your time.
Carla: My pleasure thank you.
Howard: Thanks for fixing me all those people because I would like to tag if you want me to do 5 minutes on Skype tag with like the founder of Nusmile or Doxa or any of these thing.
Carla: For sure, no they’ll do it.
Howard: I would love to do it.
Carla: They’ll do it for sure.
Howard: Tell your catapult elite colleagues that I’ve talked to you, I’ve talked to Paresh I’d love to Lou Gramm I’d like to have him that song Midnight Blue live on, but thank you so much for your time.
Carla: I’ll put in a good word for you. Thank you.