Dealing with Down Months as a Practice Owner

[MUSIC] >> Set down your sleepy water in your Mr. Wessel. Take off that raincoat and grab a cold beer. It's time to have a real talk about pediatric dentistry. You're listening to Bruce and Tiny Teeth, the unfiltered pediatric dentistry podcast. [MUSIC] What's up, Bruce and Tiny Teeth fans. It's your boy, Casey Gets, coming at you. A quick little housekeeping thing before we get going with today's episode. I wanted to just make a little quick personal announcement slash maybe apologize because I was scheduled to have a bunch of podcasts recorded over the next few weeks. My wife and I were expecting our second kiddo to be born mid-March and we went out to dinner about a week ago. And she started having a little water leakage, not crazy, but just like, man, I think my water might be breaking. So we swung by the hospital just to double check and sure enough, baby was coming three weeks early. So just had my second little girl at home, kind of full fledged, like diapers, the whole baby situation. But I had to reschedule and kind of get creative with a bunch of my podcast scheduling. So I don't think I'm going to skip a beat on getting episodes out. But if things are a little bit late or things are a little bit more unpollished or kind of flying by the seat of my pants here, I apologize if it's maybe not quite as smooth as it usually is. I'm just trying to get everything rescheduled and not miss any Tuesdays with episodes coming out. Luckily, Dr. Andrew from West Virginia did a podcast that I'm dropping today. We recorded this about a week before my baby came early and had a great conversation. We talk about a whole bunch of different kind of grand bag topics with, starting a practice, life in West Virginia, going out of network with Delta on Brella plans. We talk a lot about how you have good and bad months as a practice owner. Talk about, like not seeing as many traumas as you would think you would as a practice owner. So just a whole bunch of really cool, fun, grab bag topics in this conversation. But yeah, so I think you guys will enjoy this episode. If anybody is just kind of interested or heads up, I am going to try to make it out to or I'm planning on being out in Denver for AEPD in May. It's still going to be a couple months out, but I'm going to be out there running our little smiles practice mastery startup booth. So I'm going to be in the exhibitor hall, probably throw my podcast banner up. Just people want to see me or stop by. But I'm going to be out there just trying to promote our course to some of the younger residents that are maybe interested in being practice owners and just kind of doing a little marketing and networking and branding and that sort of thing. So hope everybody's having a great spring. Hope you guys enjoy the episode and enjoy. Cheers. Okay, and we're good. So I was going to start by asking if you were working today because you're rocking the casual hoodie look, just looking comfy. I didn't know if you still had to go into the office to finish out the day. No, Fridays I tend to do administrative stuff. And then I have some one Friday at month, I'm in the OR. And then I can pick up some Fridays in the OR if I need to. I got you. I got you. Yeah, it's in the ice. When I first started, I was doing like eight to one on Friday. And I just I didn't have people scheduling. And so it was actually my staff came to me and they were like, do you want to keep still working Friday? Like why are we working Friday? And I was like, well, I don't know. That's a great question. Maybe we shouldn't. And I, I never looked it back. So we cut it back. What's a, yeah, I don't know. That's kind of a nice thing too. If you get to that point where you can cut back a half day or a full day and your office metrics like collection and stuff really don't change all that much, which it seems to almost be the case. Like when you, I mean, that's just like the whole working world. But if you can get all the things done, all the patients you need to see everything done in four days instead of five, like you're saving on overhead, you're like way more efficient, like more profitable. And like everybody almost seems to recharge more on that day off. And then you come back more fired up and are more productive on the other days. So like does make sense? And I do see why a lot of dentists go four days a week. Yeah. I mean, even, even if I made less money, it's just one of those things. I would, I feel like I'm playing out the dental game really long term. And so I would rather not run and gun so hard early and just kind of have a nice steadiness in the career. And then I, yeah, I just like being, being home with the, with the family. My wife wants me home on Fridays to help with the kids and just to do family things. So I'm more, you know, it's, I, that's my number. Well, that is higher for me than the business stuff. So it's like, that's number one, number two would be like business stuff. So as long as, you know, if the business really needed me to step up more, because it wasn't maybe doing super great, then yeah, you know, you got to do what you got to do. But as long as the business is doing all right, and I'm able to kind of cover enough that what we need, I'm not, I'm not trying to run and gun and make a, make a ton necessarily. Yeah. Well, there's some wisdom there too, though. Like, you know, I, it's obviously a lot of dentists get guilty of that of, you know, like burning themselves out and just going crazy hard, like going full send, foot down on the pedal. And then in 10 years later, they're all gray hair and have a bad heart and stressed out and divorced. And it's like, well, did you do yourself any favors? But it's cool. It seems like there's a lot of chat about that. A bunch of podcasts have done recently, as you know, like, there's a lot more of that discussion being had. I think people are more self-aware that that's a problem. Like, you can't just burn yourself out right off. Like, it's got to be a long game. It's better for everybody involved. You know, just like playing the long game and taking care of yourself and finding a good balance there. But you've got a couple kids at home too, though, don't you? Yeah. So I have a, um, a four and a half year old daughter, a daughter that turns three soon and then a four month old son. So yeah, yeah. And then, um, uh, like, our son was born in, so September about mid September, but, um, like mid or about middle of July, my wife got placed on like modified bed rest. So then it was like, you know, had to step up even, even more stuff at home. So, you know, was trying to not be here as much as I could to help out at home. I gotcha. I gotcha. Um, tell me about your practice a bit. I know when we were touching base here, I thought it was kind of cool, like being out of West Virginia is probably a state that gets overlooked in terms of like, a big busy pediatric dental scene, but I'd have to imagine based on the little that I know about West Virginia that I imagine there's got to be a ton of demand and a lot of. Probably underserved areas and high carries rates, but I'm making assumptions. So I was, I was hoping I know, tell me about like your practice. Were you, did your training at, but I believe you opened up a practice out there and, and I've been doing really well. And I just want to hear more about it. So tell me what's going on out there. Yeah, so like you say, and I did my training at Bonsacore St. Mary's in Richmond. My wife is in the military. She was an army general dentist. So we lived in Richmond for three years, was associate at a bunch of different places. And then when she left the military, that's when we moved, she's from here. I'm from Southern West Virginia. We're up right now around the partner DC. So we're like an hour from Northern Virginia. So that's kind of, it's, it's this weird mesh of a bunch of things here compared to like where I grew up or even if you go to Charleston. So when I was growing up, my pediatric dentist was in Charleston, which is an hour from us. And so if you had to, probably like a lot of your patients, the nearest one is like an hour, hour and a half away. So, but Charleston's in the middle of the state. So where we are, what's happened is because kind of some of the richest counties in the US are in that bordering DC. A lot of people can't afford to live there, but they need to be there for work. So they've started migrating out to us. And so we're almost the border of like kind of Northern Virginia now. And so it's this weird mix of like the sort of classical West Virginia culture that I had in Southern West Virginia mixed with like Northern Virginia elements. And it's kind of you end up getting the toughest of everything because. So I opened up I'm in a little town called Charles town. And so the part of West Virginia, I mean there's just three little counties over here. Virginia's below us. Maryland's right above us. And there was no. You're in that like you're in that Northeast tip like that Northeast corner of the state sort of right like where it kind of comes up to a point more. I'm going to map while we're talking, but like I think you're on the like East Northeast kind of side of it, right? Yeah, yeah. Okay. It's about as far East as you can go in West Virginia like the little like. Yeah, there's like a little projection of the state that kind of like shoots over towards DC. Okay. We're right there. Gotcha. And so. There are three counties there. The middle county has about, I think, 150,000 people in it. My county has like 65. Those are the biggest two counties where everybody's kind of moving. There was no pediatric dentist prior to June of 2022. Martin'sburg is kind of the central city around. There was a guy who moved in to the area about a year before I was able to get there. Back here, so he's in Berkeley County. I'm in Jefferson. But what's, and we're about 25 minutes apart. What's tough is, so when I started, I made the decision. I didn't go in with every insurance. I was kind of going to use West Virginia Medicaid as my barometer. And in West Virginia, Delta pays, so the best fee schedule Delta would give me was basically equal to Medicaid. And that was their specialist fee schedule. And so with Medicaid as my barometer, I was like, well, if no one's better than the state, or at the state level, I'm just not going to go network with them. And so I didn't go in network with Delta. I also didn't get United Concordia because they're just a little better. But unfortunately, in the area, probably everywhere else too, that's the main two insurances everyone has. And so I was in network with all the Medicaid's, but not in network with those. I used Unlocked the PPO to help me negotiate fees and set fee schedules and whatnot. So the good news with that was I got a Karrington umbrella, which includes a bunch of insurances that give me 95% of my fees. So that was nice. And then I got a decent at the umbrella with about four or five insurances. But again, unfortunately, none of them were Delta or United Concordia. So the tough thing with this area is there's obviously there's a lot of Medicaid need in West Virginia. A ton of that need. That's everywhere pretty much. But especially here, the tough thing here is I compare a lot of my experiences here to everything I saw in like basically Richmond or Fredericksburg, because that's where I practiced before. Even the, I would say a lot of the times in Richmond, you didn't have a bunch of stuff to do on patients with private insurance. Now you might have eight little M O D O type things you would want to do, but they're not coming to you with like, you know, 16 teeth really, really broken down and having private insurance a lot of the times. Now obviously it randomly trickles in, but here I'm like getting that a lot of the time too. And they'll be out of network and you know, you're hitting people with like 4K treatment plans out of network and even though, you know, I understand from their perspective right now, it's like I can't do that. And so the tough thing about being here is say most of the time it's dealt to patients, right? So they can easily drive down to Virginia to somebody in network, you know, go there and it's maybe even not even half the price. Because where I live, so I live in Berkeley County, right off of 81, the big interstate goes up through there. So it's like 20 minutes to Winchester. There's two pediatric dentists in Winchester, so people can around here, they can easily go to Virginia or easily go to Maryland where they get way better fee schedules from those insurances and the dentists can be in network. And so they go there over us and you know, I can't say that I blame them, especially when you get a giant treatment plan. And I try to help people and work with them, but still. So that's kind of tough. And the other tough thing is I'm in the Northern Virginia wage market, but I'm like, you know, you're still getting like the Medicaid, a lot of your operative is Medicaid now. The private patients on the hygiene side and a little bit of operative they need are trickling and slowly, but it's like people can drive 30 minutes and you know, I know there's the last time I posted a dental assistant job on indeed. A lady applied and she was at an ortho office in Northern Virginia. She lives in my town, but she was like, you know, I got kids in sports and I was just looking to be closer to home. And I was like, well, the best I can do is this. And she was like, I can't do that. I'm making, you know, $33 an hour here is a dental assistant at the ortho practice. It's like, I'm in that sort of wage market getting like, you know, Medicaid fees. And that's what's tough because like in the rest of West Virginia, you're in the West Virginia wage market. So things are a little more scaled properly, but man, that's so crazy. I didn't think about that. But yeah, when most of the state is what you think of traditional West Virginia and then you're kind of in that weird hybrid zone where it goes from being some of the wealthiest counties probably in the country to probably arguably some of them on the lower end. Like it's pretty interesting geographically how stark it sort of makes that change where like if you're if the people are working and living by you, they'll just commute the opposite direction and go, you know, where they can have better opportunities. So that's a, that's got to be a tricky area to do a startup in, I would imagine. Yeah. Yeah, because the, I'm pretty sure Loudon County, Virginia borders us. And if I'm not mistaken, that is one of the not like wealthiest counties in the US. So it's a, like you said, it's a pretty huge stark difference. And it's only, I think the one of the bigger towns there where you can find people's personal ville and it's only 30 men and drive. And so that's been a challenge and coming from Virginia. So I could be wrong about how it is now, but Virginia, the assistance, basically you can be working at like waffle house one day. And the next day, if you're employed as the dental assistant, you can be like coronal polishing and doing sealants and whatnot. West Virginia for coronal polishing, basically at a minimum, if you have to have a bunch of hours and get certificates and whatnot. So the earliest you could get it if you just started as an assistant would be a year and a half. Wow. So I'm having to find, you know, dental assistants with experience. And those are the ones obviously that because they can coronal polish, they, from the practice perspective, cost a lot more than somebody who doesn't or just starting out, you know, or whatever. Because, like I said, they have to have two years. They have to get their restorative expanded duties certificate first. Then they can get their coronal polishing certificate. Now you can get them kind of back to back, like apply for them at the same time, which is still technically have to pay for the one and then pay for the other. And a lot of people don't have it because there wasn't any pizza practices here that they're coming from and a lot of the general dentists around weren't using that. So like, I'm having the higher people and then sort of you have to do a couple of those. So you like get them done for that, pay for their trainings and that all of way to round. So that was kind of different than being in Virginia as well. I think, but part of that's in my favor because it prevents some people because there's a couple like I said, two practices in Winchester. I'd heard kind of through the grapevine that they had thought about coming up here, you know, because they've been there for years and years. But because of that, they, because it was a little way tougher than Virginia, they were just like, I'm not going to fool with the hassle of moving up there because you got to have basically higher hygienist and all this. So that was what. But how many years is your startup or is your practice? So about a year and a half in. Oh, okay. Okay. So pretty new. I've seen it maybe it was a little farther than that, but it just listening to you just makes me feel like I can just feel the like I can tell you're in the trenches or in that stage where like you really got to start making some, some really serious business kind of decision and really watching numbers and walking that line of like, okay, does it make sense if I hire this person, you know, how much is it going to cost me on an annual basis if they're one 30 plus bucks an hour and then like does will my increasing collection kind of justify like where I'm at there. But there's a lot of those decision before you get to that point of just it's the same daily, you know, more so where my practice is at where it's like you're at capacity. It's the same number of staff like everything sort of just dialed in, but those, those grow stages where you're trying to make do the math on, you know, is this the right business decision can be kind of a tricky spot, especially when you have payroll as expensive as it is and to try to take care of your staff members and pay them well is not cheap anymore either. Yeah, it's been a it's been a learning whirlwind. That's for sure. So like some bigger things that I've had. So I don't know how Virginia does it, but I feel like West Virginia does or other states do it. I feel like West Virginia does Medicaid very weird like there's traditional Medicaid, which you have to sign up for first, which pays right out of West Virginia's treasury. But like hardly no one is on that. And then there's when I first started, there was three managed care plans and people just they were all the same and they just signed up. up for him, kind of like Willie and Ili. And now there's a fourth managed care plan. But one of the managed care plans July 1st, which to like a different third party administrator, which was like just made a lot more headache. And so I actually made the decision, it was almost half my patience. I made the decision not to go not to continue my in networks as with them. So around like July, I lost a decent amount of people or didn't get the new patient flow I was getting because that one switched over and I didn't you know, re-up it. And then it's a summer was slow and then picked back up October and November was good. And then December was awful. Between just like sickness and holidays and everything December was bad. And then like the first two weeks of January, we're not great with like snow and still others and everything. This week picked back up pretty good. I mean, decently could be better. But and then February's looking all right. So yeah, hopefully I'm over the hump. But yeah, it was getting a little hairy in January. Yeah, it's that's another another interesting kind of component of being a practice owner that you take for granted when you're an associate is the consistency of a paycheck. You know, and obviously there's going to be people listening to this that are associates and people that that are practice owners. But eventually I feel like it's inevitable when you when you own a practice, you know, even if things go really well right off the bat, eventually you hit a sticking point where like you have a bad month or two. And it's a bit of a shock. It's like, oh dang, like I normally am able to collect this and I normally can take home this to pay my bills. And this month like that money is just not it doesn't exist. It's not there. So then you have to choose like, do I take home less money? Do I not pay ahead on this? Do I not, you know, make this extra mortgage payment this month? Whatever you do with that extra cash. And it's that's when it hits you like, whoa, like nothing's guaranteed. Like if you don't show up and find a way to keep doing collectible dentistry, like this could all go away. And you just don't have any of that as a problem when you're an associate and people take it for granted sometimes. Yeah, I am like you said, I didn't there was two three paydays where the last couple ones I just didn't pay myself because I was like, oh, if I pay myself, the bank account's going to be looking real real. Yeah, real real sketchy. Yeah, yeah. So, um, but so like, for example, um, I think in October, um, collection wise was like 75 or 80 K, uh, and December dropped down to like 45 or something and then obviously, and then production in December was not good either. And so January collection was kind of slim because of December production. Yeah. Like I said, there's been about two month period where like you said, as the associate, you get a little protection from yeah, yeah, those are the hardest ones to your point. When you take a vacation or I'm like, I know you've got kids, like you're out on paternity leave and you're a practice owner, it's hard because like you'll be out for two weeks and the checks roll in from production that you did a couple months prior. So your office manager, whoever's entering all these checks in, you're like, okay, we're good. Well, then you come back and you work your butt off for, you know, two, three weeks and you get like zero income, zero checks because everything's so delayed where you always feel it, you pay for it like a month later. It's got a lag effect when the insurance checks don't show up in the mailbox. And then you just showed up and you work super hard and you got nothing to show for it like damn. But yeah, another another kind of practice owner a bit there. But the yeah, the the whole like how to take money home is like an interesting cash flow conversation that they don't also, you know, you don't learn a lot about until you're an owner and you do those sorts of things. But there's a science to like how much money like how do you manage the cash in the account, especially like I always talk to people like the end of the year is always the worst like December is like you've got to have a big pile of money almost like plan because it seems like everything, especially as the office grows and gets more mature, but you've got Christmas bonuses for everybody. You've got like your Q four tax payment when you start paying like orderly estimates. So you'll have a big IRS bill. You got to write a fat check for that. We do the same thing with state, like if you have a pass through entity like some states, you can pay your personal taxes for state taxes through the business and get a deduction. So whole thing, but then there goes another 20, 30, 40 grand or whatever. And then you've got profit sharing like 401k. We do all of our match and our profit sharing, you know, after the end year and numbers are run. So it just seems like, you know, come January first, like, you know, there's just you've got to have like 150 grand. I'll just evaporate out of this bank account on this big practice that you run, which you're going to, you know, you're not, you're going to get there right away too. But yeah, so I guess if anybody's listening and you're either in the early stage of a practice or going to start one, like don't, don't try to just like whatever money is left over at the end of December, like, I'm just going to pull that out of the bank account and go buy something or get a new card. You like, you got to have a lot of cushion there because it all goes quickly in January. It feels like. Yeah, it didn't help in December either. Like, it was like all those dental supplies that you don't have to buy too often. Just were out in December. And so it was like the supply bill was also like large because I buy a lot of, I do a lot of, use a lot of glass out of my and rest modify glass out of my and I buy them off of a crazy dental and they'll do like, buy four, get one free. So like, you know, there are like 300, 50 or whatever they are per package. So it's like, well, let me load up on equia. Let me load up on Fuji too. So I can get the free one because like, I'm going to use it. So then it was like, you know, it just keeps adding and adding and adding. Oh, dude, this is, you'll, this is a funny one you'll like from the other day. So I think Monday I had a new patient who was like three or four little girl, cute little blonde thing, really approachable and sweet, but you know, kind of classic like nervous three or four year old. And I did her exam and K and T. She had these like giant K and T big, like this teeth were big. And the, she had these wicked deep grooves and she wouldn't let us get X-rays, but you could see just looking at them. Like, there's something starting in there. They're sticky and like, you know, if you pry open it up, there'd probably be some decay in there. But she just wasn't super cooperative. I didn't really want to sedate her just for these two didn't have good X-ray. So I told mom, I'm like, I'm a little suspicious or not. I'm not losing sleep yet. But I'm like, I would love to try to squirt some, sometimes I'll do like Fuji triage pink. I know you use Fuji 2 LC, but that's like there. Does that ring a bell like Fuji triage? Yeah. Yeah. So, but sometimes I'll use the pink because then I'll know in my brain if I see that kid back like, okay, that means there's something going on with this tooth. That means we're not finished yet. And so I right at the end of the appointment, I had my assistant run the pink. I tried to get a little conditioner and squirt some in. And as soon as she saw that gun, she just really freaked out. Or the air water got her first panicked, like, sat up, ran into mom's arms. And, you know, immediately it sets up. So that triage is done. So then I'm like, okay, well, let's try this again. Let me do a little more TLC walker through it. And long story short, we tried a second time. And I got to the point I was about ready to squirt the GI on there. And just to do some sealants to kind of like cover the so we could buy some more time till she's older. And she flipped out again and hopped out of the chair. And so I was a little sad that I didn't get something on there. I like tried to even hold her down for a second and finish that didn't happen. But I'm like, damn, I also just wasted like 20 bucks worth of carp, you know, capsules. And bucks a piece. Yeah. Yeah. It's not cheap. So when you're in residency, you just like keep running on or if you fill it with key tack and you drop it on the floor, you drop the crown on the floor, whatever, you don't lose sleep. But when you're paying 10 bucks a piece, it's like, okay, that's a real expense. And that adds up if you mess it up a couple times. Yeah. I um, speaking of that, my daughter, she came in in July when she turned four. And I was like, we have to seal your teeth. You're like, I know you're going to get cavities if I don't seal those. So I had to seal her KNT. Did you? Yeah. I just, and they're still there. That was six months ago. I kind of also use it as a reference of like, if I recommend this to patients, like, and they're paying for it, how long can I expect it to last? So I just squirted on the glass on over the equae on each finger and then just swiped it on her teeth. KNT and then covered it with a little like Vaseline. They're still there. Right. So I like you're an equae guy. And I, I, about two or three years ago, really got into using quite a bit of equae and I'm a pretty big fan. So I want to get your input on if you have any handling tips or just kind of talk about that a little bit. But I seem to use it a lot on, especially like hypoplastic teeth, it seems to work way better on than trying to bond resin onto that bad enamel. But it seems like some kids come back and you know, it's pure glass on them or if those don't know it equae a forte is you squirted on treat it like a glass on them or and then there's a top coat you can paint on it like a, I don't care remember what they call it. But that kind of is like an acrylic top coat that seems to help it set up. But some kids come back and they look buttery smooth for like years and just perfect sealants or I'll even do like big occlusals with them. And then some kids they come back and they seem to chip and wear off sooner. So I don't know if it's a diet thing or something but does it have you noticed like sometimes they come back looking really good and some kids. So I don't know if it's like a technique thing on my end, but I just curious if you've seen that at all. I would say not as much with permanent teeth, but like primary. I, so this is kind of a whole topic I did want to get into because I like to try to, I'm a minimally invasive guy. I like to try to start things treat more minimally basically if I can, but this practice is kind of humbled me a little bit because I've tried, I'm seeing a lot of stuff come back that I've tried and it's just not holding up like I want it to, unfortunately. So I've had to change my tone a little bit on some things. I could say that I primarily use equia if something, whether it's primary or permanent class one, I'm using equia. I know L, O, B's pretty much using equia. If it's a, and I feel like it behaves better on permanent teeth for me, then it does like primary teeth. Primary teeth as far as I've had the problems with like a chipping out or looking kind of just, like you said, kind of just weird. Now I was at a CE course this past weekend with Dr. Brian Novi, and he was saying, with pure glass anomer, what can happen is if they have a terrible diet, the pH of glass anomer, or when it, when it starts to dissolve, it dissolves at a higher pH. So if they have acid attack, the glass anomer will dissolve and not the tooth around it, supposedly. And so that could be happening. If they have a very like acidic mouth, that's one hypothesis, is that it could just be, the glass anomer is dissolving so that the tooth is not. Or it could just be something with, if you were, 'cause you're more likely to probably use it on a kid that's kind of tough case anyway. So it could, you know, there might be a little bias there in that, well, I didn't try resin on this case, so the resin would just chip out probably, whereas glass anomer, it's like, it doesn't look great, but it's still kind of hanging in there. - Yeah. - I don't know. But I, I've tried to do, 'cause I, compared to what I had in Richmond, I have a lot more kids that just cannot tolerate treatment under nitrous here, I feel like. Or kids that, I didn't have much of a problem with the dry shield using it in Richmond, but here, kids cannot, I just like most of these kids will not or cannot tolerate the dry shield either. And so, and a lot, like I said, a lot of them, they won't even hardly sit in the chair. So I've tried to do a lot of the smart technique, but I find that I can't get the glass anomer to stay in there. It's chipping out a lot, and they're getting, like, they're reactivating the carries around the SDF. And I do, at least two applications of SDF first, before placing the glass anemones. But that's just not, it's not working out, like I've wanted it to. And maybe there's something I'm not doing, correct that I could, you know, maybe do better. And then I'll try to do a lot of like, strip crowns to avoid the OR on kids. And they're just not. - Hold on, yeah. - But all either. - They look good for, like, you know, he gets six, 12 months out of them, but when that, you know, you're trying to get him to be long-term solutions, they never end up, the handful that I've done, I see the same thing. But I don't, so that's probably less a technique and more so. Like, I think a lot of the downfall with baby teeth is so much of it is about like retention and getting good bond. And when they're so small and there's just hardly any an amulac, little tiny scoop and like, just little tiny micro fillings and slot preps and little, like, we think about a lot of those strip crowns on D through G. There's the amount of actual material going in there. It's not very much, it's a pretty thin shell. And it just seems like the success rate is kind of directly retired to your retention on a lot of these restorations. And that seems to be downside. - Although I've seen some back recently that it's worked in the sense that when I placed this strip crowns, their behavior wasn't super great. By the time that I catch them back again, they were able to sit in the chair. And I have, I can't remember the doctors name who does the behavior management, the magic tricks. - Oh, E.L. Simke. - Yeah, Simke. - E.L. - He has one of those, like, I think, endo, cordless endo hand pieces where you can put the latch round bars. So I'll use that and they'll sit there either with nitrous or without nitrous. And I'm able to then remove a lot of the loose, careiest material and then do strip crowns with Fuji II instead of Equia. And because I'm able to remove, I think a good amount of the loose cavity part. I feel like those last a little-- - Wow, okay, let's talk about that 'cause I've actually said to my staff before, like, in open bay where we do our recalls, that there's a lot of times where it would take me two seconds to do, you know, like, slow speed, careiest removal to your point. Like, I don't really do, like, spoon excavation anymore 'cause those would never hold up well. But, like, exactly like you said, if I can get, like, I'll start with a little fissure otomy burr, get in, just like if it's, like, a closed enamel, careiest lesion kind of popped through there and then you can get your two-round burr in and then a four-round burr. And then all of a sudden, like, you've scooped out the majority of the decay and you've got, like, a defined nice hole that's gonna actually have good retention. And that seemed to have pretty good success rate on those, but in my open bay, I don't have a way to do careiest removal. I've told the girls, I almost need, like, our little cordless, profy hand pieces that we use on needle-lap exams, like, if you could get that and do decay removal with it, I could be so efficient with, like, getting so much more done. So, tell me, is that what you're talking about? Is your-- - Yeah, so it's like, I've got mine from Benco. I think it's NSK something, it's like $1,200, but I also bought it to do Endo with 'cause I was like, well, it's kind of a dual thing 'cause I like Endo, I don't do molar Endo, but the problem is, I've already done a couple of cases in the anterior where kids will have Medicaid, and there's no, like, to get Endo on Medicaid around here, you're driving, like, two and a half hours. And so, I do it for them 'cause I can, and I like it, and it's single canal, so it's kind of, it's pretty easy. So I was like, well, I'll buy it for that, and also I can use it for this other thing, so it's kind of dual purpose, but I really love it. - Is it, is there a foot pedal involved, or do you just hit a button on it that turns the motor? Okay, and then, so you just have to use latch style round bars, like, man. - It spins at like 500 RPM or something, or really slow, but it works really well. - Wow, okay, I just pulled this up on my computer, but I'm gonna leave this up 'cause, yeah, like, I just had one this morning where I was running a little bit behind, and this cooperative, like, five-year-old had a, like, little halfway to the Denton sort of, like a Closelon K, and it was an open lesion. I'm like, man, I could stick like a two, and then a four-round bar in there, and have that cleaned out and shoot some equia, in there, and I could have that fixed in about three minutes, you know, you wouldn't have to get 'em numb, but I didn't have a, you know, air-driven handpiece back there, but man, that could be a game changer, like, that would pay for itself in a hot second, so if I took away, if I take away anything else from this conversation, you're gonna inspire me to get a cordless endo handpiece, and then even, 'cause I try not to have a lot of latch, I don't have any other latch speed, or, like, latch style handpieces in the office, I've tried to go all friction grip, but you could almost have, like, a little tiny tub or a bucket that's, like, oh, I wanna do same-day art, out in open bay, go grab that stuff, it's a little bucket, I could have that cordless handpiece, it could have, like, a little burble-lock with just a handful of friction grip burrs, it could have a little cavity conditioner, and a couple of, like, last on-rope packets, and, like, boom, you're in business, you got it done in five minutes. - Yeah, I mean, I've had pretty good success with it. Kids tolerate it pretty well, so I think you, I think it would fit perfectly for what you're describing, 'cause, you know, you'll have some kids, you'll ever have those kids that have no cavities, except they'll have one, and it's randomly, like, on H facial, and you're, like, it's perfect for that, 'cause you're, like, you usually catch it when it's kind of smaller, and it takes, like, two seconds to do. It's, like, perfect for that type of scenario, 'cause you just slap, like, a four or six round bar on there, it takes, like, you know, 10, 20 seconds to get stuff out, and then just, equi or Fuji, too? - Yep, shoot some Fuji, too, and there, and off you go. I was gonna, I forgot that I was gonna add this to, when we were talking about equi a little bit ago, and you were mentioning on permanent teeth, but one thing that's actually worked really well with that equi is, if you've got a tooth coming in, and you can't keep it isolated, like, I just did one this morning, on an 11-year-old, and the 12-year-molar comes in, like, crumbia, namel, or a little hypoplastic, or even, like, that a perkylum is over the back, third of the tooth, but it looks really suspicious, and you know, like, all right, I know there's some decay starting, but I can't actually fix it as well as I would like. You know, you go in, remove it, like, remove decay, put your equi in. Well, I'm seeing a lot of these kids back, like, a year or two later, and now they're older, and the molar is fully erupted. All that soft tissue is gone, is peeled back. But even if you do get somewhere, or some wash out of that equia, as long as, like, especially if it was good to care removal, and you're not worried about what's underneath, if it does wash out, like, a millimeter, it actually is kind of great, 'cause I'll go back in, if I'm doing a different op, and I saw that I did a glass item, or, like, equia filling, you know, a year or two ago, I'll go in an aerobrade, and, like, roughen up the surface of it, clean out any sticky margins, and then I'll etch and bond, and I'll flow in, like, I use beautiful blue. blue, but like a flowable composite. And then it almost makes this like beautiful sandwich technique where you've got like a millimeter thick layer of like a flowable resin like glassy smooth margin. And then underneath of it is all glass, anima, which is arguably going to be what, you know, with like best to go against the dent and what's the coefficient of, you know, like the tensile strength or whatever is like thermal expansion. Yeah, the thermal expansion exactly like when it comes to material selection, that's almost perfect because like you're recreating the enamel with like a resin. And then and you don't have to numb. I mean, just added on top of the washed out equia, but those come back and those look amazing. I feel like those are going to last forever. So again, to your point, like that's why the glass on them, it can be such a nice tool in the toolbox for CMPs. I like the tough thing is just like explaining to parents like I feel like they, they're sort of, I don't know if it's me projecting onto them this or not, but I feel like there's obviously a growing distrust of like medical providers and dental providers. And maybe rightfully so. And so like explaining to somebody that their two year old has this, and then you may need to do this a bunch of times to avoid like, you know, GA or whatever. I think if like there's like a, they sort of look at you like, I'm not, I don't know. Are you just trying to like, you know, pull one over on me and get a bunch of money. And it's weird because like if you do that, we're in a having chance, you know, where do you draw that line of like, Hey, we can do this, but I'll touch it up like once. And then what if we need to do something else again? And then I don't know. It's a, it's this weird scenario because I'll have a lot of, I didn't have this as much enrichment. I'm getting a lot of kids, both private and Medicaid under two years old, just D F G huge carries bombed here. And you know, if, and the tough thing here is when I was in Richmond, the hospital we went to is the same hospital we used for residency. And so they saw kids all the time. They saw like a ton of pediatric dances were there. Here I met a local community hospital. And they're real picky about their cases. And I kind of have like a sort of a line for me. It's like I wanted to be at least three, one for GA, but two even to go to this hospital. But I'm like, I'm getting so many kids that are less than two. And I'm like, I've already tried strip crowns like the kid is not great. They won't sit in the chair and I end up just having to like refer them to another pediatric dentist who can just take them to like a larger hospital. But it, you know, it's, it's one of those things. It's like, well, if you just did that and you charged for it, then, you know, who knows what the insurance will or won't cover. I know that's not our problem, but it is also because you, you need to get paid for the work that you do. But at the same time, like taking that into account for the patient, it just puts, it's this weird scenario that I'm like, what's what's what's actually best for the patient long term? What's right? Because me, like, you know, if, if I'm doing something, I try to put myself and everybody's shoes the best I can. And I'm like, I wouldn't want to pay for this like a thousand times and keep coming back and failing and this and that. But from when you're the dentist perspective, you're like, well, that's because we have to do this to just get you old enough to like go more appropriately where you need to go or whatever. I don't know. It's, it's this, it's that weird, it's weird dynamic. I think a lot of it, that seems like it's a bit, that's the one big downside or one of the few downsides of like the, the minimally invasive stuff, which I don't, don't get me wrong because I do, it's a fairly big component in my practices. I do just did a couple of hall crowns and I like doing some of those. I don't use as much SDF, but like if you're the type of provider, like kid comes in with ENF, those little inner proximals, and I feel like I try not to start touching them if I can. But if you got to get in there and you just, that's right what you jump to is let me get a little round burr or like spoon and scoop that out and I'll shoot some glass of honmer in. And then you charge that parent for two fillings on ENF, like you and you and I both know those are going to last like four months and they're going to chip and break off and you're just going to keep doing them again and again, which is like, I mean, I feel like I used to do those a lot, but for that very reason, like you get, you know, you're just getting this sticky spot of like either you're going to do a bunch of free dentistry and chew up a bunch of chair time for a kiddo elsewhere that could have used that appointment or the parent is going to wind up paying a ton of money and neither of those are a great suggestion. So that, that is like a tricky component of it. I mean, yeah, you exactly describe the scenario because it's like, I feel bad because it's not even lasting a year and I'll tend to touch it up kind of one time, but I don't really think about it, but it's like when you're touching it up multiple times, then it's like, I feel bad charging them, but at the same time, it's like, I didn't put the cavities there. I'm trying to help, and I can't keep continuing to do and things for free all the time. So it's just, it's this weird scenario. And I kind of started, like you said, fading away from that because I just not seen it work. I think I've kind of made the decision like if I'm going to do any sort of strip crown on a front teeth, I'm going to do SDF on everyone first and then try it because I was trying to do a little removal, but people weren't really wanting SDF, but I'm like, so what I'm doing is not working. So I got to change something. And maybe it's that. Maybe I'll see if that can help out some, but I, yeah, I don't know. It's that tough. It's tough because two years old going under GA, you know, not ideal for just front teeth. It's, you know, I don't know. It's not ideal. It's, and we've all had, you know, patients, I'm sure in that, that's same boat. But my anesthesiologist, I just got a memo from the day that they're no longer taking, allowing us to take kids under two to GA, which I've only probably done three times out of the, you know, thousand kids. I've probably done it too, but I actually had one on the schedule of, you know, it's, it's usually like the nursing, a lot of it, you know, or like nursing and not brushing in a caries risk, high caries risk kid. And mom really wants to try to save these teeth and they're already bombed and the kids like my daughter's age, like little over 18 months. I'm like, man, that'd be so weird to need to put your kid to sleep for that. But, you know, so yeah, then it gets to your point like, what do you do? Do you throw SDF on there to try to buy time until they're older? There's a pretty good chance this decay is going to keep progressing. I mean, you could put a lot of rounds of SDF on, but once he gets to a certain point, you know, it's like a bucket of water on a raging house fire. It's just not going to do much, you know? I saw the earliest I can remember, like the worst case in the earliest that I've seen here, 15 month old, like D E F and G were already just like pretty bombed. Not, I don't think they were into the nerve or anything. So I used to, I'm hitting them with SDF. I don't know how many times and they just kept coming back and it was just like still worse. And I'm just like, I don't, I just referred them to like the dental school to see about going under GA to get them, I guess, taken out or something because I'm like, like you said, it's like I have tried what I can do here and whatever you're doing is just far out competing anything I can do. Do you do zirconia at all? Like, like, anterior zirconia. So do you have, is it more so an issue of like hospital access time for you to be able to do those? Is that the big funnel there? Well, no, so just from my experience that, so this hospital they've seen kids, I wouldn't say kids are a majority of their people. And so I just kind of under two is my hard line to go to this hospital personally. Because if they're under two, I, I want them to go to a more equipped hospital to sedate like the little or ones. So that's kind of, that's just a personal thing. I have taken kids like right around two and also when I've done that, I'm kind of like, well, I don't know that I love taking two year olds here. For sure. So that's the reason I didn't do it just because like when they first came in, they were like 15 months. And I don't remember when I, maybe they were like 18 months. And then when I referred them out for that, because like I said, I was trying to just buy time for them to get a little older and also just stop the carries. And then because they didn't have that many other teeth in. And the thing is that I'm pretty sure it was from like nursing in addition to other things, just on demand all the time still yet. And so it's like, you know, the other teeth, especially the upper first mullers are probably going to get the same ways. And it's like, you don't really want to sedate the kid twice. You don't want us to date him at like a year and a half and then like three, three and a half. So it's like, you're kind of also playing that game. So I don't know, it's every day you kind of get presented with something a little different. And you're like, oh, I thought I had this figured out. I had to get humbled. Yeah, you do you do and I so there was a little girl the same thing like maybe two But mom's had a whole bunch of kids and nursed them all way too long and they've all gotten cavities up there But this little girl was like two and not cooperative and it was just GG was really bad the other ones had some insipiancies But she wasn't gonna sit there like definitely too big for SDF strip crowns trying to do feelings wasn't gonna work But she had good spacing So I came up with this wild idea. I just like we kind of held her knee to knee style I took around burst scooped out the fluffy stuff and I took his like I would I don't advise this would never tell anybody But I found is there Konia crown and just so happened her tooth was the perfect shape Where I was able to almost do like a hall crown with zirconia like I I filed I took a sandpaper disc or something and just shaved down like a millimeter of a namel off the incisal edge and that That steam that or that does or Konia crown it looked a little chicklady But it actually went down to the gingable margin covered up to decay. I cemented it on I'm like that basically gonna pop off in about three months But I mom didn't would not sedate her had no other options So I tried it and I saw her just back like a month ago and it probably been about a almost a year and it was Holden up great mom's like yeah, it works awesome So I feel like normally I try that stuff and it bombs and that one actually went right So did you use a G or did you use like a central to make it? I used a G but it was like a size four. It was a big one Yeah, and you know normally it hits on like the lingual like the singulum on that side, but I mean it was big and chicklady, but it like I said it I thought for sure she'd fractured or something, but I was impressed Sometimes sometimes when you get the handcuffed on you I like what you said you just have to kind of keep in perspective like I didn't put the cavity here My analogy I always show parents like I'm a chef with them in you Here's the options of things I can offer to you and you can pick any of these things But I'm just here to provide solutions to the problem that you guys presented me with and it's easy to take it personal when things don't hold up or Yeah, there's you feel like you're charging too much or things to yeah, but it's just like you're just trying to be a Problem-solver. You just got to keep it in perspective. Yeah, for sure Yeah, and you're I I've got a couple well up before we go. I said I had this emergency earlier. I had a dirt bike kid 13-year-old that wiped out on a dirt bike and was hospitalized any fractured nine And the emergency room whoever was there put like a temporary filling over it But he had a concussion and a neck brace so we left it alone and that was in November and I just saw him back today I wanted to wait for insurance reasons which is funny But yeah, so end up doing this giant out But I took off the filling and the pulp pole porn was there bleeding Some cold symptoms and everything else But I wound up doing like a speckpulp out of me impacts the MTA and a big strip crown it actually looked pretty good But it's the theme of today is just trauma. I've got like another kid with a broken tooth But my my schedule has red appointment speckled all over meaning it's a it's a trauma Friday here So that's when we will be working on this afternoon. Yeah, it's funny I actually in residency never splintered a tooth and in splintered tooth Three years out of residency either it wasn't till about six months in practice of two days after Christmas Not 2024 2023 This 16 or 17 year old a lamp hit him in the face and he completely evolves. I think it was 10 and He's pretty smart and so I was talking to him. He put it back in perfect and was biting down on a rag and then I was able to Splinted in everything here and it's funny because when I was when I was in there the mom asked he was like Hey, have you done this before and I was like oh yeah totally And then when they came back in For like the two-week e-vow They had went to endo already and they were like we had the end of Donnance's comments and on like the split was Was look pretty good. I was like, you know, it's funny. I was the first one I've ever done She was like you told us then you had done this I was like, yeah, well, I didn't want to worry I was like I mean we did or though in residency so like, you know, it's it's Same concept. I just used fishing line like it's not I was like I know the concept. It's not hard like he was great It's I do like you said I had a kid this week. They broke off number nine had to do Shrek ball bottomy It's like when you build up a whole tooth from resin doing a little flowable on the facial services and bonding fishing line Yeah, not Nick canine is not that not that hard because he wasn't bleeding everywhere It's not like he's like a you know a six-year-old who was really scared and He had to like not or I did numb him but You know, so that was it was kind of funny. I've only had to go in for two traumas that one and April four months later after that six-year-old rector bike and then D and E were just so super loose like they needed to come out so that's only to go ahead to go in for less far in my practice I feel like you know Splinting and evulsions are like in the dental comparison of like quick sand when you're a kid like you you prepare and you're like What happens it that when I do fall into quick sand like it's gonna happen all the time and then it ends up not being a big problem And I feel like it's the same way where you know You see a few of them in residency and you just think that that's gonna be the norm but you like I mean at this trauma you get a few of those but like it's I mean I was busy rule of a practice as I have had I've not had an evulsion yet and I've just had one or two couple times I've had to splint but it's not like you're getting one of these every single weekend like you think you're going to you know In residency. That was a pretty great analogy. I just came up with that one, but yeah, yeah, it's comparable Andrew I sorry. I got a cut of short, but the schedule starting to light up here. So I'm gonna I'm gonna go finish out this Friday and go home and chill and have a beer and have a end to a good week But I appreciate you hopping on on a lunch break and talking shop with me a little bit. Yeah, I appreciate the invite Are you gonna be in Denver this year? I am yeah, yeah, I got our our startup course that Corey and I put together that I've been kind of Promoting a little bit. I'm gonna do a booth out there just to kind of talk to some residents that maybe want to start their own practice and kind of just Share kind of the resources we have so it's gonna be more of a working style APD, but I'm gonna go out there and meet meet people and say hi and I didn't get to go to Toronto So yeah, are you gonna be out there? Oh, I think I'm gonna try try on you know with three kids and one thing and who knows? It's a lot. Yeah, yeah, that's a big the wife has to be on board with that as well Yeah, if you can swing it give me a shout and let's meet up while we're out there, okay. Yeah, sounds good. Thanks for your time Thanks for listening to the Bruce and tiny teeth podcast be sure to DM our hose Casey gets on social media with any listener questions Comments or tough clinical situations. We'll see you next week for another unfiltered episode