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欢迎收听《牙髓之声》，本节目由美国牙髓病学协会为您呈现。
Welcome to Endo Voices brought to you by the American Association of Endodontists.
在这个节目中，我们推动牙髓病学艺术与科学的发展，并与当今顶尖专家一起，促进最高标准的患者护理。
The show where we are advancing the art and science of endodontics and promoting the highest standards of patient care with today's top experts in the field.
现在，有请我们的主持人，医生。
Now, here's your host, Doctor.
马库斯·D.
Marcus D.
约翰逊。
Johnson.
非常感谢。
Thank you so much.
欢迎回到《牙髓之声》的又一期节目，今天我们为您准备了一场传奇性的对话。
Welcome back to another episode of Endo Voices, and we have a legendary conversation for you.
我们有请医生。
We have Doctor.
迪恩·瓦菲亚迪斯医生，他是纽约大学全口修复项目的主任，已经执教超过三十年，在修复学领域有着丰富的指导经验，真正提升了整个行业的水准。
Dean Vafiadis, who is the director of the Full Mouth Rehab Program at NYU and has been teaching for over thirty years, has a legacy of mentoring and just really elevating the profession from a prosthodontic standpoint.
所以，医生。
So Doctor.
迪恩，欢迎。
Dean, welcome.
今天能请你来真是太好了。
It is really just great to have you on today.
非常感谢你抽出时间。
Thanks so much for the time.
谢谢你，医生。
Thank you, Doctor.
马库斯，谢谢你让我们做这个。
Marcus, for letting us do this.
我一直很喜欢和同行们分享信息。
I always enjoy sharing information with our colleagues.
再说，如果我们能帮到一两位医生，或者几位病人，我觉得我们就尽到责任了。
And again, if we could help one or two doctors, a couple of patients, I think we did our service.
我确实觉得，这正是我们相似的地方——我们总是充满热情和动力，追求卓越，无论是在病人护理、教育方面，还是你的名声，大家都知道你一直在突破极限。
And I would definitely say, think that's kind of where we are alike in that we always have a passion and a motivation to just strive for excellence, whether it's with our patient care, with our education, and your reputation definitely precedes you as someone who's always pushing the limits.
我想我们聊到了技术，还有扫描仪，以及你如何发展和塑造你的诊所，并且真正指导了这么多年轻牙医，这真的很鼓舞人心。
I guess we talked about technology and just scanners and the way that you've grown and shaped your practice and really have mentored so many young dentists, it's really inspirational.
所以，恭喜你。
So congrats to you on that.
我们真的想聊聊全口重建，我想在牙科范围内，但牙髓治疗如何融入其中，你知道，在整个计划里？
We really just want to kind of have a conversation about full mouth rehab and I guess within the scope of dentistry, but also how does endodontics fit into that, you know, into the whole plan?
所以，如果你能先简单介绍一下自己的背景，然后概述一下全口重建以及牙髓治疗在其中的作用，那就太好了。
And so if you can just maybe give us a little bit of background about yourself and then kind of overview of full mouth rehabilitation and endodontics within the scope of that, that would be fantastic.
谢谢你，马库斯。
Thank you, Marcus.
嗯，我们在1991年，在我完成修复学项目之后，开始了我们的诊所。
Well, we started our practice, you know, 1991 after I finished the prosta program.
就是去不同的诊所，学学手艺。
And it was, you know, kind of going to different offices, learning the trade.
然后我就自己开了诊所。
And I started my own practice.
刚开始也就一个病人。
I kind of had one patient.
我就给他做了个洁牙。
I did a cleaning.
你知道，起步总是很慢的。
You know, you start off really slow.
我……
I...
但在修复科，我学到的一点就是跟专科医生合作。
But one thing I was taught in prost, though, is working with our specialists.
这在我的职业生涯里一直非常重要。
It's always been a very important part of my career.
而且，你知道，没有……
And, you know, without...
我称之为团队。
I call it the team.
这是我的牙周、牙髓、口腔外科、正畸医生的梦幻团队。
It's the dream team of my perio, my endo, my oral surgery, my ortho.
但现在我们有像杰伊·纽豪斯这样的睡眠呼吸暂停专家。
But now we have sleep apnea specialists like Jay Newhouse.
我们还有一位颞下颌关节专家。
We have a TMJ specialist.
我们终于找到了一位非常出色的颞下颌关节医生，他真的能帮助患者好转。
We finally found a phenomenal TMJ doctor that actually helps the patients get better.
都三十年了，我终于找到了这样一位医生。
It's been thirty years and I finally found one.
他的名字是医生。
His name is Doctor.
彼得·法拉格。
Peter Farrag.
他在我们诊所。
He's in our office.
如果有人需要真正好的颞下颌关节专家，能真正帮人好转的，就是这个人。
If anybody needs a real good TMJ person that actually helps people get better, that's the guy.
所以我找到了那个专家梦之队。
So I found that dream team of specialists.
而且，听着，我们昨天没法干活。
And listen, we can't do our work yesterday.
又发生了。
It just happened again.
我们有全口重建的患者。
We have full mouth rehabilitation patients.
他们是残疾的。
They're disabled.
我们制定了一个治疗计划。
We put together a treatment plan.
这个治疗计划的一部分包括病历记录和诊断。
And part of that treatment plan includes the records, the diagnostics.
每个人都要做CBCT扫描。
Everybody gets a CBCT scan.
每个人都要拍X光片和数码照片。
Everybody gets x rays and digital photographs.
有了这些，我们现在就利用这些信息。
So with that, we now take that information.
我们把它交给我们的牙髓病专家。
We give it to our endodontist.
我们把它交给我们的外科医生。
We give it to our surgeon.
我们把它交给牙周病专家。
We give it to the peri-.
每个人拿到的信息都是一样的。
Everybody's got the same kind of information.
然后我们打电话会诊的时候，就会说，好，我先从临时牙开始，确定垂直距离。
And then when we get on that phone to do the consult, we'll say, okay, I'm going to start with provisionals first, setting up the vertical dimension.
我周五需要做完根管治疗。
I need the endo done on Friday.
我需要你周五做五个根管，因为我们不喜欢浪费时间。
I need you to do five endos on Friday because we don't like to waste time.
我不会让病人跑十趟来做六个根管。
I'm not going to have the patient sitting there 10 visits to do, you know, six endos.
我希望我的牙髓科医生一个人坐在那里，放松地，一口气做完三四个根管，一次搞定，不管牙髓是活的还是死的，这样效果真的很好。
I want my endodontist to sit there alone, relaxed, bang out the three or four endos, you know, one visit endodontics, which really works well, whether they're vital or non vital.
当然，如果有大感染的话，可能会多花点时间，也许需要第二次就诊。
Obviously, if there's a big infection, you know, it'll take a little bit, maybe a second visit.
但我希望我们的团队高效工作。
But I want our team to work efficiently.
你说，你是想给病人打六次麻药，还是一次搞定，全部做完？
You know, would you rather numb up the patient six times or do it once and just get it all done?
尤其是下前牙，磨损得那么厉害，全都磨平了。
Especially in the lower anteriors where they wore their teeth down so much, they're all flattened out.
我需要先做根管治疗，这样我才能打桩，开始堆核来抬高垂直距离。
And I need the endo done so I could put my posts in and I could start building up the cord to raise the vertical.
这些不是普通的烂牙，不是随便做个根管就行，这是针对FMR类型患者的不同工作流程。
These are same shit, not just a blown out tooth that you're just doing an endo because a different type of workflow for the FMR type of patient.
你知道吗，我真的很喜欢这个。
You know, I really like that.
听起来你确实有一个高效运转的多专科诊所。
It sounds to me like you really have a high functioning multi specialty practice.
那我们聊到这个，你觉得根管治疗的治疗计划应该在哪里制定？
And so when we talk about that, where do you kind of feel that the treatment planning for endodontics should take place?
我很喜欢你提到扫描仪。
And I love that you're talking about scanners.
每个病人都要扫描。
Every patient gets scanned.
你知道，我也用CBCT。
You know, I use a CBCT as well.
我们发现，有了现代技术，这真的是更好的诊断工具。
And we find that with modern technology, it's just a better diagnostic tool.
而且从全口重建的角度来看，这让我们大家能更好地沟通。
And obviously from a full mouth rehab standpoint, just allows, I guess, all of us to communicate better.
就像你说的，从这些数字技术中获得的信息才是最重要的。
Like you said, it's the information that we gain from this digital technology that's so important.
对，我说过，根管治疗是我们团队的重要部分。
Yeah, well, I said, endo, it's a big part of our team.
有时候，我们会遇到不同的情况，比如我们准备好了病例，临时牙也戴上了，然后病人开始觉得敏感。
Sometimes we'll, you know, different scenario whereas where we'll prep the case, we'll have the provisionals in and then the patient starts getting sensitive.
所以，我们跟病人沟通的方式，其实是一个很大的信息披露。
So then again, and the way that we talk to our patients, it's a big disclosure.
嘿，嘿，我们正在重建你的口腔，就像重建一栋房子一样。
Hey, hey, we're rebuilding your mouth like rebuilding a house.
你肯定会发现有些管道不好使，对吧？
You're going to find some plumbing that doesn't work, right?
你会发现有些东西不工作。
You're find some things that don't work.
我跟你说，如果牙齿敏感了，别不高兴。
I said, don't be upset if you get a sensitive tooth.
如果牙齿动了，也别不高兴。
Don't be upset if a tooth's moving.
我们在这里支持你。
We're here for you.
你告诉我们发生了什么。
You tell us what's going on.
我们准备好之后，你牙齿敏感了。
You got a sensitive tooth after we prepared.
我们正在做根管治疗。
We're getting the endo done.
我们的诊断治疗计划里有一部分提到，可能会有两到三个问题，我们会和牙髓病医生一起看这个病例。
There's a little part of our diagnostic treatment plan that said, There may be two or three, and we look at the case together with the endodontist.
大多数时候不是牙周脓肿。
Most of the time it's not a PAP.
大多数时候是牙根裂了或者牙齿磨损了。
Most of the time it's a sort of a cracked root or a tooth that's worn down.
我会跟我的牙髓病医生说，嘿，你觉得那个牙齿需要做根管吗？
And I'll say to my endo guy, I'll say, listen, do you think that one's going go in there?
因为我得准备它。
Because I got to prepare it.
我觉得，对，我们提前做吧。
I think, yeah, let's do that preemptively.
我们跟病人说没问题，我们会做这些，因为我们知道会敏感。
We have no problem talking to the patient saying, look, we're going to do these things because we know it's going to be sensitive.
所以我们为什么要让你受这个罪呢？
So why are we going to put you through pain?
干脆一次性搞定，这样我们在做病例的时候，就不会一会儿冒出一颗牙有问题，一会儿又冒出一颗，耽误进度，我管这叫让病例脱轨，对吧？
Let's just get it done so that we know when we're doing our case, we're not popping up a tooth and popping up another tooth and delaying the case and kind of, I call it derailing the case, right?
我们本来有计划，按计划走，有治疗顺序，按这个流程来，结果突然两颗牙变得敏感，整个病例就脱轨了。
We have a plan, we're going through the plan, we have our sequence of treatment, we're following this course, and all of a sudden two teeth become sensitive and you're derailing the whole case.
有时候这甚至会变成一个问题，连牙髓专科医生都头疼。
And sometimes it becomes a problem, even for the endodontist.
他那边临时牙都戴上了，我们准备收尾了。
He's got temps in, we're ready to finish.
然后我说，我的牙冠都准备好了。
And I go, have my castings ready.
他却说，这颗牙你没法完成。
He's like, you can't finish this tooth.
我们还不确定能不能保住它。
We don't know if we're going save it.
然后这就变成了那种糟糕的情况，哎呀，我们真的
And now it becomes this bad kind of like, oh no, we really
有点
kind of
得等着看能不能保住这颗牙，然后改变治疗方案。
wait now to see if we can save the tooth and change the case.
所以经过三十多年犯下所有这些错误，现在我们就会说，好吧，你至少需要五次根管治疗，准备好钱，你知道的，一万块用于根管治疗，我们提前为他们准备好，这样他们就不会感到意外。
So over thirty years of making all these mistakes, now we're like, okay, you're going to need at least five endos, put aside money, you know, 10,000 for endo, and we have that ready for them so that they're not kind of surprised.
所以有很多的告知。
So a lot of disclosure.
在治疗过程中，你需要做四到五次根管治疗。
You will need four or five endos during this treatment.
我们从一开始就告知这一点。
We're disclosing that from the beginning.
不是那种，哦，我们不知道会发生什么。
It's not like, Oh, we didn't know what's going to happen.
医生，发生了什么？
What happened, doc?
这是怎么发生的？
How did this happen?
这不是意外。
It's not a surprise.
这是非常非常精心计算的……
It's a very, very calculated...
而这来自于经验。
And that comes from just from experience.
你知道，和我的牙髓科医生、牙周科医生、外科医生、正畸科医生一起做治疗计划，有时会开始移动牙齿。
You know, treatment planning with my endodontist, my periodontist, a surgeon, orthodontist sometimes will start moving teeth.
你开始移动牙齿，现在就有了牙髓问题。
You start moving teeth, now you got an endo problem.
没错。
That's right.
对。
That's right.
根管治疗。
Endo.
这就成了一个因素。
That becomes a factor.
所以走过这条路这么多次，我知道看X光片、看根管、看病人、看咬合，好吧，你知道的，咱们马上做这些根管治疗，赶紧把它搞定。
So being down the path so many times, I know looking at an x-ray, looking at a tube, looking at the patient, looking at the bite, all right, you know what, let's do these endos right away and just get it out of the way.
然后我们就知道可以继续推进我们的病例了。
And then we know we can kind of go with our case.
不，我觉得那太棒了。
No, I think that's fantastic.
而且就像他们说的，预防胜于治疗。
And like they say, an ounce of prevention is worth a pound of cure.
所以有了这个，你知道的，提前告知，我猜你做了很多修复前的根管治疗，听起来甚至有些，你知道的，你让病人知道，嘿，根管治疗可能就在眼前了。
And so with that, you know, upfront disclosure, I guess you're doing a lot of pre restorative endo, sounds like even some, you know, you're letting the patient know that, hey, endo is probably on the horizon.
当你进行这些对话时，我知道你用了很多技术。
And when you have those conversations, I know you use a lot of technology.
像CEREC这样的技术在哪里发挥作用呢？
Where does technology like CEREC come in?
因为如果你做当天完成的修复，牙齿现在开始有症状了。
Because if you're doing same day fittings, now the tooth becomes symptomatic.
你知道，我们到底是怎么处理这些情况的？
You know, how are we really managing those situations?
所以，一次就诊做根管治疗，我们先稍微聊聊单颗牙的修复。
So one visit, Endo, let's divert to single unit dentistry for a second.
好的。
Okay.
我们在2004年就有了CEREC。
We had CEREC in 2004.
好的。
Okay.
我是第一个用CEREC的。
I was the first CEREC
早期使用者。
Early adopter.
在纽约市。
In New York City.
他们把我当靶子。
They had a target on my back.
他们觉得我疯了。
They thought I was crazy.
他们说，你不能这么干牙科。
They said you can't be doing this dentistry.
这是糟糕的牙科。
It's bad dentistry.
我说，如果牙医不是好牙医，机器再好也没用。
I said, if dentist is not a good dentist, the machine is no good.
但如果你有一个好牙医，配上好的技术，那真的是前途无量。
Said, but if you can have a good dentist with great technology, the sky's the limit.
我是说，我们用CEREC做单颗前牙的修复。
I mean, we were making single unit centrals with CEREC.
那技术真的很棒。
Was an awesome technology.
所以如果你把它应用到普通牙科诊所里，牙医在制作牙冠或嵌体时，如果备牙稍微深了一点，需要垫底，而患者又敏感，那就会变成一个问题。
So if you bring that into the general dental practice situation where a dentist is kind of making a crown or an onlay, and now the preparation becomes a little bit like, you know, it's a little deep and he's got to put a base, the patient's sensitive, you know, that becomes an issue.
所以我觉得回到年轻牙医身上，他们的问题在于不太确定怎么备牙，也不确定那颗牙是否需要根管治疗，而且他们无法提前预判。
So I think also going back to the younger dentists, the problem that they have is they're not really sure how to prep and they're not really sure if that tooth is going to need the endo and they can't preempt that.
然后就会变成，哎呀，我刚做了这个CEREC。
And then it becomes like, oh, geez, I just did this CEREC.
看起来很棒。
It looked amazing.
也很贴合。
It fits.
但现在病人会感到敏感。
But now the patient's sensitive.
所以这涉及到牙齿的管理。
So that's a management of a tooth standpoint.
他们必须学会这一点。
They have to learn that.
我学会了。
I learned it.
你必须知道怎么备牙。
You you have to know how to prep.
这是个问题。
It's an issue.
所以我总是偏向另一边。
So I always error on the other side.
夫人。
Mrs.
琼斯，我现在就停下来。
Jones, I'm going to stop right now.
这有点太深了。
This is a little bit too deep.
我会先放一个临时牙冠，看看你会不会敏感。
I'm going to put a provisional on and we're going see if you're sensitive.
如果你觉得敏感，那可能就得做根管治疗了。
If you're sensitive, we're going to have to have a root canal.
如果你不敏感，我都准备好了。
If you're not sensitive, I have everything ready.
我会把牙冠打印出来。
I'm going to print the crown.
你明天可以过来。
You can come in tomorrow.
你看，这就是退一步说，我不确定。
See that's like backing off saying, I'm not sure.
可能是牙髓问题，也可能不是。
It could be an endo, may not be.
通常来说，概率是一半一半。
And usually it's fiftyfifty.
你知道，一旦你准备好了，一半的病人需要做根管治疗，一半不需要。
You know, once you prepare the two, half the patients eat endo, half the patients don't.
所以我就说，看吧，就是一半一半的机会。
So I say, look, it's a fiftyfifty chance.
我们先临时封上。
Let's just put a temp on it.
我已经为你准备好了CEREC。
I have the CEREC ready for you.
所以如果你不敏感的话，我可以把临时牙拿掉，下周再装上，那就没问题了。
So if you're not sensitive, I can pop off a temp, put it in the next week and we're good.
所以你一开始的想法是，嘿，我们一次就能搞定，但当你看到所有情况后，你退一步，改变你的立场，而不是事后找借口。
So your initial thing is, hey, we're doing this in one visit, but you see everything, you back off, you change your position at that point, not making an excuse afterwards.
我觉得大多数普通牙医的问题，尤其是年轻牙医，他们总是想着，我得做一颗牙，把牙放进去，然后问题就来了。
I think the problem the most general dentists have, especially the young ones, they're in the mode of, I got to make a tooth, put the tooth in, and then they have a problem.
他们不会跳出固有思维，想一想，等一下，这个有点深了。
They're not thinking outside the box, wait a minute, this is a little deep.
她可能会有问题。
She may have a problem.
他们有点那种短视的看法，只把牙齿看作一个独立的东西，而没有把它和病人联系起来。
They kind of have that myopic view of just seeing the tooth as an entity and not attached to the patient.
你知道，我和一些转诊的医生聊过一件事，我总是鼓励他们，对于修复很重的牙齿。
You know, one thing that I've kind of talked with some of my referring docs and I always try to encourage them with the heavily restored tooth.
在牙髓病学里有一种现象，叫做应激性牙髓现象。
There's a phenomenon within endodontics kind of known as like the stress pulp kind of phenomenon.
如果是一颗修复很重的牙齿，会有一些，你知道，会有一些……
And if it's a heavily restored tooth, there's certain, you know, there's gonna be certain...
不同的参数，你可能需要评估。
Different parameters that you'll probably evaluate for.
另外，你还要看影像上的特征。
And then also characteristics you'll look for on the imaging.
牙髓腔变窄，根管看起来有点钙化。
Recessed pulp chamber canals seem to be a little bit more calcified.
你可能会看到牙周膜间隙增宽。
You may see just widening of the PDL.
所以就是……
So just...
在开始备牙之前，提前做个牙髓活力测试、感觉测试，看看牙齿的反应，总没坏处。
It never hurts to get a little pulp vitality testing, some sensibility testing preemptively before you go ahead and start to prep that tooth, just to see how it responds.
还有一个因素，医生。
And another factor, Doctor.
马库斯，另一个因素是患者的年龄。
Marcus, another factor is the age of the patient.
所以确实跟年龄有关。
So that's indeed age.
你知道吗，我经常跟我的医生说，20到30岁，30到40岁，40到50岁，50到60岁。
You know, I always tell my doctors, you got 20 to 30, 30 to 40, 40 to 50, 50 to 60.
你看，这些十年一个阶段，病人二十多岁的时候补了个大洞，现在到了三十多岁。
You know, you got these 10 increments where the patient had a big filling in their 20s and now it's their 30s.
好吧，她还活着。
All right, she's still alive.
她的牙髓活力还不错。
She's still got some good vitality.
那是另一种对冷热敏感的病人。
That's a different type of memory sensitive patient.
现在你遇到一个60岁的病人，带着一个40年的补牙。
Now you get a 60 year old patient with a 40 year old filling.
有继发性牙本质，你把汞合金去掉，牙本质是暗色的，而且很硬。
You you got secondary dentin, you take out the amalgam, it's dark dentin, it's really hard.
那不是需要做根管治疗的病例。
That's not an endo case.
那没问题。
That's going be fine.
所以我觉得看病人的年龄，很多时候，这周就发生过，病人把牙咬裂了，她70岁了。
So I think looking at the age of the patient, a lot of times, it happened this week, where the patient cracked the tooth, she's 70 years old.
我看不到牙髓腔。
I can't see the pulp chamber.
现在我面临一个难题。
Now I got a dilemma.
我该把病人转给牙髓科医生，让他去跟钙化的根管硬碰硬，那真是件痛苦的事吗？
Do I send to the endo and him try to battle through a calcified root, which is a miserable thing?
顺便说一句，各位，如果你是普通牙医，你把病人转给牙髓科医生，你看不到牙髓，他也看不到，她也看不到。
By the way, ladies and gentlemen, if you're a general dentist and you're sending it to the endodontist and you can't see the pulp, he can't see it or she can't see it either.
所以他们没有什么神奇的工具。
So they don't have magic tools.
提醒一下。
Flash alert.
我都70岁了。
I'm 70 years old.
你看不见。
You don't see it.
它根本不在那儿。
It ain't there.
所以我不会把那个病人转给牙髓科医生，这有点奇怪，因为我们还得在里面打桩。
So I'm not going to go ahead and send that patient to endo, which is kind of weird because we need to make a post in there.
所以我自己来，自己花时间。
So I go myself, take time for yourself.
反正病人现在也在你手上。
You have the patient now anyway.
我自己进去，试着找根管。
I go in there and I try to find the canal myself.
这事儿就发生在昨天，我是说，几天前，我找不到，找不到，就是找不到。
And it happened yesterday, I mean, days ago and I couldn't find it, I couldn't find it, couldn't.
我一直在找，最后终于找到了。
I kept going and then I found it.
我说，Kim，我找到了。
I said, Kim, I found it.
她就说，那是什么意思？
She's like, what does that mean?
可以把你转给牙髓科。
Can send you through the endo.
有时候你得跳出常规思维。
It's like sometimes you got to think outside the box.
你不能直接把病人转给牙髓科，然后他们跟钙化较劲，病人还付了根管治疗的钱，结果没做成。
You can't just send the people endo and then there's fighting with the calcification and the patient's paying for a root canal that they didn't get.
然后又回到你的诊所，大家都问，这颗牙怎么办？
And it's back to your office and everybody's kind of like, what do we do to the tooth?
哦，那就拔了种个种植牙吧。
Oh, let's take it out for an implant.
不，她都70岁了。
No, she's 70 years old.
牙根有25毫米长。
It's a 25 millimeter root.
我不会拔掉它的。
I'm not taking it out.
我们要保住这颗牙。
We're saving this tooth.
所以这些都是关键的决策和思考，我们必须真正告诉年轻牙医，因为事情并不总是那么明确，你明白吗？
So these are the critical decisions, critical thinking that we have to really tell our young dentists because it's not always cut and dry, you know?
牙科确实有时候需要临场发挥，你得随机应变。
Dentistry is really, you know, kind of on the fly sometimes you have to adjust.
但我想指出一点。
But I did want to just point out one thing.
我喜欢你凭借经验能够处理那些根管。
I like that you're, you know, with your experience, you're able to navigate those canals.
但现在有了CBCT、显微镜和先进的冲洗技术，那些钙化的病例变得更容易处理了，而且我们也能取得不错的结果。
But now with the CBCT, the microscope advanced irrigation, those calcified cases are becoming a little bit more approachable and, you know, we have favorable outcomes.
所以如果你以后遇到什么顾虑，随时可以找我评估，或者找任何一位牙髓专科医生，你知道吗？
So if you ever do have a concern, you know, I'm always happy to evaluate that or any endodontist, you know what?
我得跟你说，我，我……
I gotta tell you, I I...
我女儿现在在牙科学校读书。
My daughter's in dental school now.
天哪。
Oh my goodness.
她真是……
She's so...
太让人高兴了。
What a joy.
这就像养了个小宝宝一样。
It's it's it's it's like having a baby.
你就像，你对这件事特别明确。
You're like, you're so unambiguous about
我刚生了个小男孩。
I just had a little boy.
我儿子五个月大了。
My my son's five months.
还有别人也像我们一样痴迷。
Somebody else somebody else is obsessed the way we are.
你知道吗？
You know?
这真是太神奇了。
It's such it's such an amazing thing.
我女儿在佛罗里达的NSU，就是Nova大学。
And I go down and she's at NSU Florida Nova.
我每个月都去那边，因为我是修复学的兼职教授。
And I go down every month because I'm an adjunct professor of prosthodontics.
所以我说，我每个月都会去那里教课。
So I said, I'm going to come down there and teach every month.
我走进修复诊所，那里很棒。
I walk into the prosto clinic, it's great.
我走进牙髓诊所，他们有10台显微镜，10台。
I go into the endo clinic, they got 10 microscopes, 10.
哦，是的，高科技。
Oh yeah, high-tech.
10台显微镜。
10 microscopes.
我当时想，终于，学校明白了。
I'm like, finally, the school figured it out.
你懂我的意思吗？
You know what I mean?
看到这些真是太棒了。
It was so great to see.
看到他们的技术这么先进，修复科的技术也进步了，我真的很高兴。
I was so happy to see that, that their technology advanced, the prosto technology advanced.
牙周科现在也在用CBCT。
Perio is using the CBCT.
所以我跟你说，这所学校，Kaltman院长在那边做得非常出色。
So I'm telling you right now, this school, the Dean Kaltman is doing an amazing job down there.
如果谁在考虑让孩子去上学，我强烈告诉你，那真是一所非常棒的牙科学校，我在那里也很享受。
If anybody's thinking about your kids going to school, I'm just going to tell you emphatically, it's a phenomenal dental school down there and I'm loving it being there.
就是告诉你一声。
So just letting you know.
听到这些我太高兴了。
I love hearing that.
而且，说到这个，你知道，尽管有这么多先进技术，牙髓科医生还是有个老难题，那就是牙裂。
And, you know, speaking of which, you know, with all the advanced technology, there's still always kind of the bane of the endodontist, so to speak, and that's the cracked tooth.
所以我特别想了解一下，你们在诊所里是怎么处理牙裂的，因为最近有一篇文章，大概2021年，发表在《纽约时报》上，是一位修复科医生写的。
So I'm really interested to just kind of understand how are you all managing cracked tooth, you know, within your practice, because there was a recent article, I would say, know, within 2021, came out in New York Times and prosthodontist, Doctor.
Tammy Chen在评论疫情以来她看到的牙齿裂开的病例有多少。
Tammy Chen was commenting on how many cracked teeth that she's seen since the pandemic.
这种现象在我的诊所和转诊医生那里也见过，就在整个
This has been a phenomenon that I've seen in my practice, my referring doctors, In just across the
纽约。
New York.
在纽约，我们可能会看到双倍的数量，因为你在挤地铁的时候会想，这是怎么回事？
New York, we're gonna have a probably double amount just due to the fact that you're bracing the subway and you're like, What's going on?
你得保持警惕。
You gotta stay vigilant.
我在纽约压力很大。
I was stressed in New York.
俄克拉荷马的朋友们，你们过得真舒服。
Those of you in Oklahoma, you got it nice.
天哪。
Oh, man.
你知道吗，我有个好朋友，是俄克拉荷马的牙周病专科医生。
You know, I had somebody up, my good buddy, periodontist in Oklahoma.
那你是怎么处理牙裂的？
But So how are you managing the cracked tooth?
当牙齿出现症状时，你总是用牙冠来修复吗？
And are you always restoring those with crowns when they become symptomatic?
你会把那些病人转给牙髓科吗？
Are you referring those to endo?
你在自己的诊所里看到的情况是怎样的？
What are you seeing in your practice?
这个问题提得很好。
So a great point there.
我把牙裂分为三种类型。
I look at it as three types of cracked teeth.
牙裂，还是那个年龄段，20到40岁。
It's a cracked teeth, again, age group 20 to 40.
他们咬下去的时候不疼。
They bite down, they don't have pain.
但松开的时候会疼。
They have pain when they let go.
这是个很重要的诊断点，对吧？
A big diagnosis, right?
不是咬合痛，而是年轻患者松开时疼。
It's not a meeting and it hurts young patient.
让他们咬棉卷，问疼不疼。
And they bite down the cotton roll, they don't have, does that hurt?
他们说‘不疼’，但一松开就‘哎哟’。
They say no, it let go, ow.
所以是松开时的疼痛。
So it's a let go pain.
这说明有压力，而且有轻微裂纹。
That means we have some pressure and we have a minor crack.
对于这类情况，我会先做个临时牙冠，看看症状会不会消失。
On those kinds of cases, I'll put a provisional on and see if that goes away.
我同意。
I agree.
X光片上可能看不出来，CBCT也未必能发现。
You can it on the X-ray, can't see it CBCT.
这就像是最初的那种微小裂纹。
That's like the initial kind of minimal crack.
不一定非得是补过的牙。
It doesn't have to be a filling.
天然牙也可能出现这种情况。
It could be natural teeth.
我在天然牙上也见过。
I've seen it on natural teeth.
以前我以为只有补过的牙才会这样。
Used to think it was only fillings.
我以前也以为只有补牙才会这样。
I used to think it was only.
就是那种范围的情况。
You got that kind of range.
现在你遇到一个病人，有40到60年的老汞合金，颊舌侧壁，咬下去疼，对吧？
Now you got the patient with a 40 to 60 old amalgam, buccolingual wall, bite down pain, right?
你知道它裂了。
You know it's cracked.
在CBCT上，你看到裂纹延伸到牙髓。
On the CBCT, you see the crack endo.
又是继发裂纹，牙髓。
Again, secondary crack, endo.
然后呢，戴上临时牙冠，不疼了。
And then again, crown temporary, no pain.
一切正常。
Everything's okay.
我们要做牙冠。
We're going to make the crown.
然后很明显，你能看到裂纹，就是那种能看到裂纹的情况。
Then obviously you got the crack where you kind of see the crack.
我的意思是，这颗牙保不住了。
I mean, you can't save the tooth.
所以另外两种情况，我觉得有一半是处于中间那个范围。
So the other two are, I think fifty percent of them are in that middle range.
年轻患者中有百分之十到二十，还有百分之十到二十是已经裂了，保不住的。
You got ten, twenty percent of the young patient, you got ten, twenty percent that's cracked, you can't save it.
所以大概有百分之五十到六十的患者，他们的牙齿能感觉到。
So you got about fifty, sixty percent that those teeth, can feel it.
当他们咬下去的时候，感觉有裂纹。
As they're biting down, they have a crack.
在这个类别下面，还有一类是天然牙上已经戴了牙冠的人，对吧？
Now subcategory of that, we have the people that have crowns on natural teeth, right?
那情况就不一样了，因为你真的看不到裂缝。
Now that's a different story because you really can't see the crack.
上面已经戴了牙冠。
You got the crown on there.
这时候就要考虑，这颗牙还能不能保住？
And now it's like, do we save the tooth?
要不要做根管治疗？
Do we go to endo?
还是直接把牙拔掉？
Or do we take the tooth out?
我觉得这种情况比较棘手，因为有修复体在上面，你根本看不到任何问题。
Those are the tougher ones I think when you have a restoration and you can't physically see anything.
还有一种情况，就是已经做过根管治疗、打了桩的牙齿。
Other subcategory is the already endodontically treated teeth with posts.
这些在CBCT扫描上能看到裂缝，那就只能把牙拔掉了。
And those we see on the CBCT scan where they're cracked and we got to take the tooth out.
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对，那些就是没救的。
Yeah, those are the hopeless ones.
你知道吗，我很欣赏你给牙齿机会的做法，就是你提到的第一批，那种释放时有咬合痛的。
You know, I I like the fact that you're giving teeth the chance, you know, the first cohort you kinda mentioned where they have the biting upon release.
我完全支持并提倡全冠修复。
I'm all in support and advocate, you know, full coverage.
而且我们看经典文献，我们刚发了一篇新论文，就是卓越同行那个，Keith Krell，爱荷华的，简直是传奇。
And when we look at classic literature, we just put out a new paper, colleagues for excellence, Keith Krell, who's Iowa, just legend.
他讲牙裂，还有Eric Rivera。
And he talks about cracked teeth, him and Eric Rivera.
大概百分之二十的病例最后需要做根管治疗。
Maybe twenty percent of those will go on to need endo.
所以听到你真的在努力救那些牙，真是太好了。
So nice to hear that you're actually trying to save those teeth.
说到牙裂，咬合关系怎么影响，还有更重要的，材料的选择？
When we talk about cracked teeth, how does occlusion come into play and more so the type of material?
我们用的是那种金属加强的，还是什么E-max之类的？
Are we using, you know, force infused to metal, any sort of Emax?
你一般用什么材料来修复这些牙齿，来帮助抵抗这些力量，以及这些裂纹牙齿上的咬合创伤？
What are you usually restoring these teeth with to help prevent against the forces and the occlusal sort of trauma in these cracked
这问题得分成三部分来回答。
That's like a three part question.
所以……
So...
慢慢来，医生，你可是专家。
Take your time, doc, you're the man.
我们先说第一部分。
Let's go to the first part.
第一部分是，病人咬下来的时候，他们有个填充物或者甚至是个牙冠，然后上面或下面有个东西，有个楔形牙尖，我们叫它磨损过度的牙尖。
The first part is a patient bites down, they have a filling or even a crown, and something on the top or lower, there's a plunger cusp, we call that a cusp that's been worn away over time.
这就是问题的根源。
And that's what's causing the problem.
所以我首先看的是，我告诉我的医生们，先看看周围发生了什么。
So the first thing I look at and I tell my doctors, take a look around what's happening.
然后你有一颗大的第二磨牙，不管是牙冠还是种植体，有时候种植体现在会导致牙齿开裂。
And you got this big second molar, whether it's a crown or an implant, sometimes the implants are cracking the teeth now.
而且你有一个杵状尖。
And you got a plunger cusp.
我说，你必须改变这个环境。
I go, you got to change the environment.
你要做一个新牙冠。
You're going to make a new crown.
在不好的环境里，试着做新填充或新牙冠是没用的。
It's no use trying to make a new filling or a new crown in a bad environment.
所以你要谈咬合。
So you talk about occlusion.
对。
Exactly.
环境不好，东西就会坏。
You got a bad environment breaking something.
你就算做新牙冠，它还是会坏。
You're gonna make a new crown and it's still gonna break it.
你得把上排牙齿调整好，把咬合面弄平，因为时间久了，疲劳和压力会把填充物磨掉，牙齿也会伸长。
You got to change the upper teeth and level everything out because as time goes on, fatigue and stress, they've worn that filling down and that tooth is extruded.
现在有个大牙尖往下压，最后就把牙弄裂了。
Now you got a big cusp going down and then it finally cracks it.
所以对我来说，我得改变环境，把牙尖磨平，做新牙冠。
So to me, I got to change the environment, soften up the cusps, make the new crown.
再说，跟牙医们聊的时候，上周我们刚有大约600位牙医参加，我做了四场不同的讲座。
And again, when you talk to dentists, just did, we had about 600 dentists last week with four different programs that I did.
每次讲座和演示中，我都问了同样的问题。
And I asked the same question in each of the lectures and the presentations.
我问，你们希望自己嘴里有什么？
I said, what do you want in your mouth?
第二磨牙。
Second molar.
有人说用金，有人说用烤瓷，有人说用E-max，有人说用氧化锆。
One guy said gold, one guy said PFM, one guy said emax, one guy said zirconia.
所以我觉得牙医们也会根据自己的经验，非常明确地知道自己想用什么，对吧？
So I think the dentists are also very, very specific to what they wanna do from their experiences, right?
我有用过氧化锆的经验。
I've had experience with zirconia.
我不喜欢它。
I don't like it.
它其实不太贴合。
It doesn't really fit well.
他们说它很坚固，但真的不太贴合。
They say it's strong, but it doesn't really fit well.
所以对我来说，这有点矛盾。
So it's an oxymoron to me.
显然金冠一直很好，但没人想要。
Obviously gold has been great, but nobody wants that.
我们大约百分之七十的病例还是用金冠。
Is still about seventy percent of our cases.
Emax大概占我们病例的百分之三十五。
Emax maybe thirty five percent of our cases.
我们回头看看。
Let's go back.
比如说百分之五十用金冠，百分之三十五用Emax，然后前牙用百分之五十的烤瓷。
Let's say fifty percent, Emax thirty five percent, and then fifty percent philspathic with the anterior teeth.
但我对氧化锆的使用率非常低，因为它贴合不好，粘接效果也差。
But I'm very, very low on the zirconia because it doesn't really fit well and it doesn't bond well.
外面的牙医觉得它很坚固。
The dentists out there think that it's strong.
他们还在用它做粘接。
They're bonding it.
其实并没有真正粘合。
It's not really bonded.
它本质上还是金属。
It's still a metal.
氧化锆的粘接力不强，时间长了会有渗漏，然后导致牙齿开裂或者修复体脱落。
They don't have a good bond strength on the zirconia and they got leakage over time, and then they have cracking of the teeth or dislodgement of this...
就是氧化锆的问题。
Of zirconia.
所以对我来说，它虽然强度高，但贴合度不好。
So to me, it's a strong material, but it doesn't fit.
这可是个十亿美元的生意。
It's a billion dollar business.
大家都在买氧化锆。
Everybody's buying zirconia.
但我没跟风。
I'm not on the train.
抱歉。
Sorry.
所以如果我们说的是氧化锆，我猜你会在备牙时做斜面。
So if we're talking about zirconia, guess you're putting bevels on your preps.
你确实在努力，听起来好像……
You're really trying, it sounds like it's...
是的，确实如此。
Yes, you have.
这是牙医们的另一个大问题。
This is another big problem with dentists.
他们在氧化锆上做肩台。
They have a shoulder on a zirconia.
他们把氧化锆放进去，如果你问任何牙医实话，每个人都会这么说。
They put the zirconia in and if you ask any dentist the truth, everybody said it.
我有一个120人的房间。
I have a room of 120 people.
我问他们，你们的氧化锆会不会晃？
I said, does your zirconia dance?
粘接之前，牙冠会不会晃？
Does your crown dance before you cement it?
他们就说，会啊。
They're like, yeah.
我就说，那你就是有晃动的牙冠。
I go, you got dancing crown.
那就说明它不合适。
That means it doesn't fit.
所以如果你在那边加个斜面，你就改变了闭合角度，把氧化锆加厚了。
So if you put a bevel on that, you change the closing angle, you thicken up the zirconia.
嘿，现在闭合好了，贴合度也好了。
Hey, now you got a good closing and now you got a good fit.
你能感觉到，它稳稳地落位了。
You could feel it, it fits down.
所以，倒角这事儿，牙科学校现在又不教了。
So beveling is again, something that's not being taught in the dental schools.
我们那时候是学过的，但他们根本不知道倒角是什么。
We got learned with that, but they don't know what a bevel is.
他们连怎么做倒角都不知道。
They don't even know how to make a bevel.
所以现在你面临一个备牙的问题，材料本身粘接性又不好，还得靠粘接。
So now you got a preparation issue with a material that doesn't really bond that you got to cement.
你得用粘接剂，得把它粘上去。
You got to lute it, you got to cement it.
这完全是另一种思路，但我跟你说，我亲眼见过，那样根本行不通。
It's a different mentality, but I'm telling you, I've seen it and it doesn't work that way.
肩台预备根本不行。
The shoulder preps don't work.
对于Emax Vital T来说，它行得通，因为Emax的粘接强度很高。
For Emax Vital T, it works because you got a great bond strength on Emax.
氧化锆的话，就没有那么强的粘接力了。
With zirconia, you don't have that bond strength.
告诉你的全科医生，他们其实没有真正的粘接力。
Tell your GPs that they don't really have a bond strength.
我不知道有多少，这个问题是问你们的。
I don't know how many, this is a question for you guys.
你们有多少次是通过氧化锆做根管治疗的？
How many endodontic treatments are you doing through zirconia?
天哪，太多了。
Oh my, way too many.
我用了好多金刚砂车针才钻进去。
I so go many diamond burs trying to get through.
谢谢。
Thank you.
所以我说得没错，它就是不贴合。
So I'm right that it's not fitting.
他们会出现渗漏，会有敏感，然后你还得穿过氧化锆牙冠做根管治疗。
They're getting leakage, they're getting sensitivity, and you gotta do endo through zirconia crowns.
这简直是灾难。
It's a disaster.
你们现在都知道了，对吧。
You guys know now, you know.
穿过那些难搞的家伙要多花十分钟。
It takes an extra ten minutes to get through those bad boys.
不过有意思的是，我想这可能是粘接牙科的一个范式转变。
You know, it's interesting though, I guess maybe it's the paradigm shift of adhesive dentistry.
就像，好吧，粘接，粘接，再粘接。
It's like, okay, bonding, bonding, bonding.
我和David Allman还有Davey Allman聊得很愉快。
You know, had a great conversation with David Allman and Davey Allman.
我们主要从生物医学的角度聊了粘接的优势，还有关于边缘、深边缘提升的话题。
We were talking kind of from the biomedic perspective and just the advantages of bonding and how we're talking about margin, deep margin elevation.
我把自己定位成以修复为主的牙髓病医生。
And I kind of classify myself as restorative based in Endodontist.
我会尽量做龋坏导向的入路，保留很多对抵抗断裂非常重要的牙本质。
I'll try to do caries directed access and preserve a lot of the dittin that's so important to resist against fracture.
那你一般用什么粘接呢？
But what do you kind of cementing with?
你用Duralon还是你比较倾向于……
Are you using Duralon or are you kind of a...
你知道，做粘接牙科的时候，你的首选是什么？
You know, what is your go to when you're with adhesive dentistry?
如果我们做带斜面的氧化锆，那必须用Duralon。
Or if we're doing zirconia with a bevel, it's gotta be Duralon.
Duralon，明白了。
Duralon, got it.
那能保护牙髓，就这么简单。
That protects the pulp, period.
是的。
Yes.
如果你用Emax做粘接修复，就必须用牙本质封闭剂。
You're doing a bonded restoration with Emax, you have to use a dentin sealer.
你需要酸蚀，然后用牙本质封闭剂。
You need to etch and use a dentin sealer.
现在，如果遇到年轻患者，我是这么看的。
Now, if you have a young patient, this is what I see.
年轻患者的神经末梢特别敏感。
A young patient's got super high nerve endings.
那我真的需要把整个牙冠都酸蚀一遍吗？
So now do I really want to etch the whole crown there?
那样会引发敏感问题。
I'm gonna start the sensitivity process.
这里有个小技巧。
So here's a big, a little trick.
如果你在年轻患者的天然牙18、19号上涂酸蚀剂，比如30到40岁或20到40岁的患者，你会刺激到牙本质小管。
If you put etchant on a natural number eighteen, nineteen on a young patient, 30 to 40, or 20 to 40, you're exciting these dentinal tubules.
这在蛀牙上和牙冠上是不一样的。
It's different on a cavity, it's different on a crown.
我们现在做牙冠时，不用普通的酸蚀剂。
What we do now, we don't etch with a regular etchant on the crowns.
我们用微蚀刻机。
We use a micro etcher.
对。
Yes.
好的。
Okay.
那我做了什么？
Now what did I do?
我稍微打开了牙本质小管。
I slightly opened up the dental tubules.
我已经把表面清理干净了，因为这里没有细菌。
I've cleaned out the surface because there's no bacteria.
我们用洗必泰冲洗一下。
We do a chlorhexidine rinse on it.
然后现在把牙本质粘接剂放进去，大约一分钟，让它充分渗透。
And now we put the dentin bonding agent in there for about a minute to soak in the dentin bonding agent.
这至少需要一分钟。
That takes at least a minute.
厂家说十五秒就够了。
The manufacturer say fifteen seconds.
我觉得不行，得一分钟。
I'm like, no, a minute.
我们把它放进去。
We put it in there.
然后慢慢用气吹干。
We slowly air dry it.
现在我们把它固化。
And now we cure that.
这样就密封好了。
That's sealed.
我把牙齿密封起来。
I seal the tooth.
我可能几乎不会有敏感问题。
I'm going to probably have really, really low sensitivity.
下一步，如果你要做粘接，就放上你的粘接材料，比如Emax。
Now the next step, if you're bonding, is you put your bonding material like Emax.
但如果你用的是氧化锆，那就粘不上去。
Now, if you have zirconia, you're not getting a bond to that.
所以这就是你们在氧化锆上做根管治疗时遇到的问题。
So that's the issue that you guys are having that you're doing endo on zirconia.
他们以为有粘接效果。
They think they have a bond.
他们的预备做得并不好。
They don't have a really good prep.
牙冠其实不太贴合。
The thing's not really fitting around.
病人吃东西的时候，牙冠晃来晃去，还会移位，让他们很疼。
Patient's eating and the thing is dancing and shifting and they're hurting.
对。
Yes.
更别提他们没怎么检查咬合，调了二十次都调不好，也抛光不了。
Not to mention that they didn't really check the bite like 20 times and they couldn't even adjust it and polish it.
简直就是灾难。
It's just disaster.
天哪。
Oh, man.
咬合又是另一回事了。
Occlusion's a whole another conversation.
我很喜欢你刚才说的关于牙本质封闭的内容，即时牙本质封闭来保护牙本质，把一切都封闭起来。
I love what you said about the dentin sealing, immediate dentin sealing to protect Dentin seal everything.
你必须这么做。
You have to.
所有地方都要。
Everything.
而且你不能买那些便宜的。
And you can't get the cheap ones.
明白吗？
Okay?
对。
Way.
牙医试图，比如说，
Dentist trying to, like,
省两块钱。
save $2.
对吧？
Okay?
然后他们想用那种便宜的牙本质材料，比如，你懂的，不知道是哪家公司的，反正就是别的地方的。
And try to use this cheap dentin from, like, you know, I don't know, from a company in somewhere else.
你得用……
You've got to use...
我们用的是Ivoclar Xcite。
What we use is Ivoclar Xcite.
我觉得它是最能脱敏的。
I found it to be the most desensitizing tooth.
它对所有情况都有效，贴面、牙冠、补牙都行。
It works on every case, veneers, crowns, fillings.
它是最好的。
It is the best.
它也是最贵的，没错。
It is the most expensive, yes.
但我不想处理敏感问题。
But I don't want to deal with sensitivity.
所以你想多花20美元，让病人少受点罪。
So you want to spend another $20 and like relieve your patients from stress.
就是这个材料。
That's the material.
IvoClar Xcite。
IvoClar Xcite.
我从中不赚一分钱。
I don't make any money from it.
我不是什么意见领袖。
I'm not a KOL.
我只是告诉你什么有效。
I'm just telling you what works.
这就是你的厉害之处，在牙科行业干了这么久，还一直担任导师角色。
And that's and that's what's cool about you have being, within dentistry so long and and serving in that mentorship role.
我们基本上是在从你的错误中学习。
We're learning from your mistakes essentially.
我现在毕业十年了，所以我教住院医生。
And I'm I'm ten years out now, and so I teach residents.
你知道，这真的是智慧的来源。
And you know, and that's really where wisdom comes from.
所以有像你这样愿意分享的人真好，而且你的手艺本身就说明了一切。
So it's nice to have people like you are so willing to share, but also your craft, it speaks for itself.
我们知道你有名人客户，不是说我会像你妈妈那样对待每个人。
We know you have a celebrity clientele, not that I'm shooting everybody like your mom same way I do.
这里稍微透露一下。
Little little disclosure here.
名人不是好病人。
Celebrities are not good patients.
只是说说而已。
Just saying.
有时候他们也不想付钱。
Sometimes they don't wanna pay too.
别提钱了。
Forget about the money.
他们就是……
They just...
每次预约都取消。
They cancel every appointment.
太糟糕了。
It's terrible.
对，没错。
Oh, yeah.
嗯，从这点来看，牙髓治疗比你有优势，因为牙疼的时候，你会来……
Well, well, that standpoint, that's kind of where endo has you beat because when you have a toothache, you'll come...
你会守约的。
You're gonna keep that appointment.
确实如此。
That's true.
到现在为止，最好的病人是秘书、行政助理、律师、建筑师和CEO，他们从来不会错过洗牙预约。
The best patients to this day are secretary administrative assistants, the the lawyers, the architects, the CEOs, they never miss their cleaning appointments.
他们非常准时，日程安排紧凑，是很好的病人。
They're on point, their schedule's tight, they're great patients.
没人知道他们有多少钱，可能比名人还多，但他们总是准时，总是付清账单。
Nobody knows how much money they have, probably have more than celebrities, but they're always on time, always pay their bill.
这些是我最喜欢的客户。
Those are my favorite clients.
你知道吗，我们现在真该聊聊时间管理了。
You know, really, we should be kind of talking now about time management.
我知道你说过你女儿在牙科学校。
I know you said your daughter's in dental school.
你也有儿子吗？
Do you have a son too?
我有一个儿子。
I have a son.
他已经在赚钱了。
He's making money.
他已经毕业了。
He's already out.
他读完了纽约大学，对吧？
He finished NYU, right?
他读完了。
He's done.
管理。
Management
时间管理对牙医来说是一门必修课。
Time management is a day course for dentists.
即使在修复科住院医师培训中，甚至我在私人诊所看到他们，我都在观察，然后说，他们就是在浪费时间。
Has to be like has a Even in the Prosthodontist residency, even I see them in private practice, I'm watching and I'm saying, they're just blowing time out the water.
我给你举个例子。
I'll give you an example.
有很多牙医一周工作五天。
There are very many dentists that work five days a week.
对。
Okay.
然后他们赚一定数额的钱，对吧？
And they make X amount of dollars, right?
总收入，一定数额的钱。
Gross income, X amount of dollars.
我知道我自己，还有另外三个人，我们一周工作三天，赚的是他们的两倍。
I know myself included and three other of us that make work three days a week and make double what they make.
我喜欢这样。
I love it.
这跟
It has nothing to do with
跟收费没关系。
the fees.
别管收费了。
Forget about the fees.
效率。
Efficiency.
你就是效率高，兄弟。
You're just efficient, man.
你得讲究效率。
You got to be efficient.
我毕业第一年就明白了这个道理。
I learned that my first year out of school.
我在皇后区杰克逊高地跟一个人干了三年。
I spent three years with this guy in Jackson Heights, Queens.
这家伙是个高手。
This guy was an operator.
他不是世界上最好的牙医，但天哪，他可真会管理时间。
Wasn't the best dentist in the world, but boy, can he manage time?
我以前总是看着他心想，你是怎么做到这些的？
And I used to look at him and go, how are you doing all that?
你怎么能一个小时看五个病人？
How are you seeing five patients in an hour?
这对我来说简直太震撼了。
It was mind blowing to me.
而且，细节也做得很好。
And I mean, detail was there.
他并不是在敷衍了事。
It wasn't like he was being sloppy.
他只是把每件事都安排得井井有条，时间管理得让人佩服。
He just had everything to a time that was so impressive.
从那天起，我就想，哦，好吧，你知道吗？
From that day I was like, oh, okay, you know what?
我们不一定非得一小时看五个病人，但一小时看两个绝对没问题，时间安排也能搞定。
We don't have to be have five patients in an hour, but I definitely can have two in an hour and manage the time schedule.
所以我和我的前台经理每周都要花好几个小时研究日程，调整时间。
So me and my office manager spend hours every week looking at the schedule, switching the times.
我知道她不知道我对乔安妮会怎么做。
That I know that she doesn't know what I'm gonna do on Joanne.
她不知道乔安妮很麻烦，我会很快进去又很快出来。
She doesn't know that Joanne's crazy and I'm gonna get in and get out.
她以为我需要一个小时。
She thinks I need an hour.
我实际上要花一小时十分钟在那位女士身上。
I'm getting in an hour and ten minutes on that lady.
所以把她安排到旁边。
So put her on the side.
所以你必须能和前台沟通，说，如果是根管治疗，也一样，你知道这个人很麻烦，你需要更多时间。
So you have to be able to communicate to your front desk and say, if it's endo, the same thing, you know that this person's crazy, you're gonna need more time.
我在给马克做补牙。
I'm doing a filling on Mark.
那需要一个半小时。
That's an hour and a half.
好的。
Okay.
我在给乔安妮做四个贴面，我知道大概需要五十分钟。
I'm doing four veneers on Joanne and I know it's gonna be fifty minutes.
所以你得了解你的病人。
So you have to know your patients.
你得知道……
You have to know what...
你知道，你得清楚自己的情况，这样才能高效利用时间。
You know, where you are so that you can be really efficient with your time.
而且我想说，这就是你能拥有多专科……的一大优势。
And and I guess I would say that's one of the big advantages of you being able to have that multispecialty...
你们几乎可以在同一个空间里实时交流。
You can communicate almost in real time in the same space.
是的。
Yep.
我想我们现在要做的就是先休息一下，插播一段赞助商的内容。
I guess what we'll do is now is let's take a break from our sponsors.
牙髓治疗实践伙伴团队的成员们很高兴在盐湖城与这么多朋友相聚。
The team at Endodontic Practice Partners loved connecting with so many of you in Salt Lake City.
在那里，EPP的医生
While there EPP's Doctor.
特雷尔·普罗珀录制了一期特别的《牙髓之声》节目，分享了她几十年经验中的领导力心得。
Terrell Proper recorded a special episode of Endo Voices sharing leadership lessons from her decades of experience.
这期节目将于6月19日上线，记得收听，获取见解、灵感，还有不少笑料。
That episode is available June 19 so be sure to tune in for insight, inspiration and a few laughs.
你看到今年“为你最爱的根管投票”T恤设计大赛中，住院医师们提交的那些令人惊叹的牙髓主题设计了吗？
Have you seen the incredible endo theme designs submitted by residents for this year's Root For Your Fave T shirt contest?
你可以在Instagram上查看入围作品，在Endo Practice Partners的Instagram页面上。
You can check out the finalists on Instagram on the Endo Practice Partners Instagram page.
获胜的T恤将在圣路易斯的APICES大会上分发。
The winning T shirt will be distributed at APICES in St.
前三名的设计将获得资金支持，用于他们的住院医师培训项目，以满足住院医师的需求。
Louis and the top three designs will win funding for their residency program to use for resident needs.
EPP与各种规模的牙髓病医生合作，提供人员配置、薪资、IT、认证和运营方面的支持，这样你就可以专注于提供优质的患者护理。
EPP partners with endodontists of all sizes, providing support in staffing, payroll, IT, credentialing, and operations so you can focus on delivering excellent patient care.
他们还帮助住院医师找到合适的诊所，让他们自信地开始职业生涯。
They also help residents find the right practice to start their careers with confidence.
更多信息请访问endopracticepartners.com。
Visit endopracticepartners.com for more information.
Endodontic Practice Partners。
Endodontic Practice Partners.
支持牙髓病医生，赋能诊所，塑造职业生涯。
Supporting endodontists, empowering practices, shaping careers.
好的，非常感谢。
All right, thank you so much.
我们回来了。
We are back.
作为牙髓病医生，一个挑战是我们可能只见病人一两次，他们总是说，哦，我希望再也不要见到你。
One of the challenges of being an endodontist is we see patients maybe once or twice, and they always say, Oh, I hope I never see you again.
是的。
Yes.
我们从不介意。
We never take offense.
就像，我会在超市见到你，但绝不会在治疗椅上。
Like, I'll see you in Whole Foods, but never in the chair.
但你不知道那个病人会有多紧张，多焦虑。
But you just don't know how nervous that patient will be, how much anxiety.
他们能完全麻醉吗？
Are they going to be profoundly numb?
所以时间管理是牙髓病医生一直在努力完善的事情，你知道吗？
So time management is something that endodontists are always trying to perfect, you know?
我给你一个牙髓病治疗的小技巧。
I'm going to give you an endodontic tip.
说来听听。
Let's hear it.
你的诊所经理必须能在电话里做好分诊。
Your office manager has to be able to triage over the phone.
她非常棒。
She's amazing.
顺便大力表扬一下Kim。
Kim, big shouts to Kim, by the way.
好，那你有了你的诊所经理Kim。
Okay, so you got your office man Kim.
她非常出色。
She's amazing.
在她的清单上多加几个问题。
Put a couple more questions on her list.
这里还有几个问题。
Here's a couple more questions.
嘿，女士。
Hey, Mrs.
约翰逊，我知道你是来做根管治疗的。
Johnson, I know you're coming in for your root canal.
我们之前没见过你。
We haven't seen you before.
你以前做根管治疗的经历怎么样？
How has been your experience with root canals in the past?
关键词。
Keywords.
我喜欢这个。
I love that.
还有一个问题。
Another question.
你以前做过根管治疗吗？
Did you ever have endodontics?
没有，这是我第一次。
No, this is my first experience.
那我们让它变得很棒。
Let's make it amazing.
好的。
Okay.
你以前有过其他根管治疗的经历吗？
Have you had any other endo experience in the past?
有，我做过很多次根管治疗。
Yes, I've had tons of root canals.
好的，那她说她做过很多次了。
All right, that's So a green she says she's had a lot of it.
她了解这个过程。
She knows the process.
然后还有一个问题。
And then another question.
你对麻醉感觉怎么样？
How are you with anesthesia?
你很难麻住吗？
Do you have a tough time getting numb?
哦，是的，上次他们给我打了一百针。
Oh yeah, they gave me a 100 shots last time.
砰。
Bang.
所以你知道你面对的是一个超级敏感的人。
So you know that you're already dealing with somebody who's super hypersensitive.
他们需要很多针。
They need many shots.
他们从来没做过根管治疗。
They've never had endo.
这些都是很重要的问题，我觉得很多牙髓科前台在VAE里都应该问。
These are important questions to ask that I think a lot of the endo office managers need to ask in the VAE.
我们这边也是这么做的。
We do the same thing on our end.
你以前做过牙齿矫正吗？
Did you happen to have orthodontics done?
做了几次矫正？
How many sessions of orthodontics?
你戴过隐适美吗？
Did you ever have Invisalign done?
戴过。
Yes.
你戴了几副？
How many sessions have you had?
你戴了几年？
How many years did you have?
这些是她进来之前需要问的重要问题。
These are important questions before she walks in.
我知道那是个正畸患者。
I know that's an ortho patient.
那你猜怎么着？
Well, guess what?
那些牙齿已经移动了很多很多年了。
Those teeth have been moving for many, many years.
所以我对那个咬合有不同的看法。
So I have a different perspective on the occlusion on that.
所以这些是我们提前问的问题，能让我们了解我面对的是什么情况。
So these are questions that we do preemptively that gives us an insight of what am I dealing with here.
哇。
Wow.
你知道吗，我真的很感激。
You know, I really appreciate that.
他们看不到，但我其实一直在记笔记，你知道吗，这就是作为主持人最棒的地方，我能和导师们交流，学到了很多。
They can't really see, but I was actually taking notes and, you know, and that's what's so cool about being in this position as a host is I'm able to engage with And mentors like I've learned a lot.
待会儿去你办公室啊，兄弟。
Gonna up to your office, dawg.
我们一起去坐坐。
We're gonna hang out.
还有，真的要特别感谢……
And actually, big shout out to...
你知道吗，前几天晚上我和你以前的一些学生在一起，大家都特别喜欢你。
You know, I was hanging with some of your, I guess, past students the other night, and everyone loves you.
你性格特别开朗。
You have a gregarious personality.
难怪你能这么成功，一看就明白了。
It's easy to see why you have a lot of success.
还有，特别感谢纽约的这门课程。
And, you know, big shout out to the course New We York
行业里都叫直来直去的人。
industry call straight shooter.
直来直去。
Straight shooters.
我们不喜欢拐弯抹角。
We don't, there's no fluff.
就是实话实说。
Just tell the truth.
对，直接说重点，对吧？
Yeah, just get to the point, right?
是的。
Yep.
所以，我知道你时间宝贵，但我还是想听听你对帖子发布的看法。
And so, you know, I want to be mindful of your time, but I did want to just kind of get your thoughts on post placement.
还有，如果你的诊所里有牙髓病专家，嗯，你确实有一位牙髓病专家，如果他在做根管治疗的同时，顺便把某些病例的修复也做了，你会怎么想？
And then also, if you were to have an endodontist, well, you do have an endodontist in your practice, how would you feel if he were to maybe restore certain cases while he's under isolation?
你对此有什么看法？
What are your thoughts on that?
因为这是一个很大的转变，我们看到越来越多的牙髓病专家开始做修复性牙髓治疗，因为文献里有很多证据，而且明确表明，最好的修复牙齿的时机就是在根管治疗完成的时候。
Because that's been a paradigm shift where we see more and more endodontists practicing restorative endodontics because the literature is pretty replete and it's unequivocally states that the best time to restore the tooth is at the time of endodontic completion.
好的。
All right.
所以这是个多层次的问题。
So it's multi tier question.
我对此有几个看法。
I have a couple opinions on that.
首先，如果我找到一个会放桩的牙髓病专家，那真是谢天谢地了。
First of all, if I find an endodontist that knows how to place a post, God bless him.
赶紧把他请过来吧。
Go get him.
我不在乎。
I don't care.
我不在乎。
I don't care.
我不是靠打桩来赚钱的。
I'm not trying to make money on a post.
这又是那种小格局的想法。
That's again, small thinking mentality.
如果那个牙髓科医生做完根管治疗，然后用我的技术打桩，你必须用我的技术，好吗？我觉得这对病人来说是增值的。
If that endodontist does an endo and he puts the post in my technique, you gotta use my technique, okay, I think that's value added to the patient.
上帝保佑你，打桩收费没问题。
God bless you, charge for the post.
我不在乎。
I don't care.
把我想要的东西还给我就行。
Give me back what I wanted.
现在我可以准备这个病例了。
Now I can prep the case.
你帮我省了时间。
You just saved me time.
你帮他省了时间。
You saved him time.
我们还是能赚钱，而且病人也满意。
We're still going to make money and the patient's happy.
所以对我来说，什么是对病人最好的？
So to me, what is the best for the patient?
百分之百。
100%.
我有个牙髓专科医生。
I had an endodontist.
他非常厉害，但他搬到夏威夷去了。
He was amazing, but he moved to Hawaii.
他在夏威夷过得很好。
He's doing great in Hawaii.
去夏威夷也怪不得他。
Can't blame him for Hawaii.
这确实怪不得他。
Can't blame him for that.
我当时可羡慕了。
I was like so jealous.
他在我们诊所的时候特别厉害，我还教了他我的技术。
He was so amazing in our office and I taught him my technique.
到现在他还时不时给我发消息。
And to this day, he texts me every now and then.
他说，医生，我又用了你的桩核技术，因为这些人不想做。
He's like, doc, I did your post technique again because these guys don't wanna do it.
他们害怕。
They're scared.
他们想把牙弄断。
They wanna break the tooth.
然后他说，大家都喜欢你的技术。
And he goes, everybody loves your technique.
到现在还管用。
It still works.
太棒了。
It's awesome.
所以我们用弹性桩。
So we use flexi post.
我的理念是每颗牙都需要打桩。
I'm in the philosophy of every tooth needs a post.
我不认同碳纤维桩的理念。
I'm not in the philosophy of carbon fiber posts.
它们会断，你用手就能掰断。
They break, you can break them in your hand.
X光上看不到它们。
You can't see them on the x-ray.
非常糟糕。
Very bad.
情况不妙。
Not a good situation.
我想在那里放一个弹性桩。
I want a flexi post in there.
不用铸造桩，因为那会伤牙。
No cast post because that hurts teeth.
但我可以用Duralon粘固剂和核堆积来放一个被动弹性桩。
But I can get a passive flexi post in with Duralon cement and core buildup.
这是我们的标准流程。
That's our protocol.
效果非常好，但你必须把弹性桩的头部压到牙本质上。
It works really, really well, but you must get the head of that flexi post down on the dentin.
你不能让它立着，因为那样它会裂开。
You can't have it sitting up because then it's going to crack.
这是一种非常特殊的技巧。
It's a really specific technique.
所以这就是一个答案。
So that's one answer.
是的，我不在乎。
Yes, I don't care.
你可以做任何你想做的事，只要用我的技术，而且我能把桩和核装回去，我会教你怎么做。
You could do anything you want as long as you use my technique and I get a post back with a core and I'll teach you how to do that.
我会教你如何做。
I will show you how to do that.
你会非常成功的。
You'll be very successful.
如果牙医不想在课程里放桩，那也没关系。
If the dentist doesn't want to put posts in the course, that's fine.
如果他们想自己做，因为想多赚点钱，那你至少得做到那一步。
If they wanna do it themselves because they wanna make more money, at least you gotta do that.
但那个技术是有效的。
But that technique works.
这是第一件事。
That's the first thing.
对。
Yes.
答案是肯定的。
The answer is yes.
你问的第二个问题是，我想你说的是在桩放进去之后，还是你当时问的是什么？
The second question that you had was, I think you said after the post is in or what was the question you had?
我觉得你差不多已经回答了。
I guess you kind of answered it.
就是关于以修复为导向的牙髓治疗这种理念转变，因为我们看到的是，用粘接牙科来做深部边缘提升。
Just the more of the paradigm shift of the restorative based endodontics because what we're seeing is that deep margin elevation with adhesive dentistry.
你相信这个吗？
Do you believe in that?
这真的是，牙冠延长术是不是……
Is this really, is crown lengthening...
我有点觉得牙冠延长术几乎就像是一个概念。
I I I kind of feel crown lengthening is almost like it's it's a concept.
它不是一条硬性规则。
It's not a rule.
你看，这里有一个牙髓治疗的问题，我跟你说实话，因为我见过牙髓科医生三十年，起起落落。
You Here's one of the endodontic problems, and I'm gonna be honest with you because I've seen endodontists up and down for thirty years.
有些牙髓科医生的问题在于，他们太专注于根管了，以至于忘了那里还有龋坏。
One of the problems that a couple of endodontists have, they are so focused on getting the canal, they forget that there's decay there.
所以你说到修复牙科。
So you talk about restorative dentistry.
我希望你进入根管，填充根管，但在你准备封闭之前，让我们把龋坏去掉。
I want you to get to the canals, fill your canals, but then right before you're ready to close, let's take out this decay.
这是我的桩道钻。
Here's my post drill.
这是我的核心堆积材料。
Here's my core buildup.
我会把它给你。
I'm gonna give it to you.
你会拿到它。
You're gonna have it.
你要把粘接剂放进去，然后填满你刚刚去除的那些空间，因为如果你只是把白菜放进去然后填满咬合面，病人可能会咬合，然后牙齿就裂了。
You're gonna put the bonding in it and you're gonna fill up the spaces that you just took out because if you just put cabbage in there and fill up the bite, the patient may bite and then they crack.
现在你刚做完根管治疗，他们却把牙齿咬裂了。
Now you got an endo that you just finished, they crack the tooth.
那是个严重的问题。
That's a serious problem.
并不是每个牙髓病医生都到了这个地步，因为全科医生告诉他们，只管做根管治疗，其他一切他们都会处理。
Not every endo- Endodontist has been kind of like gotten to this point from the GP telling them, just do the endo, they'll take care of everything else.
所以那个人就说，好吧，我就只管做根管治疗。
So the guy's like, okay, I'm just gonna take care of the endo.
然后他们就把心思封闭了，觉得，等等，这里有一大堆被破坏的牙釉质。
And then they kind of closed their mind of like, hey, wait a minute, there's a whole bunch of undermined enamel here.
我得把蛀牙去掉，酸蚀，粘接，做核心堆积，如果他想做桩的话留出空间，但要保护牙齿。
I gotta take out the decay, etch it, bond it, make the core build up, leave the space for the post if he wants to do it, but protect the tooth.
做完根管治疗后要保护牙齿，因为他们会咬下来。
Protect the tooth after you finish with your endo because they're biting down.
他们一咬，然后牙齿就裂了。
They're biting and then they crack it.
你刚做完根管治疗，他们付了两千美元，现在病人说，我刚把牙齿弄断了。
You just did the endo, they paid $2,000 and now the patient's like, I just broke the tooth.
哦，我们得把它拔掉。
Oh, we gotta take it out.
这就是根管治疗没有处理内部蛀牙的问题。
That was a problem of an endo not taking care of the decay inside.
所以这就是我的一点小建议，多花点功夫，在牙齿开始裂之前把它保住。
So that's just my 2¢ on go to the extra mile and save the tooth before it starts cracking.
说到保住牙齿，那咬合面的降低呢？
When we talk about saving teeth, what about occlusal reduction?
你知道，我们知道这颗牙已经裂了。
You know, we know the tooth is cracked.
我们知道它下面已经空了。
We know it's undermined.
我们要降低多少？
How much are we reducing?
我们是不是遵循那个“牛”规则？
Are we following the bull rule?
你会让你的牙髓科医生怎么做？
What what would you have your endo?
你是让他们保持咬合不变，还是直接把牙尖磨平？
Would you just have them keep occlusion as is or just flatten the cusp?
不是。
No.
在你做任何事之前，先问两个问题。
Two questions before you do anything.
嗨，医生。
Hi, doc.
你是要装牙冠还是补牙？
Are you gonna put a crown or a filling?
牙冠？
Crown?
那就磨掉它。
Cut it off.
不要咬合。
No occlusion.
让它脱离咬合。
Leave it out of occlusion.
不要咬合。
Out of occlusion.
如果要装牙冠，就磨掉一毫米，不咬合就行，我没问题。
If I'm putting a crown, just cut it down a millimeter out of occlusion, I'm fine.
明白了。
Gotcha.
全部磨掉。
All cuts.
你要补牙还是装牙冠。
You're putting a filling or a crown on.
补牙。
Putting a filling in.
好的。
Alright.
保持原样。
Leave everything as it is.
磨掉大概零点二五毫米，这样就不会咬得太紧。
Take it down maybe a half a quarter of a millimeter so it's not hitting hard.
但如果是做牙冠，就把它磨平。
But if I'm doing a crown, just level it off.
就磨平就行。
Just level it off.
我不希望有任何咬合接触。
I don't want any occlusion.
我不希望牙齿裂掉。
I want the tooth to break.
从你那里到我这里三周后，我不希望牙齿裂掉。
By the time it get from you to me three weeks later, I don't want the tooth to break.
所以只要磨掉一毫米，避开咬合。
So just have a millimeter off out of occlusion.
这样能保护牙周膜。
It saves the PDL.
这样能让牙齿愈合，我之后会给它戴上牙冠。
It allows the the tooth to heal, and I'm gonna put a crown on it.
但别磨掉两毫米、三毫米。
But don't do two millimeters, three millimeters.
不行。
No.
就磨掉大约一毫米。
Do like a millimeter off.
让它脱离咬合。
It's out of occlusion.
还有，如果
Also if
因为那会是个电话。
because that's a phone call.
那会是个电话或短信。
That's a phone call text message.
你是做牙冠还是补牙？
Are you crowning or are you filling?
这是你必须问的。
That's what you gotta ask.
不。
No.
这是好建议。
It's good advice.
那如果牙齿又疼了，临时处理一下怎么样？
And what about if the tooth does come back temporize?
你更喜欢用棉花吗？
Do you prefer cotton?
因为你知道会有引流条。
Because you know it's gonna have the wick.
它可以阻止
It can hold back
到“不”为止。
to No.
不。
No.
不用棉花。
No cotton.
棉花。
Cotton.
谢谢。
Thank you.
把那个棉花扔掉。
Throw the cotton One away.
再
More
一次。
time.
再说一遍。
Say it again.
那一定是……
It's gotta be the...
我喜欢黄色的特氟龙。
I like the yellow Teflon.
黄色的特氟龙。
Yellow Teflon.
对，特氟龙。
Yes, the Teflon.
是的。
Yes.
特氟龙是我的最爱。
Teflon is my favorite.
如果你们开始用那个的话。
If you guys start using that.
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