Dr. Valerie Cooper is a private practice prosthodontist with a passion for dentures. Called the “Denture Queen” by her prosthodontics coresidents, the name stuck, and her love for removable prosthodontics grew with time. Dr. Cooper presents a systematic approach to digital denture treatment which she has been refining since she switched to all-digital denture fabrication in 2015. Dr. Cooper’s practices are located in Dayton, Ohio, her hometown. She owns a practice limited to prosthodontics as well as a general dentistry practice. Since 2014 Dr. Cooper has fabricated free dentures for patients in her community during National Prosthodontics Awareness Week, NPAW. Many volunteer lab technicians, students, and prosthodontists helped prepare up to 20 dentures in a single week with the conventional denture process. Once the process became all digital and required less human work, the focus turned to education during NPAW 2016 and 2017. In 2018 her plans are to fabricate more free dentures than ever before using 3D printing technology.
AUDIO-DUwHF #1094 Valerie Cooper
VIDEO-DUwHF #1094 Valerie Cooper
Howard: It'll just be a huge honor today to be podcast interviewing Denture Queen on Instagram. Her name is Dr. Valerie Cooper she's a private practice prosthodontist with a passion for dentures called the denture queen by her prostadonic co-residents the name stuck and her love for removal prosthetics grew a ton. Dr. Cooper presents a systematic approach to digital denture treatment which she has been refining since she switched to all digital denture fabrication in 2015. Dr. Cooper's practices are located in Dayton, Ohio her hometown. She owns a practice limited to prosthodontics as well as a general dentistry practice. Since 2014 she has fabricated free dentures for patients in her community during national prosthodontics Awareness Week, many volunteer lab technician students and process help prepare up to 20 dentures in a single week with the conventional denture process once the process began all digital and required less even work the focus turned to education during the MPAW 2016 and 2017. In 2018 her plans are to fabricate more free dentures than ever before using 3D printed technology and I want to tell you that I'm in Phoenix Arizona and they just had the digital dental conference you were the keynote speaker you didn't even leave town you came by my house because you're lecturing again at another big conference right here in our backyard you are the bomb and thank you so much for coming by my house. So I got to ask, of all the things to go into dentistry why the denture Queen?
Valerie: Well I didn't intend to go into dentures I actually didn't even like them much at all until my residency actually when I graduated from dental school I didn't like them at all I had the usual
Howard: and what school was that?
Valerie: Ohio State
Howard: Oh the Ohio State
Valerie: The Ohio State I had the usual problems that most dental students have they don't like dentures they don't feel confident they don't know what very much about it and so it wasn't why I went into Prost but I did go into profs and my instructors kept giving me all the difficult denture patients and more so than a lot of my other classmates and that kind of what happened is I got gained the love for the challenge of the difficult denture patient. So you know the lady who has no Ridge wants to eat celery and carrots has a bag of rejected dentures most people are like no way not touching that I'm like well maybe I could try this or maybe I could try that. So the thrill of a success in that case is what makes me love it.
Howard: You know I'm a huge fan of yours and I want to get you involved and dentaltown anyway and because when you go to all these conventions the limelight is always the on four like I'm lecturing I'm next weekend in Vegas at the MegaGen symposium and everybody in dentistry they always love the rich the famous Lamborghini.
Howard: The all on four at $25,000 an arch but I'm from Kansas and Arizona is pretty much Kansas and it's not you know it's not whoty totty California or Beverly Hills or anything like that and there's a hundred all on nones.
Howard: A denture done for everyone all on four. What do you think the all on for twenty five thousand arch, how many full mount dentures are done on none implants what do you think the ratio is?
Valerie: I don't know I probably a hundred to one.
Howard: Oh yeah.
Valerie: You know that sounds totally reasonable but...
Howard: I mean when I tell people in Phoenix I mean I'm in Phoenix I'm not in Scottsdale, I'm not paradise valley, when I tell him it's $25,000 an arch some people just laugh yeah I mean it's like it's like you know it was like a joke.
Valerie: That's also my experience in Ohio too. So I know people friends of mine who have successful prost practice in big cities and they're like people get dentures like yes and it's not always so much about the cost. Dr. fine has done studies about people who are presented with you can have implant dentures for free some people actually turn that down and there's a lot of people especially elderly people who say I'm worried about the surgery I'm worried about the impact of my health and they don't want implants. The other thing I would want to mention is for the all-on-four folks you have to know dentures to be good at all on four, it's the basics.
Howard: That was Carl Misch's intro to implants, he was first a denture making prosthodontist and these implants came out and everybody kept saying that these titanium implants were snapping and he goes yeah because the denture was so bad, if the denture would have been done right it would have the titanium implants wouldn't have snapped.
Valerie: Yeah you can't fix all the problems with implants.
Howard: Now do you place implants too?
Valerie: A few by now not to many.
Howard: but is it being denture clean is the majority of your practice dentures?
Valerie: No I would say I have an average prosthodontics practice. So I do implants, crowns just general prost, in addition to the dentures but I like doing the denture so I try to get them. So I would say I do more than most prost.
Howard: So you're without a doubt I mean you just had you just look at the largest digital dental conference period it's sold out.
Howard: You were the keynote speaker that's just you got it just did you tell your mom did you Lisa did you take a selfie and tell my mom I'm keynoting at the biggest denture did you?
Howard: Okay good good
Valerie: Which it's kind of weird for me I was voted most quiet in dental school I was also extremely shy in all other all my other classes so, I never ever ever thought I would speak in front of that many people or actually have the desire to do so.
Howard: So did you were you scared were you nervous or did you love it was it fun?
Valerie: No I really don't get scared I mean I'm a little nervous everybody's nervous when they start you know talking people but if you asked me about dentures on a bus or in a taxi I will go on and on and on and on so I honestly find it easy to talk about dentures I talk about them for two days, so it's once I have an audience that actually wants to hear what I want to what I'm what my interest is I will just talk their ear off.
Howard: If you go to my YouTube channel its youtube.com/dentaltownmagazine and then you click videos then you can sort, oh here it is my most viewed I've got a thousand and sixty classes on podcasts on the number one view the only the the one over 10,000 views on just YouTube alone was my journey with Christy lend have you heard of her and it was and she's another phenom because um she was a young bride who just got married and had a needed a denture and people that want to talk about dentures yeah there it is right here people that want to talk about dentures don't I mean who do who do our girls gonna talk to they don't want to tell people that they don't have any teeth or losing their teeth. I mean these girls don't any want to talk to their sister or their friends so it's just great pain and and I've seen it and and there's also if you talk to suicide people there's people who lose all their teeth get a denture and check out and I find it amazing a mismatch supply and demand is one of all the podcasts I've done that just on YouTube alone the only one the past 10,000 watches on YouTube was about a denture and that this is my new mantra it's like the dentist so is they always ask you know what bonding agent you use what percent of the people that call your office go to voicemail, isn't that more important than what bonding agent use. So I just love the fact and I never would have pictured if someone said to me who's gonna be the keynote speaker at the biggest digital dentistry conference I thought it'd be some sixty five-year-old Brooklyn dentists with a mustache and crooked teeth you know up there slug it out and it's like a beauty queen
Valerie: Thank you.
Howard: It's amazing so you have so much to offer because these dentists need to get focused on real world real dentistry and then and then they want to be a cosmetic dentist in their in persons kansas and they're taking every course by some guy from Beverly Hills and saying do you not know you live in Kansas.
Valerie: They can do cosmetic dentistry the next day by focusing on dentures I think it's the most artistic of all the types of dentistry it's certainly more difficult than fixed prosthodontics doing veneers for example you can only do so much you can't change very much about someone with veneers but you can change their a whole face with dentures so yeah.
Howard: cuz that's what the American witches is right she went a dentist and so she's over closed which makes it look like she has this big nose in this big chin, when basically he just opened her up and had some teeth pull off the lips she wouldn't be that way.
Valerie: It's totally different, yeah.
Howard: Totally different, you went digital dentures before anybody that I'm aware of.
Howard: I mean Ryan McCall is like the denture guru on dentaltown and he pays homage to you and he just bows down to you and says you're the digital denture queen and so is digital dentures is it bleeding edge or is it really here?
Valiere: I think it's really here right now I when I started doing digital dentures I was fortunate that I have specialty practice, fee-for-service practice so I was able to start making digital dentures when the costs are higher and I know that a average doctor who is in PPO's cannot do expensive dentures the lab bill that you can afford is relatively low. So really it's reached kind of a tipping point with a lot of the newer technology that's out now there's a lot of different software systems there are different ways to manufacture dentures and it's becoming attainable for an average provider.
Howard: That's the only line I think dentist should be fighting over, it's like so the employer wants to help his employee so he gets a dental benefit.
Howard: because it's not insurance it's a benefit it's only a benefit of someone else paid for it because insurance is you know 100 people drive a car we all have insurance probably one person a year tax car but in dentistry is just only benefit is you insured 100 people everybody needs to see the dentist twice a year.
Howard: but it's not that the PPO says that you can only charge say 700 for a denture it's the line they say that they tell the dentist you can't charge more than that.
Howard: and that's the only line in the sand the dentist should be fighting for that if you want to it's like if I give four people a hundred dollar benefit for a filling and I go to you and you say well I'll do $100 amalgam nothing out of pocket awesome so when I'll say well tooth coloureds 200 you give me 100 you give me a hundred out of pocket next first time I say well I was same-day dentistry I want a cad cam I want to apply my hundred to a 500 dollar cerec and next person like me might say well I only have gold in my mouth I just want to do a hundred but the insurance company cuts off all the other markets because when a denture doesn't factory doesn't take insurance out here and Mesa I mean there's a lot of retirees, they always they advertise that the value price and it might be 500 for a full set but then you go up there and then when you get in there they show you the premium there might be a thousand and then they show you the supreme that might be twenty five hundred and then they tell you that that on two implants might be forty five hundred you know me that's a stair-step and you know GM has a Chevy and it started in the beginning where a Chevy was going after the Model T same price 668 but Henry Ford did that he was he was like denture companies today there was a nothing beyond that and then people complaining well the wheels don't come off, so $100 more from the Chevy which is the same price as the Model T you could have a Pontiac where the wheels come off. For hundred dollars more you have a Buick that had the spark plug from Indiana because people didn't like whining up their car for a hundred more you can have a roof and then the Cadillac which is 100 above that had the new technology from Motorola which was the radio.
Howard: Well current dental insurance today it would just be you can only have a Chevy and you cannot ever have a Pontiac within removable wheels of olds with a spark plug a Buick with a roof and all of those things and a Cadillac and that is just absolutely wrong these PPO doctors if they should be able to take that supplement and say hey yeah we can give you a value denture for this PPO price but would you like to apply it to a premium or a same-day or a digital or over implants.
Valerie: I think that that's why so many dentures are made in corporate denture centers where they don't take insurance and they're all cash based and so but I do think that digital dentures it's not about making a more premium product it's about the way that you make dentures that is so different and more forgiving for the average provider and more fun. So I would hope that a lot more regular doctors start making dentures even though they may have a PPO practice because they'll be able to.
Howard: So let's talk specifics how do you make a digital denture what technology have to buy what kind of investment what techniques materials
Valerie: Really you don't need to buy anything so most of the time you can start with making a preliminary impression this is I'll just go through the most popular approach that most laboratories work with their doctors. You make preliminary alginates you send those to lab they make custom trays and wax rims so you make at your second visit you make your border molded final and press and you realign the wax rims mark them make a bite your normal things, you send those custom trays and wax rims back and you're labs scans them then they generate a design and you can see that design you can ask for a design approval then they'll mill or print a solid set of denture try-in's. One of the things I love about the try-in's is that you can determine if the dentures fit you could send them home with your patient and say chew on these try them out you can make adjustments to those try ends knowing that any adjustment you make will be reflected in the final dentures take photos with those try-in's in and when you're ready send them back to the lab they will scan those try-in's and generate the final design based on your comments or patient's comments the photos and all those things. So that's the kind of the I like to go a little more accelerated than that I do a 2:00 appointment denture but that's the typical route that most people.
Howard: So the typical route was how many appointments?
Valerie: Preliminary records, final impressions and wax rims, try in's, deliver.
Howard: So four
Valerie: Yes now Dr. Steven Wagner has a 3 appointment approach which is really unique a novel he has YouTube videos on it so I would just suggest people look at that but my approach is a little bit different. So I do a two appointment denture so my first appointment
did you get the idea from that, what was that movie Something About Mary, 6 minute abs.
Valerie: So why not 5 minute abs, no there's plenty of 2 appointment denture approaches I think mine is the best one. So what I do is most people who need dentures or seeking dentures already have a set and most people want the same thing so they want a little bit bigger smile they want whiter teeth they want a little bit fit but the dentures they've been wearing are okay and most people are actually very comfortable with the dentures they've been wearing they like the teeth they like the size they like the borders so all I do is I make realign impressions with their dentures and a bite and then I use my intraoral scanner which is a Trios and i scan the dentures remove the impression material send them home with their dentures so my average appointment is about 60 to 90 minutes depending on if it's a single arch or both arches and then I will create a new design and fabricate the final dentures.
Howard: So you bought this bought the 3shape Trios?
Howard: You take their existing denture use that as a custom tray...
Howard: and what impressive material to use?
Valerie: Right now I use the bunch of different aqua seals, so aqua seal rigid if I want to add to the borders.
Howard: That's Dentsply Sirona?
Valerie: Yes, I also use mono phase as a single step impression sometimes and then I use their light body or a wash if I need to.
Howard: So after you take that impression?
Howard: Then you just scan it?
Howard: and are you scanning it with a wand
Howard: because I know when you walk into labs a lot of those hands and just put it in a box.
Valerie: Right which if you have a box scanner use it but I kind of focused on using the trio's or the intraoral I've used other ones too just to help make this process more accessible to a doctor that stay is going to have an intraoral scanner but not a lab scanner. You definitely want to use this scan spray so I use opti spray to spray these before I scan them.
Howard: Spray the impression?
Howard: and what is the opti spray do?
Valerie: It actually based on my limited research it has improved the accuracy of the Trios scanning and impression material because intraoral scanners are not necessarily intended to scan large smooth flat areas like a denture impression so if you can improve its accuracy then it's better.
Howard: and just a clearer spray it's not a white powder?
Valerie: It's sort of it's sort of powdered yeah it just it makes the impression material matte instead of shiny.
Howard: So you do that on a tray or in your hand?
Valerie: In your hand
Howard: You just scan that on your hand?
Howard: and you have a youtube video on that?
Valerie: I do
Howard: Can you post it on dentaltown?
Howard: The reason some people's there are YouTube videos it's so high is on dental town you know you can put the name of your YouTube video in the link but when you share a YouTube video that has link but the next button over is embed if you click embed that's the code so you copy the code and then on dental town there's a YouTube button you click that right there drops right in there yeah so and there's so many dentists who you know had two or three interviews on their YouTube deal and they dropped their YouTube in dental town a square a million members and next thing you know they got 1020 thousand views on their YouTube.
Valerie: Okay well that's good.
Howard: and then a lot of those people will subscribe to your YouTube channel.
Valerie: So my technique is called the cupcake technique.
Howard: Only the denture queen would have the cupcake technique.
Valerie: cause it's just like holding a cupcake and frosting it with your intraoral scanner like and then it's got an entire analogy I went too far with it but it's it's kind of funny.
Howard: Well let's hear it.
Valerie: So well first you hold the denture this way and you scan it with your intraoral scanner just like your frosting a cupcake and what do you do when you're done frosting it you peel the paper off so you're taking your scanner around the edges down the initials the ledges of that denture next step is you take a bite out of each side of that cupcake so you're taking the fight with your scanner and then I have this additional optional step called now brush your teeth because that's the last step when you're eating a cupcake right you gotta brush your teeth, so you actually take the scanner and have the patient smile really big and then brush their teeth with the scanner which captures their lips and the tissues around their face including their nose and chin which you can take that and merge all that data into a virtual patient. So now the reason why in my technique I don't do a tryin most of the time it's because you don't need a try and when you have all of that information you have their face you have a photo you have their old dentures that they usually like and want to stay about the same size of teeth same position same shape so when you have all of that you can most of the time skip the tryin in patients who are you know accepting of that kind of an approach.
Howard: So the next appointments delivery?
Howard: and do you do all this with one lab?
Valerie: Well there are several different labs who could do this, I work directly with Avadent.
Howard: Here in Scottsdale?
Valerie: Yes and I am allowed to do that because I'm a prosthodontist they don't normally accept general dentist clients directly but there are quite a few partner labs that you can work with but I work directly with them because I wanted to be able to change the setups myself and do all of this myself and I'm weird and crazy most people don't want to work directly with manufacturer.
Howard: So you send yours too Avadent but I could not because I'm not a prosthodontist?
Valerie: Well they don't mean prosthodontist they mean like if you have a denture only practice or you are prost and you demand control over every step of that set up then you can work directly with them but most of the time I suggest that doctors work with an experienced technician who can help and has a lot of knowledge about borders and you know setting the teeth correctly and so on. So if you really desire to learn setting teeth and putting them in the right place and all of that you can do it and work with some of these people yourself but I don't recommend it.
Howard: So Avadent it's avadent.com and what is ava for the dent?
Valerie: Avatar it's an avatar denture that's the root of their name and I actually think that's brilliant because I just mentioned this in my presentation that the term digital denture is actually a big no-no according to the glossary of prosthodontic terms.
Howard: Digital Dentistry?
Valerie: Yeah they want you to call it a digitally fabricated denture because the denture is not a digital product it's not a digital denture it's an actual denture. I think that's missing the point I think that the digital denture is a unique entity because it's not just the denture it's everything that went into making that denture all the information is still maintained which is critical. So if you remember back to my workflow of records, deliver what happens if you deliver a denture and the patient says I don't like it the shade isn't right or these teeth that the middle doesn't line up and it happens it happens all the time when we make dentures that you place it and then it's not right and you're sitting there thinking ah do I you know try to talk them out say no no that shade looks good it it matches your eyes look or do you just do what they want and make it right. So this denture is not a normal denture where you can't really go back you have to start over if you're making a denture conventionally a digital denture you can just reorder it in a different shade you have all the data you still have your impressions you still have all that information maintained and so if there's a problem like the midline you want to move the midline exactly two millimeters, normally with a conventional approach if you ask your lab to move the midline to millimeters what happens they do but then they also can't all the teeth or they you know kind of shift it and don't resettle the posterior teeth and now you've got this weird unevenness, with a digital denture you can say two millimeters you click to push enter and the whole thing moves like precisely.
Howard: I've always thought the midline was the most bizarre concept I know in beauty they study beauty symmetry is very important so if your nose goes one way your eye design of this and this I get that I get that all in nature two strands of DNA it's always symmetrical but I can't tell you how many times I've been with like an orthodontist and I catch his wife's midline and get it down and then I turn to the orthodontist and say is your wifes midline to the right on the left with her eye and he's like a deer in headlights and then you'll be a dead old seminar and you know dentist who says yeah this is my wife and I'll say stop is her midline straight on left right nobody knows where the midline is.
Valerie: It's tricky
Howard: and then you have these or some more than I was to say well in order to get the midline right up I got a pull for bicuspids or you know all this so I'm like is the midline even or for real thing?
Valerie: I think it is sort of important the best tip that I ever heard for determining the midline was from Dr. Steve Wagner he said forget about nose and chin and you know points and the floss it's tricky it's hard what he encouraged encourages people to do is count the teeth on both sides of the smile if you can when they smile big you can see all the way back to the first molar evenly on both sides you're good if you see the first molar on the left and you can't see it at all on the right you might have a problem that and most people what you want to see is a very beautiful symmetrical frame for the smile and that approach has helped me with midline.
Howard: I've been to Avadent I think I went down there a couple years ago is this mostly I heard that at their symposium here in Phoenix at least 40% of the dentists were prosthodontist?
Valerie: I don't know
Howard: Yeah the numbers I got is like 690 dentists and 40% of those are prosthodontist, there's only like what a thousand prosthodontist in the United States.
Valerie: Not very many yeah 1600 I think.
Howard: Is it 1600. So you had 690 and 40% prosthodontist so and so the prosthodontist are like I'll back up where I'm going to this like certain techniques to come out say in perio or endo and my first question to rep well can you name it endodontists in town that uses this yeah patron saint of endodontist and in Phoenix oh yeah it's a buy. So are the prosthodontist on us buying into this I mean I mean I I think I think there'd be no greater thing you could tell the market then oh you know that you know those prosthodontist I got a master's degree after their DDS yeah they like it are the prosthodontist were they all there in curiosity or are they buying into this?
Valerie: I think that a lot of them are starting to do it so um I think that prosthodontist are a weird group so sometimes they're very old-fashioned sometimes they're very reluctant to change or accept new technology but what has helped digital dentures is that there is a lot of actually good research and studies that support it so I think that that has helped prosthodontist get on board with it.
Howard: So when you send your so you're sending your digital a via DICOM file?
Howard: STL file to Avadent here in Scottsdale?
Howard: and I first goes to Phoenix my house and then we ship it up to Scottsdale. Are they do they CAD CAM the teeth to or they using denture teeth from like Ivoclar?
Valerie: Either so they offer like three different molds of conventional manufactured teeth that they will mill out the base and then put in the teeth and that is the way that I think most people start out with digital dentures because it's the conventional the look of the denture is what they're used to so you can have I have Ivoclar teeth or DENTSPLY teeth or whatever but that's not what I do now, the first probably hundred or so cases I did I was using mostly bonded teeth but after that I switched to fully milled teeth which is a technology that they have where they make a custom puck that has three different colors of resin in it so two tooth and one pink into a custom puck and then they mill the whole thing.
Howard: In one piece?
Valerie: In one piece. So the teeth and the base are continuous the whole thing is one piece it's nothing that was ever looted together or bonded together and that results in a denture that is one piece which to me makes perfect sense that it would be stronger than a denture that has a denture tooth bonded in so out of probably I would say 400 of those that I've placed in the mouth I have had three for fractures of the denture and all of them with the exception of one were over implant bar structures where I really should have had a metal reinforcement but for every single exception of one regular denture one fracture out of probably 400 the teeth can't break out the teeth actually you can throw it across the parking lot and it won't chip or break I have a video on YouTube that shows me destroying a bunch of dentures actually it's on YouTube it's on my Facebook but...
Howard: You're on Instagram and Facebook and YouTube.
Valerie: Yes so it's really exciting what the new products are for dentures. So just imagine your elderly patient who drops their dentures or and you know you can give them a product that's probably never going to break also give somebody dentures maybe who has dementia and know that if their family calls and says their dentures lost you can just order another one without having to or nothing at all you just type in your order.
Howard: You know whenever you talk to an engineer they they don't think of right and wrong they think of everything's a trade-off, redundancy you know all that kind of stuff and so obviously if a tooth is looted in that's the weak spot that's why I'm gonna break I mean...
Valerie: Think about locator overdentures.
Valerie: So that's right where they break.
Howard: Right so you sit there and if it's one piece you just got rid of the weakest link.
Valerie: Yep so I've had zero fractures over locators.
Howard: Yeah now so on your denture market is that is it 50/50 boys girls or is one more likely to get dentures in the other?
Valerie: I haven't looked at that but it seems like I see more female patients.
Howard: Seems like more female?
Howard: and when you what percent of your patients are the traditional nightmare that you know they come in you know ten times you know you seem like you've made them a denture and now they're your friend for life versus you deliver and maybe no adjustments one adjustment two adjustment they're off and running how does that break down?
Valerie: Well I think it's tricky because I remember the ones who come in more and I forget about the ones that get their dentures and then don't come back. So I feel like I have more of the difficult patients, I think that a lot of that is because the dentures that I offer are in general more expensive than most other options so people who come to me are usually referred by general dentists my community which means there's usually a reason so but I don't back down from that and I actually like it so it's fine.
Howard: and is that because where does that come from are you just a very competitive person you just like challenge where does that come from?
Valerie: I think it's just that I I am very competitive I will act like I'm not but I kind of have that in me and it's also just very rewarding when can actually help someone who has a challenging case and denture patients in general I can't think of a dental patient that is more needing of extra help better technology innovations things like that like you like our initial conversation dentures are it's a huge thing it's they're hard to wear it's very difficult to have them be a good prosthesis.
Howard: So when I got out of school in 87 the big trend was you know oh the old fashion guys have all these rooms and you want these open bays and and and I think they just want to sell your cabinets back there was Health Co. you and so they were all these cabinets and I was hearing you know again I'm in Phoenix it's a little different demographics within a mile of my offices I mean this is a retirement community if you're retired east of the Mississippi you go to Florida if it's west of the Mississippi you go to Phoenix it just is what it is so Phoenix believe it or not is 10% Canadian and then it's you know you North to South Dakota, Minnesota all that stuff and so many people would tell me why I can't go to that guy I mean I'm not he wanted me to take my teeth out and I can hear the lady in the next room and I can hear a lady over there and no privacy and one lady said to me just punch me right tonight she goes do you think gynecologists would do that and I realized oh my god of course they wouldn't do that and our proctologist or what have you do you see a lot of embarrassment about taking your teeth out do you recommend that there be a closed room with the closed door or that not there's that an overblown issue?
Valerie: I haven't noticed that so much I I do have the tip you know a female denture patients whose you know I look in their mouth and I say you you have read horribly swollen gums are you taking your dentures out at night no can you never I'll never do it so I think...
Howard: because their married and sleeping with their spouse.
Valerie: Yeah they just won't do it so I mean there's that issue but I've never really had them feel uncomfortable in the office although my office was built in the 80s so it's very kind of closed.
Howard: I mean is each one of your operatories a closed?
Howard: So it's all enclosed, you know what I'm talking about the open cabinet deal?
Valerie: Yeah we don't we don't have that
Howard: Yeah and I think that when all your bays are open I don't I don't think you're gonna really have a denture practice.
Valerie: Yeah all right a lot of denture offices you don't need air, water necessarily you don't need your hookups so you can have a chair in an OP it's not even a fully functional OP and still make dentures there.
Howard: So what do you recommend to a lady who's never taken out her teeth because of her spouse?
Valerie: Well I you know I don't try I try not to make them feel bad and say well you'll just get yeast infections I mean you don't want to make them feel ashamed but I do tell them if there's a time during the day that you could take them out maybe for a few hours that would be helpful I also have them try to take them out for a little while and soak them and usually look at ten percent bleach solution just to really kill everything in that denture before they put it back and then gently massaging their gums sometimes you could also suggest like a power toothbrush if they want to just stimulate their gum tissues that's also helpful. So it's not like it's not like you tell them ah well it's too bad for you he just try to figure something out.
Howard: what's that grip called the denture grip?
Howard: Poligrip you know it's kind of weird because when some of my friends think that if someone comes in he gives you money and at the end of the day they need poligrip you failed as a clinician other people sit there and think no it made it better is Poligrip a sign that you didn't do your job?
Valerie: Absolutely not because a lot of times even the best of dentures can fall out especially with dry mouth people with flabby ridges or just poor ridges in general also people who have a lot of times neuromuscular problems and they just aren't very coordinated have a lot of trouble, so I don't think it's necessarily a sign of failure. I will tell people that my goal is to absolutely not you wear any adhesive but that it may not be reasonable depending on the case so some cases yeah it you should be able to get good fit but there are a lot you know a few cases where you can't.
Howard: So is the company Avadent in Scottsdale are they agnostic to the scanner or are they partnered with bio lace and married there?
Valerie: They are agnostic to the scanners so you can send them any scan file as long as it outputs an STL.
Howard: You know I always notice my homies are you're more interested in a decision that affects the $30,000 scanner or $100,000 laser than you are a $50 bottle of bonding agent. As well as the dollars go up it's never go up it's more yeah so walk through your oral scanner decision why 3Shape?
Valerie: This is a funny story yeah so about two years ago I was going along using impression materials had no interest an intraoral scanner had no desire for one people had asked me oh why don't you get an intraoral scanner and I said well cuz I'm doing just fine I don't need one impressions worked great for me and the I work in the same office with three periodontist and they came to me and said hey we're getting a intraoral scanner we're getting a trios they already decided do you want to use it and I said oh okay give it a try see how it goes see if I like it and I tried it and probably within a week I had to have it for every I use it probably ten times a day and I could not imagine practicing without it at this point and that is from a person who said mmm I really don't need it to suddenly I love it. Now I didn't actually buy it I was just fortunate enough that the periodontist I work with her like yeah go ahead use it ten times a day we use it once a day so I am lucky I would definitely buy it myself if I had to at this point like if they took it away from me I would buy my own but that's how it went.
Howard: So you I think the easiest wall the lowest-hanging quality is always magnification I mean obviously you wouldn't go to Stevie Wonder if he was your dentist then you have the a man with vision and then you have loops makes everyone better I think everybody knows that but then when you go in their office the wet hands don't have loops the assistants don't have them the hygenist don't, anybody sticking their hand the mouth the quality you know race the whole boat the endodontists used microscopes and not a lot maybe only six to eight magnification do you but is a lot of the thing that you love about the scanning the fact of seeing everything on a screen?
Howard: 25 to 40 times larger is that a big part of it?
Valerie: Part of it also you can virtually a minute eliminate getting undercuts because you can spin your prep around and see it you can eliminate not reducing enough because you can check your clearance. When you see your margins blown up you're definitely going to do a better job but the real benefit I think is that all of the benefits of just digital dentistry in general, so the fact that when you do your scan if there is a margin that's not captured well you don't have to redo the whole scan like you would an impression you just rescan that area if you let's say you've finished your prep and your assistant makes a temporary and part of the prep is sticking through the occlusal instead of having to reprep the tooth remake the provisional redo the impression you just delete the area rescan it you're good. So and there's all of the archiving being able to capture the incisal edges of teeth before you prep them do your prep then scan your preps allows your lab to know where to put the incisal edge there's just so many intangible benefits that help you with.
Howard: Now do you have your own CBCT also?
Howard: What did you go with on that?
Valerie: Again my periodontist bought it they got an Icat and I'm just lucky that I get to use it all the time so I didn't go I didn't make those decisions but I think it's great.
Howard: It is very obvious to me Icat I mean when somebody has a CBCT a third a specialist mm-hmm they're an oral surgeon or a periodontist that that's a number one brand.
Valerie: Yeah they got rid of a they had a Seriona and they got rid of it because of the I guess there were fees that were out of control I don't know.
Howard: Well it's amazing because I mean some of these scanners and you know you'll buy a scanner and they have a they say the first thing they're telling us how much you'll save on impress material and the next thing you know the service agreement it's $200 a month yeah for your sign to say okay well that's 2400 a year.
Howard: and then some of these other machines it's even crazier so it's like you got a great machine but the and I get it because it's the reocurring revenue model I mean why is Netflix how the same value as Disney because Disney has to put a hundred million dollars into a movie they hope it's a 300 million dollar blockbuster it's feast or famine feast or famine and sometimes they release a movies that flop or whatever whereas Netflix just everything first the month you're doing a gazillion credit cards for ten bucks so everybody wants that recurring revenue model and if you that's why laser companies in the 30 years I've been out. I mean I cannot tell you how many people came out with a laser solar for 50,000 sold a thousand of them so everything at fifty thousand times a thousand these are big numbers and the next thing you hear they're bankrupt, well they had big numbers but if they had a summer dry spell and they didn't have enough savings to go through cash flows I mean if you need a dollar a month for overhead and you don't have three dollars in the bank and and after summer they're gone. So I get it they all want the recurring revenue model.
Valerie: and that's happening in printing companies now I think it's fascinating. So 3D printers it's a piece of technology if it's easily could become obsolete you could buy one in the next year could be obsolete so there's a printing a printing company that has moved towards a subscription model which i think is really interesting and you might be seeing more of that in just the general dental equipment market.
Howard: The reoccurring revenue model is getting bigger and bigger Wall Street loves anything on a reoccurring revenue model and then that's where you really got to do your homework. It's kind of like the price of a house you know you you're you spend so much time looking at the price - like well this is 240 and I'd really like to do 220 and and and you're saying all these numbers I don't even mean anything because it's the interest rate what are you putting down what are you financing on is this a 15 year loan a 30 year loan so the I mean even Albert Einstein said that I'm compounding interest was the most powerful force in the universe. So when you're looking at all these scanners and CBCT's what are the financial terms what are the software support deals can you get out of these what is the cancellation fee because that's where everybody's focused. There's a reason why you can go fill your house up with furniture and have no payment for the rest of the year that should be your first red flag really I can get all the furniture and no payment until next year yeah because the financing the non cancellation the interest charge. GMAC usually netted three dollars of net income profit for every dollar GM did the entire links of these companies so you know everybody talks about the factories the unions the auto workers that was one dollar a profit but the guys that were here financing the car or making three dollars a profit so financing a car is a much better to be into that then actually making the damn car.
Howard: Very interesting. I mean your name is denture Queen but I don't want to make this whole podcast about dentures.
Howard: What you said it's a traditional prosthodontic practice so after that you know other than dentures what is a traditional prosthodontic? I mean I got it's a single crown on a six year molar.
Valerie: Correct but you know I see a lot of patients referred for more complicated issues people who've bruxed severely and need rehabs so that happens sometimes that people can afford it and then I do a lot of single anterior crowns where they want it to match really nicely but one of the other areas that I'm kind of passionate about is what I would consider geriatric dentistry and that kind of falls into what I do very often so I sometimes see patients who are 90 and their dentists is just like whoa I I don't even I just don't even know what to do here and you know they've got an old partial it's barely hanging on and carries everywhere and so I like to take cases like that even though it's not fancy all on fours it's hold on let's just take care of this person so they can chew for a few more years and that's it.
Howard: So some of my regrets 30 years I mean she I got my fellowship the messages to probably before you're born I'm not even gonna ask and but you would put two implants in and do a three unit bridge on both sides.
Valerie: I've heard of that.
Howard: and then 20 years later she's in a nursing home and her sister family's calling you in there and you're thinking dang it this one implants lost, if I would have done three implants I could have just removed the one she wouldn't know anything why did I save money by not just having three implants for three teeth why did I do two implants and three number egde what do you think do you think treatment plan an implant per tooth or almost like a spare tire.
Valerie: I think an implant per tooth is kind of excessive but you know I like to help people make decisions when they're younger about letting them think you know how are we gonna take care of your teeth so that when you are elderly and you are unable to go to the dentist are you still gonna have teeth to chew with and are you still you know gonna be pain-free and doing well so because I see many people in their 60s and 70s who are when they're presented with treatment they're like well but you know I'm 65 I'm like okay well people say that to me all day just so you know and you have to try to get them to understand that I know you're looking at the next 10 20 years of your life but the last pleasures you have in life is eating food I think one of the last things that you can do and still enjoy when you're you know a couple weeks from death possibly so why not make it the best.
Howard: but a couple of weeks death wouldn't you have gone to drinking at that point?
Valerie: Probably yeah
Howard: I'm glad you brought that up because looking back at the biggest mistakes I made in diagnosing and treatment planning I was 25 I was in a retirement community Phoenix Arizona all these retired people and all these men I tell them what they needed I'll be dead I'll be dead in a years they were still alive 30 years later. I had that I definitely had that a heck of a lot more with men than women but I'm telling you when you're a young kid and some old man's telling you he's gonna die you have to do everything at the minimum he's gonna live five more years I mean he just will I mean even when they tell you look I'm on cancer I'm on I know I've heard it all for 31 years but you know what you're gonna be back here on my doorstep next year the year after the after you really I think I'm I in my practice if this has to last least five years if I'm doing something and it has to last five years and it's not even option.
Valerie: True I would say that my focus on that is more for the patient where doing dentistry would possibly put them in a worse place so if you have an elderly person with a partial that's barely hanging in, carries on all the teeth 22 through 27 if you make them a lower denture they're in a worse place than just keeping them with those Carius teeth with the partial maybe put silver fluoride on it maybe just use some very conservative treatment just to keep them eating and out of pain for a few more years. The other factor is that I deal with a lot of people who have dementia and I've become you know really observant and trying to see dementia as it develops in people and it can be a killer for your treatment I'm sure you know this from just treating people for years and years but once you get to that point where dementia happens everything you do is more difficult and won't work as well. So if they have dementia and have the signs then I feel like it's often better to step back and not do as much dentistry because it just won't go as well.
Howard: Are you using a lot more silver diamine fluoride for each surface decay than ten years ago?
Valerie: I don't think it was allowed ten years ago but yes from what I know it was approved in 2016 which is when I started using it about then but I know that there are some promising research studies from Japan and Europe that have they've been using it for a lot longer. I just I don't know for sure if it's stops carries I think we're still out on that but I have been having people do it as an alternative to doing nothing and I think it's a really good alternative than doing nothing. So if someone has like I talked to you about carries route carries 22 through 27 their partial still works I don't want to put them in a denture we can't restore the teeth because if you tried to prep it you just it's an apple core for example so in that case I will do Silver Diamine and I've done I think we counted the other day they've treated like 300 teeth or something with it and so far I really want to get more data so that I can see teeth that I've treated have they required extraction and if so how many and I don't think the number is very high.
Howard: and what do you what are you tracking this epidemiological data on?
Valerie: I do all of my tracking with open dental.
Howard: You use open dental?
Valerie: I do I love it just love it but that's how I originally got involved with presenting about digital dentures because I went through my open dental and I tracked before I went digital how many dentures did I do how many denture adjustment appointments were there how many Tryon appointments were there and so I can't remember my exact numbers but before I switched to digital dentures I was doing on average 5 adjustments per denture and that includes soft realigns for immediate and then that number went down to three adjustments per denture after I switched but the tryins were more I went from doing like for tryins or no three Tryin's per denture 2.9 to about 0.5 tryins per denture after I did digital. So then if you get out of all your fancy math and you say that's 40 minute Tryin appointments times however many trans cuz if you do you know 150 dentures a year that kind of a lot of time so I was able to graph the change in clinical chair time as a result of doing digital dentures rather than conventional. The only catch is that I wasn't doing these comparisons side by side I wasn't making conventional dentures in digital at the same time which would be a scientifically valid way to examine it I was looking at two different time periods which means that part of the improvement I had was probably just I'd been making dentures for longer and had gotten better but I still think that some of that change was the result of making them digitally and that was all open dental.
Howard: You have an amazing mind you really do.
Valerie: I love to pour into these issues.
Howard: So because they don't know about open dental because open dental is the only one doesn't advertise.
Howard: and all in every you know Dentrix is the big boy Eagle Soft would be number two wide why did you not like those two and why did you like open dental?
Valerie: My accountant recommended open dental when I started my practices so it's kind of why I did it but I do like the idea of it and I think it's excellent software it's very you can do a lot with it and the bigger software companies I just don't like their product as much.
Howard: You know I was lecturing in Toronto and Pairs and in both of those cities and dentists would say yeah I went with Open Dental because that's the only one you could go in there and change the words to French or anything like this. Australia why Open Dental, because I could buy Open Dental and then go in there and change it to all the Australian coding.
Valerie: I also get really crazy with customizing open dental you can probably expect so as an example all of my lab slips are custom lab slips in open dental and then they print just like the lab slip that the lab wants you to use but that way you know when when your assistant isn't writing the patient's name on the lab slip and misspelling it, it's open dental inserting that patients name right where it ought to go I also do extensive auto notes that are my own note and have prompts for each step in my checklist that I do so I have loved customizing it and so I really love it.
Howard: Have you got to the point where you got a programmer to go in and add something to it?
Valerie: No but I have called them and had them figure out a couple of custom queries for me which they will do.
Howard: Have you did you ever meet the the founder Jordin Sparks?
Howard: Jordin Sparks is it dentist and now his brother Nathan runs the whole show. The reason I switch from Softdent to Open Dental is because I got this accounting team and you know that the fact that their Dentrix can Eaglesoft doesn't talk to their quicken or peachtree or microsoft GP Microsoft Great Plains accounting so the Microsoft GP the GPS for great plans and you go into these dentists you ask them any of their numbers they know none of the numbers and then then you see a big surge of these dashboard companies that are going in there and taking out data from Dentrix dashboard. Well that's I mean that's it's a lot better than nothing but I mean I just love the dream that yeah when there's a this is what we need I'm gonna get a programmer I'm gonna hook these two up myself I'm gonna customize this myself. When you know I'm probably 25% to 1/3 of everybody on this podcast is in dental school I mean old people like all my drinking buddies couldn't find a podcast if I handed them their iPhone and put a gun to their head and say pull up any podcaster I'm gonna shoot you I'd have to shoot all my all my alcoholic dentist drinking buddies. So you're talking to a young crowd an email me Howard@dentaltown.com and tell me how young you are if you're younger than 12 just don't send me an email. When you look at the insurance graph of like when I lectured at this insurance claim so there's like 300 people for the insurance coming to show me all this data that say but they won't publish it they won't post it's all proprietary but you look at the 32 teeth and dentistry you know last year 127 billion it just looks like four spikes I am boom for smaller you know 3, 14 boom 1930 what's the tooth most likely to be pulled first molar crown for a smaller root canal for smaller. It basically those is just for big spikes I mean when's the last time you did a build up root canal and crown on an incisor you know. So they're in dental kindergarten and they're all wigged out of their mind to do a single crown and then when you talk to the people like big labs like Glidewell they say like 96 percent of crowns come in one tooth at a time the majority is just the first molar will get a fancy dancy prosthodontist like you what tips could you give to a person who's just trying to nail a single crown on a first molar?
Valerie: Well I think that having the interaural scanner would be my top choice because you can like we mentioned earlier you can see reduction you can check all of all of the things that are important you can check for undercuts and so on but that is.
Howard: So you'd still recommend?
Valerie: Doing it digitally.
Howard: You know what I'm look at the three shape by the way I had my own theory you know when you go to Denmark and you go to 3Shape in Copenhagen or you go to Helsinki Finland and you go to Plan Mecca I think the reason there companies are so amazing is because the country is frozen for all but like four months of the year and when you go there during during the winters they just work 10-hour days they do that's what they tell you and they tell they say you know in the Netherlands during those long cold frozen winters you either gonna drink a thousand gallons of vodka or just become a workaholic and they just pour themselves into their work and it's just those are two of the most passionate countries I've ever seen 3Shape and Plan Mecca you just you just really but again the thing that I'm liking the most about it is simply the the magnification deal. I remember the first time I scanned a tooth and I looked at the scan I mean I I thought like my five-year-old granddaughter prepped a tooth. I was like because you're looking at because you're you're thinking well this looks really really good then you see it something wrong with me.
Valerie: Yeah the other thing that I would suggest is right now I have all of my scans going to a design service where I get to then view the designs and approve them before any crowns are manufactured.
Howard: What design service is this?
Valerie: Well I use a one called Full Contour but what I love about it is it really helps you to see things about your prep that maybe you weren't perfect where
Howard: So its www.
Valerie: Full Contour
Howard: My sausage fingers type dull full I need to have a surgery reduction on my thumbs fullcontour.com
Valerie: and again this is one of the things that I do because I'm a crazy prosthodontist and I want them all I want to be like involved I don't want to sit there and click around and design things myself because that takes a lot of valuable time but I like being more involved with seeing the designs asking for changes making sure that things are exactly how I want and then I can have the designs approved by me which is nice if you're a doctor who really wants to be more involved with the lab side but you don't necessarily want to do designing yourself. Like I see a lot of doctors you know playing around with meshmixer which I love doing that too and designing things themselves but the problem is that you just your best time is probably spent at the chair side or a couple minutes per patient doing additional steps, so I've found that having the ability to look at designs and make sure that they're good has helped me a lot.
Howard: So this is a Rob Laizure and his son Rob Laizure Jr.
Howard: So were they in Vegas?
Valerie: No they live in Phoenix.
Howard: Glendale, Arizona yeah that's not Phoenix they wish they were in Phoenix.
Valerie: Okay I don't know Phoenix.
Howard: So they're also gonna be asking questions Unferth just first of all it doesn't need to be zirconium can it can it still be Ivoclar Emacs this you know old guys are doing PFM's mine are all full gold crown.
Valerie: I still do a lot of gold not a lot but if a patient requests it I think it's an excellent material but...
Howard: and who's the only one requesting it?
Valerie: Old guys
Howard: Did she just call me old. So if they have a liver spot you go full gold?
Howard: What if it's a grandpa he says I want what's best is that a default to full gold?
Valerie: No I actually think that zirconia is best although that's people can argue all around that issue it's kind of a personal choice. I think that gold is wonderful but if you can see it when they smile I think that's not that's not what I would want that's not the best according to me so I would want tooth color but the reason I don't I don't hardly ever use Emacs or lithium disilicate anymore because they're a lot better more translucent zirconias now. So like one of my favorite new zirconias is the katana multi-layer and it is you can tell it's not lithium disilicate but it looks pretty good it's a little better I think and...
Howard: Spell the katana multi-layer.
Valerie: It's Katana it's a Noritake brand I think and they make it from a multi-layered zirconia disc so you have some translucency 's that work into that disc but the strength properties are still pretty good. That is my go-to for most first molars I think that the problem with Emacs or lithium disilicate is that you have to reduce a lot more and I see especially if you're putting lithium disilicate on a second molar and you've reduced it you I mean you need like two millimeters in that case so I think that's kind of aggressive for second molar.
Howard: I'm trying to think would I know anything a prosthodontist would know.
Howard: I might know just one thing, the ferrule?
Valerie: I might have heard it but I forgot.
Howard: So the ferrule you know because what's important is they have two millimeter structure all the way around...
Valerie: For post and core
Howard: Yeah and you need that 2 millimeters and if it's shaved off at the top and you're just gonna have a post sticking out of there in a crown sitting on there you don't have a ferrule.
Howard: and even though it's only two millimeters all the way around you know where that came from, barrel making their barrels kept exploding so what they did is they found out you just need one little wrap around the barrel and then if it was really rich stuff that you couldn't lose it wasnt water but it was like wine then they put a smaller ferrule underneath and a smaller one on top well that's a ferrule and they learn that from losing hundreds of barrels of good wine and and liquor and whiskey but that might be the only thing yeah my walnut brain knows that a prosthodontist doesn't know and then what would you cement them with?
Valerie: I am really agnostic about cements the one I use I don't have a reason for I use relyX.
Howard: So the yura cement or not a bond didn't have to be bonded?
Valerie: You know you you can bond if you're lacking mechanical retention I like to just always have mechanical retention but in a situation where you don't then you would use a bonding agent and then in that case I use a nexus resin cement.
Howard: Then I'll give you a time-saving tip when you go to take a shade if he has a liver spot don't it's just an A35 and seriously just it's A35 they see the liver spot just put the shade guide away. Was there anything else that I wasn't smart enough to ask you?
Valerie: No I think it was good.
Howard: Like again I love you I love your mission I love everything about you because I don't like to talk about religion sex politics or violence for like this last election that confused so many people it was all the flyover States and in dentistry those were all day all on none states.
Howard: and they got tired of the all on four states you know our communities and again I know it's the the hottest thing in every convention but you if I see one more all on four lecture I'm gonna puke just take the the 400-pound gorilla in that space clear choice right and they Church 25,000 arch and last year they did about 18,000 arches well you look in a country with 324 million people in fact I mean I'm just gonna I'm just gonna do the math right here once and for all. So you take eight you take 18,000 arches divided by 3 2 4 0 0 0 0 0 0 I mean you're talking about point 0 0 0 0 5. I mean it's like dude I'm America is not about making rich stop for the wealthy this wasn't a country about like when Henry Ford started his car a lot of people a lot of Americans think the energy for an event in the card now that was Daimler Benz and his daughter was named or Mercedes but when Henry started that carbon there were 86 car companies that would make just really expensive cars for rich kings and queens and Noble landlords and Henry said you know if you if you just you got to make this stuff for the masses and that's what America was built on in the middle class and I wish you had to see a hundred all on none denture courses for every on four implant course and I just think it's amazing. Congratulations on being the keynote speaker to two of the biggest meetings in town this year and in-between sandwiching in a short fat bald guy in Phoenix it was an honor to podcast you.
Valerie: Thank you so much.