In-house labs II

Hey all,

I have so much going on in my life I feel like I am just spinning.
I feel like if I could get 80% of my work done in the day I am doing pretty good.

I have a front desk employee that is pregnant. Her original due date was April 19th.
I knew this about 2 months ago. I asked her if she was coming back, and she is confident that she is coming back. So I have a couple of months to find a replacement for her maternity leave.
Originally we thought we would have an assistant who would fill in.
She knows the systems and can work the front.
But as the back is picking up a little, we are getting to the point where we figured this is not going to work.
So this means I have about 7 weeks to find someone.
Well, last Tuesday this particular person was not feeling so good. We took her blood pressure and it was HIGH.
We sent her to her doctor.
Of course her doctor said she had pregnancy hypertension, and she couldn't go back to work until further notice.
WHAT?!!
Okay, we are thinking, maybe she will go back to the doctor and he will clear her to work for the next 6 weeks or so.
Well, guess what? She is not coming back to work. I mean she likes her job (I think) and wants to come back, but doctor's orders...no more work.
I have to jump into action about finding her replacement, and it has to be NOW.
Just so you know I did do my due diligence previously. I called our dental society who has a list of people seeking employment.
Problem was there wasn't any candidates that really fit the mold we were looking for. I mean I called a couple people, but nothing really excited me.
It is 3 weeks later, so I called them again.
This time I was a little less picky.
We are looking for a warm body, and that warm body needed some experience with EagleSoft.
We (when I say we, I really mean I did all the work emailing and calling and setting things up and my father showed up for the interview) interviewed four candidates.
Now you have to understand what a difficult position we are in.
We need a person for only 5 months, so who are you going to get.
Well two of the candidates had jobs at the present time.
Okay so you don't like your present job, but it is a paycheck.
So we are asking them to quit their full-time job with benefits and come to work with us for 5 months and the remote possibility that our front desk person does not come back, then it would parlay into a full-time position.
So both of the people with jobs think it would be an awesome place to work at, but they have decided to not give up the "sure thing".
So I called Dr. Crowder because I know he used CareerBuilders to find someone.
He said he got lots of candidates and about 25 good candidates.
I just thought to myself I don't have the capacity to interview 25 people. I interviewed 5, and it was all I had. I mean, playing email tag with them. Playing phone tag with them.
Don't forget I have three people to set up an interview with. And my father is not that flexible.
And it was $425 for an ad.
I know, I know this should be chump change but...

Well I did find someone, and I think she is very nice. She has experience with our software and she has a bunch of years experience.
I'll let you know.
If a title of the blog post is Temp Employees Stealing from Me, you know what happened.

We were going to talk about in-house labs.
I was so fired up about it on Friday, let's see if I can pick it back up.

I have to tell you that I am not that excited about running another entity.
We did get one comment on this thing and it said.....

"The problem with most good labs is that once the lab tech gets good enough they leave and open their own lab. For me consistency was always a problem due to tech turn over. In the future labs will be like the post office is with email. Their role will be greatly diminished due to CAD CAM. They, the labs are putting themselves out off business by embracing this monolith all porcelain crown crap that is being pushed right now. Because they are so lazy to layer the porcelain all they do is have white block tooth made by the CAD CAM and paint it. It won't take much for the CAD CAM to get the shade better than the crap they are doing now. Right now I can get a PFM done cheaper and better than a CAD CAM crown. But as time goes by with the help of the lab the CAD CAM will be cheaper and better like email is now versus the post office. Also the sad part is the art of crown and bridge will be lost just like the art of letter writing is being lost. So in my opinion unless you can crank 600 units like Strupp a lab is not worth it for you to by and the CAD CAM tech is not ready for main stream yet. But it will be in a few years.

See this is what I am talking about. People issues, technology issues, quality issues.
I don't even have time to interview 5 people for a job.
I guess I have the time, but it is a pain. I don't want to add more crap on top of the crap that I already have.
So could I invest in a lab with other guys, and let the other single, less busy dentist run it.
Yes, if I had money to invest that would be awesome.
But you know what?
I kind of like what I have pretty good. I like my ceramist (we don't call them lab techs anymore, this is the fancy way of saying it). I like not knowing any of the 80 types of porcelain. I like not having to calibrate my ovens or anything breaking down.
I like not having to put money into something when it is having a bad month. I like not caring if the price of gold goes up $25 in a day.
I like not having to try the "next big thing" because all my dentists want it, and then having to replace all of them at no charge because it turns out the product sucked.

I guess I will stick to being a dentist and not a lab owner for now.
But don't think that fire is extinguished, there is still a little spark. Maybe I will get my new associate to figure something like that out.
Maybe I will strike up a conversation with a couple other dudes.
I will let you know.

One thing that kind of has intrigued me is the digital impressions. Have you seen these?
Well you know the wand on the CAD CAM machine. So you don't have to take a PVS impression. You actually just take a series of photos of your prep and it makes a 3-D image of the prep and you e-mail it to your lab.
It is what you can do with this digital impression that is the question. Can it make a stone die of your tooth...probably soon.
But for now it is sent to the lab, and he just makes a CEREC type crown for you.

Alright I am pooped.
Sorry I am all over the place today. I am telling you, it was the interview process.
Imagine if I had to do 25. No thank you.

See you Friday,
john

Gators made the dance. It may be short lived but it is better than the NIT (just ask North Carolina, Miss St., Illinois, USF and the like)

In-House Lab

I am almost done with Three Cups of Tea. It is a remarkable story.
I will tell you about it when I am done.

I watched a couple of old movies this week. I decided to watch Full Metal Jacket. And I saw a movie called The Edge. They were both very good movies.

The Magic are front and center around here these days.
They are on a real tear since the All-Star break.
They played the Lakers and won on Sunday.
One of the big stories is this guy that we have on our team, Matt Barnes, was pushing and shoving Kobe Bryant all night.
Now Matt Barnes brings something to the Magic that we haven't had I think ever.
Toughness.
So I am reading in the paper about this journeyman (this is something you call someone who has gone from team to team. He has been on 7 teams in 8 years). Orlando really likes this guy and according to this article he really likes Orlando (you always have to say this when you are talking about getting another contract, "I love this city and I would love to stay here").
Turns out Matt makes $1.8 million.
Now to an NBA player that is disrespectful. This is chump change for someone on our team.
I started thinking. This guy plays a game for a living. Man that would be cool. He wakes up at about 9am and goes to the gym. He gets taped up. Plays basketball for 3 hours. Gets a massage. Does some more shooting (he is still looking to get more money).
He gets on a pimped out plane and goes to a major city. He checks into the Ritz-Carlton and has nothing to do until the next morning. He can go for a workout. He can go eat at Smith and Wollensky for dinner in the private room.
He then goes to sleep. He wakes up at about 10am and goes and plays basketball.
And at the end of the WEEK he gets a check for $35,000. That doesn't sound like disrespect to me.
Now I thought this was amazing. Amazing because in 2007 the nation average income was around $48,000. YEARLY
But what was amazing was that Vince Carter, another player on our team, gets $16 million a year. At the end of this hard WEEK he gets a check for $308,000.
Three hundred thousand dollars a week. This is just crazy to think about.

Man I knew I should have played basketball after school instead of studying.
Oh and they are thinking there might be a stoppage of play next year because the players and owners are arguing about money.

Topic,

One thing I forgot to talk to you about was a nugget I picked up at the Bill Strupp.
He talked about having an in-house lab.
And it got me thinking.
Here is how he breaks it down.
Cost of equipment...per year: $25K
Technician...per year: $60K
All his numbers are based on doing 600 units a year.
WHAT!!!???
Wait a minute. I am reading this again and this number sounds a little high to me.
I don't know how many units I do. I have told you before I don't look at that stuff.

So, to get more informed, I called my technician and asked him if he knew how many units I did last year. Of course he knew or he had it on his software.
Here is the breakdown.
I did 127 units last year.
That is not very much. I have to tell you that I was one of the lowest in his lab.
(for the record, I pride myself on being conservative and I am happy I am the lowest).

I went ahead and asked him about his other accounts because dentists want to know where they stand up to others.
There was a guy who I really like who is on the other side of town...he did 297. Holy Shnikeys
that is a lot. Man that is more than double my number.
The most from a dentist in his lab...360. WOW!!!

I want to go back to Dr. Strupp's example of having an in-house lab.
So he goes on to say that if you do 50 units a month (for him that is only one case a week).
You add up the equipment cost and salary of the technician and you get $85,000.
$85,000 divided by the units 600, and you get $142 per unit.

Then he goes on to say how much more efficient we will be.
We no longer have to communicate with our technician by other means. We would not have to bring in the technician for a shade match or other stuff.
So he thinks this will increase our production by 25%.
So this will add $25,000 to our production.
While I am typing this blog I am referring to his hand-out notes.
I am with him so far but the next line says
"$25,000 divided by 600 = $42 per unit.
And he goes on to say that if you only do 25 unit a month you are only paying $84 per unit.

I can't figure out his math, but 25 units a month...that might be doable.
It think between my father and I, we may do something around that.

Then the very next week after the Strupp seminar my dad was doing work on his best friend who is a dentist. And that dentist wanted a CERAC restoration. So they arranged it so the representative would come and bring a CERAC machine. So my father did a couple and the salesperson was at her best.
I mean she was using all the lines, like when my father asked how much it costs she responded, "Well it is free. Yeah because it is going to make you so much money it really won't cost you anything." By the way the real answer is $119,000.
And my father, who I love like crazy, is kind of gullible. Man did he want to get this thing.
And I had to to say, "Hold on there cowboy."
You all know how I feel about CERAC (and it hasn't changed), and if you don't then you are going to have to look some old posts.

So we have never talked about lab stuff really on this blog.
Like other things in my office, I don't look at my lab bill. Here is my thing...I like my lab. I think he is very, very good at what he does. I think he is up to date on all the stuff that goes on in the world of lab stuff. I think he would tell me if there was something I could improve on. I trust him.
Why would I be concerned if he was charging me $185 for a crown or $225? I charge $1150-1250 for a crown. My margin on the crown is not going to be changed if he raises his fees up $5 a unit.
So I don't check it. Also knowing all the things I know from above, I don't want money to get in the way of our great personal and professional relationship. And I think he trusts me. I mean he and his family are patients here.
The only way I would check the bill is to see if he charged me for a remake or something like that. I would never read his bill and say, "Man this guy is really pinching me."
Truthfully, I talked to him about a bill about once a year.

I know I have written some long blogs this week so I am going to end this one and pick it back up on Wednesday.
I want to talk about our choices.
We can keep things the way they are.
We can hire an in-house lab the Stupp way.
We could buy a CERAC machine.
But one thing I thought about was buying a lab. I started thinking...If the CERAC machine costs $119,000, shoot how much would it cost to just buy a laboratory? I can't be that much.
How about going in with a couple of other dentists and purchasing our lab guy's business.
I am not going to say anything else.
All I know is that if I made NBA money, I wouldn't be having any of these problems. Damn.

I want you guys to marinate on this for the next couple of days and then we will talk about it.
If you have something to say now throw in a comment.
If you have an in-house lab, you have to tell us about it.
If you own a lab you, have to tell us about it.

Now you think about that,
Have a great weekend,
john

Albany Marathon

Hey guys,
I hope you are having a good week.
Not bad over here.

First I wanted to tell you that I am sorry about Friday's blog. I posted it and it didn't come to people's email until Monday morning. I know it seems like when we do this it is seamless. It is because we are "professionals". Sometimes we get off our game. We will work harder to provide a product for you that is second to none....blah, blah, blah, we screwed up, it won't happen again.

I want to tell you the story about my marathon this weekend.
I didn't want to tell you about this marathon because of what happened the last time.
I got you all excited about my running a marathon, and then I didn't finish.

Okay here goes.
Ever since my sucking wind at my last marathon I have been training. I have been training harder and keeping myself ready.
I have been looking for a marathon that I could just drive to. There was a marathon in Tampa, which is about 2 hours away, but we had a 50th birthday party the night before and we knew there was going to be wine-o-plenty. So I didn't want to drink the night before, get up at 3am to drive 2 hours, and poop out again.
So I looked at marathonguide.com and looked for a marathon that was close by (driving distance) and was soon. I was ready, and I wanted to do it.
Well, Snickers puts on a marathon in Albany, GA. I looked it up and google said it was 4 hours and 45 minutes away. And it was the next weekend. PERFECT.
I called my wife and asked if she wanted to get away with me. We would take David and leave the bigger kids with my mom.
She was game.
I signed up, and we called my mom and told her it would just be for Saturday night.
She was game.
We called the host hotel, and we were able to get a night stay the night before the marathon.
We booked it.
I went ahead and did the online registration.
Everything was set. We would go to everyone's games on Saturday morning and then drop everyone off and then Hilda, David and I would get in car and go. Like money in the bank.

On Wednesday I went online and looked up what this marathon was all about.
(Before I go on, I need to tell you that I am not someone that is going to go to the Albany marathon website and read all the details. I am assuming that all marathons kind of do things the same.)
So it is Wednesday, and I go to the site and in huge letters and numbers it says, "DAYS TO MARATHON" and it says 2 days, 12 hours and 4 minutes.
I was thinking to myself, "2 days? Hmmm?"
"Holy crap this marathon is on Saturday."
I called up my wife, and we had a good laugh.
It is no wonder we were able to get a room at the host hotel....we got the room on the day after the race.
So all bets are off.
She gets on the phone and gets a hotel room, but this time it is 6 miles away from the start/finish line. No problem.
Mom can't do any kid watching on Friday night so everyone is going to come...ROAD TRIP!!!
So things are still good. It will just be a little less intimate between my wife and I.

After work on Friday, I rush home and we get on the road.
We brought our 8-inch DVD player and the kids are happier than pigs in poop.
We are making pretty good time. It is looking like a 9pm arrival. We stop for dinner, so it pushed us back to 9:45pm.
We get to the hotel, and it is brand new. Awesome. We got a suite. Now when you and I think of suites we think of SWEETS. But apparently Fairfield Inn doesn't do suites like I imagine.
It is just one big room. Well there are six of us in one room. We have our pack-n-play for David.
We asked for a roll away bed for Noah and Madison and Luke get the second double.
Problem is that there is no room for the roll away to fold down. So Noah sleeps on half the bed (we were able to find room to fold one side down, so it was in the shape of an "L".
Perfect, we are still good.
We start to settle (well if you mean the kids and adults are tired and aggravated and yelling at each other).
I have to do some laundry because my cold running outfit (which I only have one because I live in Florida) was dirty. I was going to go to the laundry room and Hilda was going to set up the computer to see about the race from a spectator standpoint.
She comes into the laundry room and drops the bomb on me, "Did you know there is not race day packet pick up? (and yes there was a tone of "you dumbass" on the end of that).
WHAT?!!!
I was like no way.
I am tired. I worked all day. I just drove 5 and a half hours to get here. I am jammed in this room with my awesome wife and my 4 bundles of joy, and now I want to kill someone.
I couldn't believe it.
I went on the website and sure enough on about the fourth page it says at the bottom of the page "no race day packet pick up".
So we email the director thinking someone must be monitoring last minute stuff coming in.
The director emailed me back and it was okay. I just had to pick up my stuff at the start/finish line before the race.
Now remember I told you our hotel is 6 miles from the start line. Well I couldn't take the car and I didn't expect the family to get up at 5:30am to get me to the race that started at 7am.
So I asked the hotel employee to arrange a taxi for me in the morning at about 6:10am. He says the race is literally 5 minutes away.
I wake up and get all my crap together. It is 28 degrees outside. I have on everything I own.
I have three shirts and a sweatshirt, and I am wearing scrubs for my legs.
See, during a cold marathon you over dress and when you get warm you shed clothes.
You throw them on the ground and the community picks them up and gives all the clothes to charity.
I know I am going to be running by myself so the whole week I was getting my ipod shuffle ready.
I walk out to the lobby at 6:05am and asked if they have already called me a taxi. And this new employee had that look on her face. The one that said, "I have no idea what you are talking about."
No problem, don't jump over the counter John. It is not her fault.
She apologized, and said she would take care of it. She pulls out the phone book.
Oh, no you didn't.
Meanwhile, I am watching herds of runners coming out of their rooms and going to the race.
After about 10-15 minutes, I am starting to get anxious. The person behind the counter is not having any luck finding a taxi service that would answer the phone on a Saturday in a small town.
I told myself that the next person who comes down is going to have to give me a ride.
Someone comes down, and I give him my story.
He says, "No problem, you can ride with me."
Turns out the guy is from Great Britain, and he has business in Tallahassee. Nice as can be. We get out to his car and he still doesn't have the steering wheel on the left side of the car thing down.
Or the speed limit is 40 miles an hour and you can probably go faster than 28.
So it is 6:35am, and we are on our way when we get to a point in the drive that is now blocked off.
And he says, "Oh dear". And I say, "Oh sh@###$%^^t".
I ask him if he thinks I should just get out and run for it.
"No way, I will get you there, no problem".
We make a couple of turns and he says, "there is the start/finish line over there."
I ask, "should I make a run for it now."
"No way" he says, "I will get you closer."
Well the dude got me right up to the line, I mean he parked about 15 yards from the line.
I am a nervous wreck by this point. It is 6:50, and I pick up my packet.
I have to put my number on. I have to get rid of some of these clothes. I have get my gloves and hat and ipod on.
I am officially ready to run at 6:58am. I put my ipod in and the f!@#$%^ing thing is not working. I have spent hours on this piece of crap getting all the songs ready and the thing won't turn on. If you don't know the ipod shuffle, it is about the size of a Susanne B. Anthony dollar coin. It only has 4 buttons on it. Play, forward, reverse and up and down volume. There is no display. So I don't know why it isn't working it just isn't. I push every button about a hundreds time and give up on it. I put it in the bag with my wallet and phone and check it in.
I get to the start and
BOOM
the race starts.

I had a great race. I finished in 4 hours and 8 minutes.
I got to see my family quite a few times during the race.
It was an absolutely beautiful day. The race finished, and it was 55 degrees.
At the end of the race I was a mess. I was totally depleted of nutrients and a woman began to walk besides me and asked if I was okay.
And I said, "No"
So she put her hand on the bend of my elbow and my back.
I said, "walk with me a minute."
And she asked me if I wanted to go to the medical tent.
I was totally out of it but said that I thought I would be alright.
My son brought me a peanut butter something, and I ate just a bit of it and I started to come to.
Man was I am mess.

I know this is a long one so I will finish up.
We were able to get a late check out. I was able to shower and we got out of there.
We were home by 6:30pm on Saturday night.

Crazy. I tell you, being married to me must be very exciting. If I would just read the small print things would be so less dramatic.

My kids were screaming, "There is my daddy."
I have no idea what is going on, this is the finish and I don't remember this.
I couldn't get off this chair for a long time.


Have a great Wednesday,
John

Oh and the ipod started working as soon as we got in the car.

38 years old and still a smartass

Well I did it. I bought myself a new car. Brand new (not just new to me). So new, in fact, that the model year and the actual current year are the same 4 numbers. Yep, I got myself a brand new cherry red 2010 Porsche 911 Carrera Turbo convertible. Park it right outside my office (diagonally to take up part of the handicapped space so no one dings the doors) with a sign that says - "Yes, your fillings bought this car!"

Oh yeah, sweet ride. . .couldn't afford the insurance on it though so I have to be careful. Plus, the property taxes are a real hassle so I am joining the Freeman society and they are giving me some license plates to use. It also has been a problem fitting the dog and cats, kids and wife in there at night since I had to sell the house to afford it. On the plus side, it has a kick-ass audio system and the leather seats are great to sleep on. The litter-box smell can be removed easily by dropping the top down and making a couple of laps around the block (at 235 kph - I bought it in Canada, with the exchange rate and kilometer/mile conversion that's like 60, right??).

Well I better get back to packing. How we are going to fit all 5 of us with luggage, skis and snowboards into that car is taking some engineering. You would think for $170,000 they would throw in the trailer hitch but nooooooo, that's extra.

I may or may not blog next Monday from the mountain. Depends on whether the voices feel like yodeling (Riiiiiicolaaaaa).

Have a great day.

ric

My discussion with Dr. Mike Miller.

I was having problem with my Optibond. I have always heard it was the best bonding agent, so I bought it and jumped in with both feet.
I was using it for about 2 years. One day I started to get people coming back with fillings, which I did with Optibond, coming out. Now all of these fillings were class Vs fillings. I am not talking about them coming out in 5 years. No, I am talking about them coming out in 3 months. I stopped using Optibond all together, and I was a bit pissed.
I have been meaning to ask REALITY about this. I finally did and this was the dialogue I had with the President of REALITY Dr. Mike Miller (Don't think I am all that. I wrote and he answered. I knew it was him by the end of our conversation because I remembered his writing style. This isn't my first time posting. They used to sign the posts and that is how I knew it was him). It is a bit long but I (and I think you will) learned a lot from this dialogue. Sorry about the spacing. In my cutting and pasting this is what it did and it wouldn't let me delete spaces.

I hate optibond
Okay I know you guys are smart. And I trust you almost exclusively.
I have been using SE Bond for about 8 years now. But the bond to etch has always been a big question mark to me.
So I looked up the best 4th generation bond and almost always Optibond was the #1 choice.
I bought it.
It was an exciting day. The old dog has learned a new trick.
And it stayed exciting for a long time until the first facial filling came out.
I kept my enthusiasm and redid the facial filling with Optibond AGAIN.
Then my excitement started to really go away when the one filling that fell out turned into a bunch more.
Then more and more and then more. Now I am redoing the fillings that fell out and I redid them with Optibond again.
What is going on?

I called the company they were obviously very surprised.
So the rep and I went over my technique, and it was exactly like the directions.

What gives?
Am I the only one or have you heard of this before.

I appreciate your honestly,
Just let me down easy.
john


I hate optibond

You are correct -- OptiBond FL has been our top-rated bonding agent for many years based on exemplary and extensive testing and clinical results. Before we can comment on why you had these failures, we need additional information. When you state that you “called the company” and the “rep” went over your technique, who was the “rep”? Was this “rep” located at Kerr’s California headquarters?

This is important because Kerr and most other companies have a policy of issuing a call tag for material that may be below their standards. If you talked to a Kerr “rep” and this procedure was not followed, then the “rep” was not doing his/her job. Did the “rep” even ask about the lot # or the expiration date? For our investigation, please give us the lot # and expiration date of the material you used.

Even though OptiBond FL is not very technique-sensitive, we still feel that our step-by-step instructions will help you achieve success. From your account, it appears that you followed Kerr’s directions, not ours. How did your application differ from that which we recommend? Did you shake the bottles before use? Or, if you used the unidose version, did you stir the material before application? How long did you cure it? What light did you use? What composite did you use? These steps/issues may seem trivial, but they can mean the difference between success and failure.

We have requested fresh material from Kerr for retesting purposes. The results will be posted shortly. In the meantime, please answer our questions so we can provide comprehensive solutions to your problems.

I hate optibond
Okay, I will answer all your questions.
Even though I not only think they are trivial I think they are kind of ridiculous.
I mean when some company puts out a product why are there all these stipulations on a product.
Like, "It is only good if you do all these things."
I am not trying to be difficult, but remember that I have used one product for a long time and it was good.
Then I changed to a new product and it is a lot of, "don't forget to store it at this temperature, or make sure you use this composite with it, oh and don't forget to shake it and make sure you are using a certain light and oh don't use the single dose you have to use this one and if you do all this then yes it is the best."
And also, "I hope you didn't get a bad batch."

Okay now that I got all that out of the way.

Now as far as the lot #. When I bought the product I put some in every room. So there is no way of knowing what room the patient came from. So to me, they are all bad. I have been using two sets. Do you want both of them.

I did call a rep and they did want me to send my product back for a new product.
She did not, however, ask me for a lot #. I do not remember if she asked me for the expiration date.
She seemed to be very knowledgeable.
But I didn't want to send it back because why would I want more of the product that doesn't work in my hands. I don't care if it is a brand new bottle or an old one. If my fillings are going to fall out I don't want a new batch. So I didn't send anything back.
I don't think we shake the bottle. And in talking to Kerr's rep she never mentioned this.
As far as the material, I was using the three step Optibond FL.
I have the DEMI light, and we cure for about 10 seconds and for deeper ones we do 20.
My composite of choice is Filtek Supreme.
I try to use all the finest products, and I pride myself on excellent work and when people are coming back with my fillings falling out, it is not only embarrassing but it is unacceptable.

I appreciate you helping me. I am sorry if I sound pompous, I don't mean to.
It is just this is my livelihood, and when doubt seeps into you patients they will just go on down the road.


While it is understandable that you are frustrated – we all need to face the music when something or somethings go wrong during patient treatment – the questions are pertinent and relevant, not trivial or ridiculous as you proclaimed them to be. All you have to do is spend a morning at a lab bench to realize how important it is to do procedures such as shaking the bottle or blotting rather than drying with air.

As mentioned previously, while OptiBond FL is not particularly technique-sensitive, it is not immune to application changes. As a matter of fact, NO bonding agent is immune. In your original post, you mentioned you have been using “SE Bond”, which we assume is Clearfil SE Bond, another really terrific bonding agent and one which is also not particularly technique-sensitive. On the other hand, if you aggressively thin out the bond resin with this product, its performance will suffer. Temperature storage is also a MAJOR factor with some products as is adequately curing it. We have always stated that details matter. Ignore them and you risk failure.

However, this doesn’t mean you necessarily did anything wrong. In asking you for info such as lot #s, manufacturers can check them against samples they retain to see if something has slipped past their quality control (QC) folks. It would be nice if every batch of every product was perfect, but whether it is a dental bonding agent or a car (Toyota), we live in an imperfect world and stuff happens.

Same thing applies when we test a product. If our results don’t jive with those claimed by the manufacturer, the first thing we do is ask for additional samples from another batch, which connotes a different lot #. This is not arcane science – it is the usual and customary way of trying to solve a problem.

We are on your side and feel your pain. That’s why our mission statement is “Protecting patients by informing dentists.” No dentist wants to redo his/her works of art, especially if the failure were caused by something out of his/her control such as a bad batch of bonding agent, which is not readily apparent during the application procedure.

But until due diligence is done, it is important not to jump to conclusions. It is important to know the lot # or #s of the batch(es) you were using. Ultimately, if a bad batch is discovered, a recall may be necessary. Alternatively, you can send the questionable OptiBond FL to us and we can perform the tests alongside the material being provided by Kerr.

Re:I hate optibond
First and foremost I want to say thank you for your time and talking to me.
Second I would like to say I am sorry for the title of this thread. It should be "I am frustrated with Optibond"

Okay in response to your last response,
You said, "All you have to do is spend a morning at a lab bench...." I would love to do that, and if you are inviting me to come to Kerr research center I am 100% game. I have always been intrigued by the process.

I get the whole quality control thing and the imperfect world thing, but what I don't get is if you have to shake a bottle for maximum effectiveness why doesn't it say, "SHAKE BEFORE USING" on the bottle.
Or "NOT SHAKING BOTTLE COULD RESULT IN FAILURES."
Or if you have to store it at a certain temp other than room temp then it should indicate.
Now we are not talking about the filling failing in 10 years instead of 12 years. We are talking about complete failure of a product in less than 4 months. So if shaking is necessary....say it.

Like you said most products have an application change well then it should be in bold letter somewhere.
Like why do I have to talk to you guys about an application change in a product. Why am I not reading it somewhere?
Why do I have to have tons of failures before I find out I am suppose to do something different and simple like shake the bottle.

Lot numbers....
Primers......
3225780
3191986
3191986
Bond....
3225780

And I am happy to do due diligence, and I would be happy to go over my technique with you as well.
I want to use a 4th generation bonding agent, and I want to use the best one.

I hate optibond
Actually, the note about sitting down at the lab bench was from us at REALITY, not Kerr. We have seriously considered holding small study-club-like group sessions in our research lab for those who are interested in really learning about all the details we publish. Not just bond strength of adhesives, but seeing for yourself what happens, for example, when you don't cure a composite long enough. Based on your comments, we'll put the plan into action sooner than later. Look for something in our e-newsletter shortly.

As far as the shaking the bottle issue, we cover this subject explicitly in the bonding agent introduction in The Ratings. This is what the section states: "Many bonding agents suffer from phase separations of their components in bottles and unidose vessels. This means that most bottles should be shaken before dispensing and the contents of unidose vessels should be stirred before applying to the preparation. Some bottles even have a small ball inside to act as a shaker to help mix the components. When in doubt, shake or stir." You are correct that manufacturers should also have this type of instruction in their directions for use, but the reason you are a REALITY member is hopefully to read our stuff and overcome the errors of omission and commission by manufacturers.

We have tried for almost 24 years to get manufacturers to write better directions, but we are fighting a losing battle. It is industry-wide and not likely to change any time soon.

We will forward to Kerr the lot #s you provided, and we will report on the outcome of our new tests shortly.

Re:I hate optibond
About the study-club-like research lab CE....sign me up. I would love to be part of the first class (this would be the maiden voyage. Totally free. Yeah everyone would be picked up in the REALITY private jet and treated to a weekend to the nines. Champagne and caviar, yeah I will be a part of that.)
In you last post you talk about generalities when it comes to bonding agents. Let's talk about Optibond specifically. It is in three individual bottles, does it need to be shaken.
Are there any other specific instructions that pertain to Optibond.
I got to tell you this is frustrating stuff and can't imagine how frustrated you guys must be.
John

Re:I hate optibond
We are very proud that our REALITY members have a terrific imagination, especially when it comes to "free" stuff! It's kinda like treating a relative for free -- you get what you pay for!

OptiBond FL actually comes in TWO bottles or unidose, not three. If you have three, that could be the problem! And yes, the bottles need to be shaken and the unidose need to be stirred.


I hate optibond
Okay okay so my Optibond only has two bottles. I got confused because I had nine bottles on my desk trying to give you all the lot #'s.
I am going to give it another try...this time shaking it.
I will let you know.

And I would still come to the CE class even if there was no REALITY jet involved.

I hate optibond
Don't use it until we can retest it. There may be something else wrong with it other than your not shaking the bottle. That's just one piece of the puzzle. We should receive our shipment of fresh OptiBond today as promised by Kerr. Let us check it out before you try it again.

I hate optibond
I want to say that Optibond has been the #1 4th generation bonding agent for as long as I can remember.
Why are you making me wait?
Do you think you are going to get a new batch of this product and something drastically going to change? Have they changed the product?
And you mentioned that shaking is not the only piece to this puzzle. Well what are the other pieces (that you know that Kerr won't tell me)?

Now I am starting to think that the REALITY CE bench top course should be sponsored by Kerr.
Yeah and we can fly on the Kerr jet (I bet it is a lot nicer than the REALITY jet).

If this is Dr. Miller, I know you are a big runner. I am leaving for Albany GA tomorrow for the Snickers Marathon on Saturday. It is suppose to be a fast and scenic marathon. Lows in high 40's and high in the lower 60's

I hate optibond
The reason we want to test OptiBond FL again is to be sure nothing has changed other than the addition of ytterbium to make it more radiopaque. We were just told about this tweak by Kerr since this thread started. The addition of ytterbium should not change the performance of the product, but that is an unknown until it is tested. Even if ytterbium were not added, we would still test the product due to your untoward experience. This is what we do when we find out something may be happening with a product. As we stated previously, this may be a QC issue.

The other pieces of the puzzle relate to items such as whether the raw materials purchased by Kerr to manufacture the product may have been changed by their suppliers. You just never know. This kind of stuff happens frequently, but usually it does not affect a product's performance.

Good luck in the marathon. Your performance could depend on your level of hydration, carb loading, wind resistance, etc. More pieces to the puzzle......

I am telling you the guys at REALITY are unbelievable. I give them my fullest recommendation. They are advocates for the general dentists. Kind of like the AGD (shameless plug). I hope you learned a lot and are kind of outraged at the way companies get away with stuff. I sure am.


Have a great weekend, john


PS. I am going to tell you something that I am very embarrassed about.
When I was checking the Lot #'s on the bottles I found something else on the bottles.
The expiration date. Two of the 6 bottles were over the expiration date. I then went and chastised my assistants. We then went through all our stuff to make sure it is all fresh.
It all was.
It is all about checks and balances and apparently our checks and balances didn't cut the mustard.

Porsche 911 Carrera Turbo Convertible

Hey all,

Hope you all had a good weekend and are having a good week.
I am kind of in a bad mood. My Gators are in the tourney but getting very close to the bubble.
They have had a grind it out kind of season. We have won or lost about 10 games by 5 or less points. I know you hate me talking about the Gators, and I have tried to talk less, but I felt like I had to tell you. I mean if it reflects in my writing you need to know.

Well last night they lost another tough one. We lost to an under .500 team this weekend, and we lost to a top 25 team last night by a total of 6 points.
And oh yeah I forgot to tell you, we play Kentucky this weekend. If you haven't been watching, Kentucky was ranked #1 last week and lost and now they are #4.
I am thinking another loss.

I watched a couple of movies last week.
I watched Star Trek. I am not a Trekkie or anything, and I haven't watched anything to do with Star Trek in a long time. But the movie was pretty good.
I watched Rudy again, and it is still awesome.

Okay I will get right to the subject.
Oh before I forget....I don't think we are done talking about Septocaine. We have had some good comments on the subject. I don't want to beat a dead horse, but I don't want to leave a stone unturned.
We are going to have our dental student give us a post soon, so we can see how he/she is doing.
And lastly, I have had some issues with Optibond FL. Everyone says it is great and my facial fillings that I did with Optibond FL are all coming out. I wrote to REALITY and this guy wrote me back. I think I might be talking to a big wig at Kerr. I didn't say very nice things, and he is defending and not trying to chew me out at the same time.
When I am done with this discussion I will post it.

The other day I am doing my thing at work. And I see a long lost patient coming out of hygiene.
I go over and give him a man hug, and we exchange pleasantries. He says, "you got a second." I say, "Sure."
"You have to come outside and see my new car. I just got it yesterday."
Now I am not into cars, but I can appreciate the feeling someone gets when they get a new car.
I often go out in the parking lot and see people's cars. We have an office that the face of it looks out to our parking lot and this wall of the office is all glass.
So I am looking at the types of cars that are out there. I often will ask people if that is their car.
And I will say, "Wow, that is a really nice car." And they might say, "Do you want to see it."
And I will always say yes.
Sometimes I have gotten in the car with people and driven around the neighborhood.

So nothing was different when I went out to see this guy's new car. Well when I went out there, and his new car was a fresh, off the lot, 2010 Porsche 911 Carrera Turbo Convertible.
Now I was not that impressed, but I asked him how much it costs. Just so you know I was $40,000 off.
Now this is where I want you to guess. Go ahead and guess how much it costs and then click this link and it will tell you how much (bottom right hand corner and before I forget he paid $17,000 more than MSRP for extra's and tax.)
http://www.porsche.com/usa/models/911/911-turbo-cabriolet/

Now, usually this stuff doesn't bother me. But I think this one did.
I recognize some of you might have nice cars. I don't have a problem with nice cars (maybe I do and some of the reason is because I can't or don't have one. I don't think for me and where I am at right now that having a nice car is a smart move for me).
I don't fault any of you for having nice cars. I think Infinities are very nice, I like Lexus', Mercedes and the like.
I don't have a problem with spending money on luxury.
I don't know why I was so bothered.

I think a bunch of reasons....
I think first and foremost the price is what bothered me the most. $160,000. Oh my gosh.
There are so many things wrong with this.
I don't know, I live in a world where I am struggling paying tuition for my kid's education. I live in a world where my patients struggle to find money sometimes to pay for a filling.
I live in a world that has people in it that will wait in a cold parking lot over night to get a $100 filling for free.
I live in a world that my wife hit the garage with the side of her minivan and that dent is still there.
I work with 9 good people that work hard and live pay check to pay check like most of the rest of us. I know their stories, and it is not champagne and caviar.
This guy is not living in my world. This guy and I don't even live on the same stratosphere.
I am thinking he doesn't live in the same world as many people.
I started to think to myself, "why did he want me to see this car?"
I can't even relate.
I am driving a 9 -year-old Ford F150 truck for crying out loud.

Could I afford a nice car? I guess I could. I think it is choice my wife and I make.
Every time I write my tithe check I am making a decision.

When I talk to people that are jealous like me, "I don't even like that car. I mean it only fits two people. It is not even a practical car. You can't even put a set of golf clubs in that car."

When I am running with my running group, who I think have money, we talk about cars. But I think it is a healthy talk. I think most of them can drive nice cars, but keep it into perspective.
As much as we appreciate the look of a nice car we also talk about the money. The depreciation of the money.
When I talked to my church group it is easy to sit back and talk about how we could build a couple of churches with that money. Or say something like, "I feel sorry for that guy he is worshiping the wrong god. He has a god and it is his car."

I don't know where I really stand. I think it is all of them.
I think I am a bit jealous (but not that much). I think I am a bit too money conscience and a bit to practical to by something like that. And I think I do feel a bit sorry for him because I do think it does become people's god.

I mean how much money do you have to have in your bank account to afford a $160,000 car.
How does the negotiations sound like, "I know the sticker says $168,000 but I am not going a penny over $160,000."
"Well then I am going to have to go talk to my manager."
"Let him know that if you don't match my price I am walking."

I don't know, I am I alone in this?
Do we all aspire to have a nice car?
Go ahead and tell me...it is anonymous.
I would like to know what you drive and your thought process behind your decision.
Do you like fast cars? Were you going through a mid-life crisis (which is okay because I am almost there)?
Do you love your car and can't wait to get another one?
Did you buy an expensive car and hate it?

I have to be honest, I don't ever think I am going to have a nice car. I think even when I am free from all my house debt and my office debt I will then move to other obligations.
Maybe I will work less. Maybe I will pay for my grandkid's tuition. Maybe I will start a college fund for them.
Maybe I will start a dental clinic. But I sure won't spend it on a car regardless of how awesome it is, at least I don't think.

See I told you I was in a mood. Those stupid Gators.
Have a great rest of the week.
John

Anesthesia & Legal Issues

This is as close to a diary as I have ever had. Mrs. Hill would tell you that even in High School I wasn't good at keeping the required "journal" for English class.

That said, I have nothing on my mind today that the voices are telling me to share, so I am simply sitting here while waiting on a patient to get numb and writing what comes to mind - stream '0 consciousness-like.

I used Lidocaine on the patient I am waiting on. That is remarkable only in that I switched back from using Septocaine about 2 weeks ago after rereading Dr. G's blog posts from last year. I know the whole debate and have ignored it for the past couple of years because Septocaine works so unbelievably well on blocks but, finally, took the scary stories to heart and changed.

Since changing, I have had to reinject about every 4th patient. I don't care what the studies may show. With Septocaine I may have had to reinject every 30th patient, and then it was most likely due to me being in a hurry and trying to start the procedure to soon after injecting. With Lidocaine, I'll wait 10 minutes go in, start drilling and the patient will jump and I have to reinject. Sure, they won't have permanent numbness, but it takes 10 more minutes of my time and an additional $3 carpule of Lido (please read sarcasm here). I miss my Septocaine, but I will not go back to it for blocks until I get the all clear from the researchers.


And since we are talking about anesthesia, anyone using that reversal agent? I initially laughed at the idea, but now am thinking it could be a great service to offer my businessmen/women clients who have early morning appointments - they can get back to work without numbness. If I did that, though, I'm thinking I should charge for the reversal. The CDT codes state that anesthesia is included in the procedure code but nothing is said about reversal agents.


Anyone doing this? Do you charge? How effective is it really?

Final thought before I go back and see how ineffective the Lidocaine was on this patient - I am speaking to the Mississippi AGD/ADA in 2 weeks on malpractice issues in the dental practice. Now, after you get over your shock at people being gullible enough to invite me to speak at a Continuing Education meeting, I am soliciting your help. Since I am an attorney I tend to overlook some basic legal issues that non-attorneys may want to learn about. Anything that you would like to hear more about as a practicing dentist in regard to malpractice/legal issues? If we get some good questions/responses I will blog the answers in future posts.


And if you are from Mississippi and are going to the meeting (and happen to have internet access/indoor plumbing/literacy - so joking, I married a woman from Arkansas to grant them some genetic diversity) any topics you want me to talk about in particular?


That's it for now, the voices want to argue about what direction to stressout today. Plus I need to go see if this patient is numb.


Have a great day!


ric