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AUDIO - HSP #142 - Thomas Mitchell
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VIDEO - HSP #142 - Thomas Mitchell
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Howard Farran and Thomas Mitchell explore the concept of ideal dentistry, and what changes that may mean for you and your staff.
I've been in practice 4 days/week for 40+ years and teaching 1 day/week for about 20 years. My training includes tons of mentoring by a famous periodontist and completion of a 3 year program in Advanced Restorative Dentistry at the University of Washington. My practice focuses on basic general dentistry with an emphasis on perio/pros combination cases. The courses at UW I'm involved with are the first year courses in anatomy and occlusion. I give up to 3 lectures/year on anatomy, bite splints and TMJ. I also run a study club.
I've been married for 43 years (Howard met my wife Linda last year when we visited his office). My home is here in Bellevue and we have a condo in Scottsdale. We have one son who lives in LA with his wife. He's a psychiatrist working for LA County Jail System, and his wife is a hair stylist who owns her own shop in Pasadena. My hobbies include golf and golf and golf.
email: twmdds@uw.edu
website: thomasmitchelldds.com
Howard: It is a huge honor today to be interviewing Thomas Mitchell. Thank you for spending an hour with me today.
Thomas: Anytime Howard.
Howard: You talk about and you teach at the dental school practicing ideal dentistry. My question to you to start with, you can't get 2 dentists to agree today is Friday, how do you get 2 dentists to agree on what is ideal dentistry? Because remember you and I are old. Remember back in the day, 25 years ago when Reader's Digest took a set of study models and X-rays and they went to 30 different dentists.
Thomas: Yeah. Everybody gave a different plan.
Howard: 30 out of 30. All the dentists sat there and said, "Oh Reader's Digest was bad, this is horrible journalism." I'm like, "Dude, Reader's Digest is on the desk and nightstand of every dentist, mom and grandma in America." It was journalism. My thoughts are 25 years after that Reader's Digest article. Has dentistry gotten any more consistent? How can you say what ideal dentistry is, when there is 150,000 dentists in America, 2,000,000 dentists around the world and they can't agree that today is Friday.
Thomas: Restoration should hold up over time. My feeling about what I do, is I look at the stuff on Dentaltown guide. My whole practice has changed since I've been involved with Dentaltown. There's not one procedure I do that Dentaltown hasn't influenced.
Howard: With your 6,000 posts you've influenced me and everyone else. I am a huge fan and thank you, I cannot believe you have taken the time to share 6,000 posts.
Thomas: Thank you. It's my obsessive compulsive disorder.
Howard: Well don't tell your doctor, I don't want you to get cured.
Thomas: My son's a psychiatrist, he won't treat me. When I look at the work that I see on Dentaltown posted by Howard Chasalen and Mike Melkers and Lane Ochi. I look at when they're starting to show their cases. I look at that and I say that's exactly how I would do the case like that. When you look at a body of work from guys who are really, really well known throughout the profession and much better known than I am and really do ideal stuff. Ideally, when I look at that it's like I'm seeing my work. Mike is showing a case right now on Dentaltown where it's a weird case and he's waxing.
This is exactly how I do things. About a third of my practice is hygiene and a third of my practice is just basic general dentistry. Doing restorations and then the other third isn't in this more comprehensive area. In that area then how I do things is I take the case my models and records or whatever. I take it back to very basic stuff and I just look at the basic concepts that we know in dentistry that hold up over time. Of occlusion, embrasure, in contour and try with that one third of my practice, where we actually need some kind of comprehensive care then that's ... I'm trying to take them back to very basic idealism.
Howard: You've been doing dentistry for 43 years and you still teach at the dental school, right?
Thomas: A little less than I used to but that's because we changed the curriculum a little bit.
Howard: What I'd love to do, what turns me on, is to transfer information from legends like you.
Thomas: Exactly.
Howard: To people are younger. I look at Dentaltown as an arbitrage play. That's what we do. If gold is selling for a 100 in London and 90 in New York. You buy it in New York and sell it in London. I'm going to try to get the information that you've picked up over 43 years and transfer it to the people who have only been doing this for 10 years. What do you think are the most common mistakes?
Thomas: Not remembering the basics, not remembering, just very ideal concepts. The program I teach at the U, is I work with the first year kids and it's in dental anatomy and occlusion. The one thing I see on Dentaltown where people make mistakes is when they're restoring something they don't try to make it ideal. It's like they don't remember the concepts of what a second premolar looks like. Where are the grooves, what a lower incisor should look like.
When they see a wear case, where all the anatomy has been wiped out or half the anatomy has been wiped out then they get afraid of just restoring and restoring. At that point you just restore back to basic tooth anatomy. It's really that simple. I think a lot of people look at that and they say comprehensive care and I hate the term full mouth reconstruction, but reconstruction is so complex and it's really not. It's really not, it's really very simple, basic stuff. You're going back to level occlusal planes, normal tooth anatomy, very basic concepts.
Howard: My job is that there's 7,000 dentists listening to our average show. I always try to guesstimate questions because with Dentaltown no one should ever have to practice solo again. Most of my fans are listening to this on an hour commute to work. That's probably what 90 percent of us have an hour commute to work. I throw this on the Dentaltown app and I'm playing it through my car stereo. You just said, "Level occlusal field?" Is that what you said?
Thomas: Level occlusal plane.
Howard: Someone didn't get that, what is a level occlusal plane?
Thomas: The Curve of Spee and the Curve of Wilson, basically when you go from anterior to posterior then the plane is basically flat. Maybe a slight curve up, but not a lot. You can develop mutually protected occlusion so that you can have the anterior's disclude the posteriors. If you have the posteriors in really strong or lateral function, then you're just putting way too much stress on them and that's when you're going to see a lot of wear. When you still can have some kind of anterior guidance, then you're going to protect the posteriors from fracturing.
Many people lose their anterior guidance due to wear or breakdown or they have teeth extracted. Here in Bellevue I'm practicing in this really dental IQ area. I see cases on Dentaltown of people that have multiple extractions and missing teeth and broken down stuff. A lot of that stuff I've never seen in practice because of where I practice. If I practiced 20 miles East of here, then I'd be doing dentures and ... I swear I haven't done a denture in years.
Howard: Dentures are still alive and well. When you look at the lab data, dentures never slowed down in 28 years.
Thomas: That blows my mind.
Howard: The United States gets 1,000,000 immigrants a year. Your immigrants come from Canada up there in Seattle.
Thomas: They're coming from India, where I am now. Microsoft is down the street.
Howard: I'm down here on the Mexican border. As long as we're getting 1,000,000 immigrants a year and a big part of them are from more poor third world or poorer countries. They're removable still, huge. In fact the lab here in Nogales, their denture units have gone up every year for the 30 years they've been in business.
Thomas: Amazing, that just amazes me.
Howard: I want to ask you a couple of occlusion questions that confuse people. They say things like why should should I care about Curve of Spee and the Curve of Wilson when every time a kid get orthodontics, the orthodontist as altering the Curve of Spee and the Curve of Wilson. The second question I hear the most about occlusion is if I do this 33 point beautiful, I mean 33 degree beautiful occlusion on a denture, the studies I read showed that the 0 plane denture teeth have the highest customer satisfaction. What are your thoughts when I say those 2?
Thomas: Dentures are different than natural teeth because you've got to have bilateral posterior balanced occlusion on a denture. Otherwise the darn thing is going to tip. O plane, flat stuff on a denture is one thing. In natural teeth we try to get a little bit of disclusion from the posterior teeth when people slide from side to side. My mentor, he was one of the guys that developed the Grad Pros program at UW and when I was in the program, a 3 year program in the 90's. When I was in that program, that was when John [Kroyst 00:10:50] and Frank Spears were in the other Grad Pros program at the ... What we were trying to do and what we talked about then and what my mentor talked about is how much disclusion do you need when you're building a case?
When you build a case, then you want a millimeter disclusion. As the mandible slides then you get about a millimeter of space initially between the posterior teeth. In actuality and actual practice, most of us try to just develop a group function occlusion. Lateral side to side group function, we don't care that much if we have to have a canine disclusion. If we can have canine, first and second molars all functioning simultaneously when you slide to one side. Then that seems to be what people bring in the most. That's mostly what I see.
Howard: What do you think, because you only know what you've known. You just don't know what you don't know. About so many times I've looked on my cell phone and I think to myself, "Could you imagine if you walked up with a cell phone, back in Salem 200 years ago and said, "If you talk into this box you can talk to someone in the next county." They would have thought you were a witch and they probably would have drowned you. It probably would have been some black magic voodoo.
Thomas: Put you in the stockade.
Howard: I would say to myself when the patient is feeling anxiety and you're sensing it and you're intuitive. I always think to myself, "I wonder if 100 years they'll discover some cell phone mechanism that their brain was actually talking directly to mine by some radio wave or, we only know what we don't know." I want you to take that, when dentists don't pay attention to occlusion and they don't know what they don't know. What is biting them in the butt if they would have paid more attention to occlusion they wouldn't be having this problem.
They just don't know the reason they're having this problem. What do you thin it is? When I go into dental offices and I look at schedules. It seems like 20 percent of the schedule is production and 80 percent of the schedule is adjust a bit or it doesn't feel right or a check or suture removal. Only 20 percent are [inaudible 00:13:17]. When a dentist does a filling, and they have to come back twice and adjust the bite or a crown or a filling. Why do you think that is? What do you think they don't know and they could have done differently?
Thomas: They don't recognize what the patient feels. You do a filling and a patient is anesthetized, you see the crown with a patient that's anesthetized. If you check the occlusion and you've got ideal markings, you think everything seems fine, what you don't recognize is what the patient feels when they wake up and close together. If your restoration is 2/10 of a millimeter high, it's going to bother them. You have to allow for the movement that's inherent with periodontal ligament. Teeth move around a little bit.
When we do our ... When we seat a single crown or do a filling. The first thing we do is we take shim stocks with Mylar paper and we see what teeth are touching on either side of the restoration. Then when we finish the restoration we try to make sure that the teeth on either side of the restoration and on the opposite side of the arch still contact. There's still contact and that the contact may be a little bit stronger than the restoration. When you have the patient close on the shim stock right over the restoration it will slip a little bit. I think the basic thing is they don't recognize that with anesthesia it's really difficult to get your occlusion ideal.
Howard: For guys like you, another question. You talk about simplifying procedures, making them ... Simplifying it.
Thomas: God yes.
Howard: Do you think, I'm going to throw out a bunch of questions about an impression. Do you think on a single unit crown a quadrant tray is enough?
Thomas: Yes.
Howard: You do? Can that be disposable plastic or does that need to be ...
Thomas: Yeah. I use side-less disposable plastic for single maybe sometimes 2 crowns. I was doing 18 and 19 monolithic zirconium crowns last week. Hindsight it was 18, 19 you always have a problem with the occlusion on 18, I'll do full arch impressions. We did full arch impressions, they came back a millimeter high. I had to send them back. It's the first case I sent back in forever. Had I done it with just a Check-Bite tray it probably would have been ideal.
Howard: Help these dentist out. When you recommend full arch impressions versus a side-less triple tray. Do you have a brand on that triple tray? Is it ...
Thomas: Premier.
Howard: I was going to say that, but I didn't want to lead the witness. That's what I use side-less Premier triple tray.
Thomas: They're great.
Howard: When should a dentist think, full arch?
Thomas: When you're dealing I think with more than 3 units.
Howard: More than 3?
Thomas: 3 units or more.
Howard: 3 units or more.
Thomas: You really want to develop good solid occlusal contact, good solid vertical contacts in your impression. There are cases where we have the little side-less Premier trays. We have another tray that's a little bit bigger, it's not side-less, but it goes almost a full quadrant. On bigger cases, that's why it should be used on that one case. We joke here that I miss one impression a year. I missed that in January so I'm golden for the rest of the year.
Howard: Really? You only miss one impression a year?
Thomas: No.
Howard: Oh you're kidding.
Thomas: I only lie about that. I do miss very few, sometimes a longer quadrant tray is better. You can get full arch Check-Bite trays as well. Although you can't use those if you're working on the most posterior tooth, because the material will ooze out the back of the tray, they don't have a bar across the back.
Howard: You've posted 6,000 times in the last 11 years. I know you can talk about anything. Talking specifics to these dentists driving to work right now. What procedure to you want to simplify for them? If you're good at impressions, do you want to walk through the impression technique? What procedures did you want to simplify today?
Thomas: A lot of people complain about their impressions, which surprises me because impressions for me are really, really simple.
Howard: Whenever I'm in someone's office, it looks like 80 percent of the people are taking 2 or 3 impressions and trying to see which one is the best.
Thomas: That just blows my mind. I literally do that maybe 4 times a year.
Howard: Okay, then walk through the specifics, brand names, specifics, do you pack a core.
Thomas: I do. Be as detailed. The only complaints I get on these podcasts is I don't do enough of them and the dentist is saying generals and not specifics.
Howard: He'll say I used composite but he won't say what kind or something like that.
Thomas: I start with I start with a rubber dam almost all the time. I have Isodry, but it's difficult for me to work with. I almost always use a rubber dam. If I'm doing a lower first molar I take out all of the old dentistry that's in there. The initial thing I do is I go right down to clean tooth structure. Then at that point I take and do my occlusion reduction. Then I do a build up. My build up procedure, I do a build up on everything. My build up procedure is I'm using John [Kangas 00:19:45] stuff so I'm using Surpass 1-2-3 over the deep areas.
For all the dentin basically a little layer of opaque white Titan Flow. Then if I'm not doing E-Max, then my build up material is white opaque Apex anchor. Then once that's cured then I do my basic prep still with the dam on. Pop the dam off and immediately I pack my first core. The core that I use is called DEKNATEL, it's double lock silk sutures is what it is. I can use any other Patterson some generic double lock cord too. At Washington I grew up on DEKNATEL so I just use that. I pack that, it takes me literally 10 to 15 seconds to pack that.
I make a loop and either hold the loop in hemostats or just in my fingers and just lasso the tooth and tease it down under the margin, snip it so the ends meet pretty close to perfect. That will retract the tissue about a half a millimeter. At that point then, I'd lower my margin to the top of the tissue. The margin is going to be at the top of the tissue or only a half millimeter below. If I have to go below tissue in approximate is usually the way I have to do it. That tissue isn't ideal, then at that point I use my Electrosurge so the tissue is as ideal as I can get it.
Howard: What is your Electrosurge?
Thomas: Sitting over there, what is it? Strobex Mark 2. It's old as the hills but it works. Then I make sure that I don't have any sharp corners anywhere on the prep. The prep is round, not circumferential of course, but I always have retentive groups. I make sure there's nothing sharp on that prep so that when that impression material hits the prep it can just flow, it doesn't get turned. Then I pack with a single lock cord it's just a plain cord, it doesn't have epinephrine in it but my assistant soaks it in ViscoStat Clear from ...
Howard: Ultradent.
Thomas: Ultradent. Great stuff. I pack that, then I walk away 10, 15 minutes. That's where I get 6,000 posts, is I go look at my computer. I go talk to ... I'm old, I talk to people now. I go talk to my staff. I go do whatever I do. Then after that is set and before I leave, I also pack some cotton down into those inner proximals, it's a 2 by 2. Down in those inner proximals, put pressure on the tissue and I will walk away. Just leave it alone 10 to 15 minutes. I do hygiene checks, I go look at Dentaltown, I go tease my staff, whatever I feel like doing. Then I come back, sometime. Ideally with our schedule then I'm going to see another patient. Get another case started which does happen some of the time. Then I come back 10, 15, 20 minutes later and we take the impression. It's just the simple thing of taking off.
Howard: You have 2 cords in there at this point.
Thomas: I do.
Howard: Do you pull the top cord and then?
Thomas: I pull the 2 by 2 out. I wash and dry the prep. Then at that point we mix the impression material. We have the guns, I'm using 3M Quick, 3M Imprint Quick.
Howard: Is that a light body in the gun?
Thomas: Medium body, with a medium body and a heavy body. Not their light body, it's too light for me. I have a plastic syringe that we put my light body or my medium body into and at that point, once it's all mixed and ready to go. Then I pull the first cord, the top cord and inject. Circumferentially, I try to go around twice and make sure everything is covered occlusally. Then the Check-Bite tray goes in and the patient bites into it.
Howard: You're not blowing down the first layer.
Thomas: You don't need to. You just introduce air and bubbles doing that. It's all dry, I dried it, pulled it out. The whole thing's dry, it's not bleeding. The margins for the most part are high and readable.
Howard: When you do your prep. Are you doing a shoulder, a shoulder bevel, a heavy sampler?
Thomas: My final diamond is a straight diamond with a 45 degree angle tip. It's a basic kind of bevel all the way around but it's very smooth, very flat, very smooth. Minimal up and down stuff, just nice and flat all the way around. Maybe a little bit higher in the front.
Howard: When you're done prepping your prep do you ever hit it with a saw flex disc or sand paper or anything of that? You also dropped that you put grooves in there.
Thomas: Sure, vertical grooves.
Howard: Talk about that.
Thomas: If there's a furcation of course, you've seen the stuff on Dentaltown about treating furcation that Danny Melkers and Howard Chasalen showed. Then if there's a furcation, I groove that. I take the roof off that furcation as much as I can and have a vertical groove. It'll be on the buckle in most cases, sometimes it's on the inner proximal. A vertical groove that goes from gingival to occlusal and it's got to taper so it draws. Preps have to draw this way and they have to draw that way as well if you have a groove. Then I give my lab instructions that I want them to follow that groove, all the way from gingival to occlusal so the buckle side of that crown looks almost like 2 fused premolars.
Howard: Exactly.
Thomas: In approximately in Washington when I was in school and it was all inlays and foils. We were doing grooves, vertical inner proximal boxes and inner proximal grooves. My training is to do that. I can do that very quickly. I almost inevitably will have a groove or a box forming inner proximal area just so I resist lingual displacement.
Howard: You got out of school in 72, right?
Thomas: Yeah.
Howard: You probably ... Did you ever do a gold foil?
Thomas: Oh yeah.
Howard: You did gold foil. When do you think they officially, what's that song? The Night the Music Died what was that when Buddy Holly's plane went down? The Night the Music Died. [crosstalk 00:28:00] Where's the song the Night the Gold Foil Died?
Thomas: In the 70's I'm sure, when we started to get some of our bonding. As soon as we started.
Howard: Bonding [crosstalk 00:28:16], tell me if you agree with this. I'm in Phoenix so we get more than our fair share of retiring people. A lot of them are from your area.
Thomas: When I retire, I've got that condo in Scottsdale. We're going to come down and move into it and I'm going to come work for you.
Howard: I'm telling you in all seriousness, if you ever decide to do that, you have a job.
Thomas: I'm doing it. I've got 4 more years.
Howard: I'm absolutely serious. I'm such a big fan of your posts. You could do clinical, you could do something in the magazine, website, whatever.
Thomas: I want to do denture adjustments.
Howard: Denture adjustments? If someone asked me after 28 years of dentists, what's the longest lasting restoration. I still see gold foils on 70, 80, 90 year old people, that everything else has gone to hell. That gold foil and it's like there's gaps you can see with your naked eye.
Thomas: Still there.
Howard: I believe that, that gold there's something about this high surface energy gold that bugs just don't want to live by. I think it has a bacterial static property because it just doesn't make sense.
Thomas: I think you're right, the same thing with gold inlays. One of Bill Farrier, you know the name Farrier. One of his patients came to see me, she was in her 80's at that time. She had every type of restoration that was possible to do in her mouth. Every one of them was ideal, it was the most impressive thing to see what this guy had done with ... We're talking porcelain jacket crowns that he'd done himself and seated. They'd been in there for 30 years. They weren't glazed anymore, but everything else about them was perfect. It was very impressive to see. Those concepts that came through from those guys starting those procedures in gold. Where in order to anything with that stuff. You had to be precise and accurate. Those are the restorations we see hold up.
Howard: When you talk about practicing ideal dentistry using comprehensive dentistry in everyday practice. Talk to these dentists listening in their headphones right now. What do you think after you've been doing this how many years? You've been doing this 43 years, what do you think is the definition or description that this is a comprehensive dentist and this is not really a comprehensive dentist.
Thomas: We talk about that a lot in staff meetings and what we say is that look, we're like Nordstom's, Nordstrom's is across the parking lot from here. We're like Nordstrom, if somebody comes in and they want to buy a pair of shoes, we're going to sell them a pair of shoes, but we're also going to say after we sold them the pair of shoes. We're also going to say, "You know there's some other things going on in here and maybe we ought to take a closer look at some of this stuff."
The way that you do that of course is just with a comprehensive exam. Hopefully then they'll schedule for their comprehensive exam. Patients come in and they haven't seen us before and they have a broken tooth and they want the broken tooth fixed, we fix the broken tooth. Then we go, there's a reason that thing broke. Maybe you want me to take a look at that. Then from that point we go into comprehensive exams. Which includes, it's the full meal deal essentially.
Howard: Would you mind going through in detail what you're getting this lady back? She came in once and you were consumer friendly, patient focused and she wanted her broken tooth fixed, you fixed it. Now you've earned her trust and love and respect. She's going to come back for a comprehensive exam, exactly what do you do at a comprehensive exam?
Thomas: Of course we have a digital pan now, so we take a pan. Then we take a look and see if there are any other extra angles we want to take. It's all digital now. I can't take an X-ray anymore. Then we start with charting and we chart for existing restorations, missing teeth and then any defective restoration areas of obvious decay, we get that charted. Then I do peri probing, I do my own perio probing. A lot of guys rely on other people to do that and I know why. I just sit down and I do 3 or 6 probes on every tooth. Then we chart the recession and mobility. The amount of attached tissue that they've got. From there then we go into, this is class 1, class 2, class 3 how much percentage of over bite, millimeters [inaudible 00:33:49], CRCO, really I'm just checking for is MIP. Can I actually close into an MIP without sliding around?
Howard: What is MIP?
Thomas: Can they close when their joints are functioning nice and smoothly and evenly, can they hit their MIP. That's my definition of centric relation, centric occlusion.
Howard: What does the M and the I and the P stand for?
Thomas: Maximum intercuspation. Just get their required bite, make sure it's reasonable to do. Do they have any wear? How much wear do they have? We measure the range of motion, max open, right, left any deviation of noise in the joints. Then what's the periodontal classification, AP 1, 2, 3. Then we go through muscle palpation, just basic muscle palpation. You have to learn how to do that, check for cancers down on the throat and under the tongue and all that stuff. Then we take a series of extra-oral photos, sometimes intra-oral photos. Which is some obvious stuff. Always a series of extra-oral photos of a smile and then retract lips, have a photo with them biting together and a second one slightly apart. Then right, left photos and occlusion and then upper, lower photo.
Howard: I want you to stop about that because most of these dentists listening today say, "That's what the orthodontist does." Why would you take extra-oral camera photos and why would you pro\int them out?
Thomas: I print them out just because I've been doing it so long before we could get them into our computer system. We jut started printing them. In fact I used to have to walk over to the Square and take a roll of film over there and have them do prints for me. Now we print it out here on a little HP printer. Then we've got that printed in the chart. It's so handy for me to pull that out of the chart and look at that when they come back in and have something broken, I've got what it used to look like. I can do a more detailed explanation for them. I can take and draw on the photos. I can show them real clearly on the photos or on the computer screen either one, exactly what I would consider it so I teach them what I see. Let them know what I'm seeing and what I think is a problem.
Howard: Is this an extra-oral camera or an intra-oral camera. Is this a camera?
Thomas: It's extra-oral, it's a little, it's just sitting over there it's a little rinky dink point and shoot.
Howard: Pick it up. Sorry I didn't have the right depth perception, I thought you could just reach over and grab it. I didn't mean to make you get up.
Thomas: That's all right, I needed the exercise.
Howard: Why.
Thomas: It's an Olympus 2.5 thing.
Howard: Is the made just for dentistry?
Thomas: No. No. It's not. It's an Olympus 2.5, it's old as the hills, it's so outdated. All my friends now went and bought 1,000 dollar Nikon's.
Howard: I want you to talk about why an extra-oral camera as opposed to an intra-oral camera? What are your thoughts?
Thomas: Because with extra-oral I can take a picture of the whole mouth. I can have the whole mouth in one photo. With intra-orals, I can take a picture of a couple of teeth. If I take a picture of the whole mouth I try to take a picture of the full arch with my intra-oral and I have the Schick system, God it cost a lot. It's all distorted, it's not real clear. Then also I've got it on a print and I can take that print and draw on it. Show them what needs to be done, how you need to re-shape something. Especially with these wear cases. When you have the lower incisors, everything is worn down, 30 percent, 50 percent of the tooth is gone. You can take and just draw, play connect the dots of what this tooth is supposed to look like right on the photo, just to teach the patient, just to teach them.
Howard: You've taken X-rays, you've charted perio recession, extra-oral pictures. What's next?
Thomas: Develop the treatment plan.
Howard: Now are you going to dismiss the patient this time or are you going to do the treatment plan on the spot?
Thomas: It depends on what they need. It depends on how complex it is, because at that point you know how complex it is. If it's a simple treatment plan, you can say look you need to have these restorations done, everything else looks good. Let's just get you in and do those restorations.
Howard: If it's not too complex you're going to do the treatment plan on the spot.
Thomas: Right there.
Howard: Now do you talk about the fees?
Thomas: No. No. My staff we get messy and we just had a big to do about this too, of getting information from out of this room to the ladies at the front so they can develop a treatment pla because they know what the insurance is. If there's insurance or not insurance. They know that and they know what the insurance is and what we participate with. They know the fees the patient is going to be charged.
Howard: Will they come and talk about that in the clinical operatory or will you move the patient up front? Do you put them in a special room or just?
Thomas: I don't have a special room we just put them in a quiet area at our front desk. I don't have a consult room.
Howard: What other ... Is there any other procedure you want to talk about simplifying procedures? You talked about the impression technique. You walked us through a crown prep, is there ... What else did you want to talk about?
Thomas: We could talk about a couple of things, you know it's important on some of these cases to take models and records and get them mounted. We do that at a separate appointment. We charge a relatively low fee from what I read on Dentaltown. We charge 250 dollars for that and tell them up front, we really should make some models and get them mounted on an instrument for you. We did that at a separate appointment.
Howard: What do you have to see in someone's mouth before you say I'm going to stop and take models? Will you mount these on an articulator or just hand? Using a mount? Will you take a facebow?
Thomas: I take a facebow and mount them on a Panadent.
Howard: Let's talk about that. What do you have to see in someone's mouth to say, "This is not a limited exam.
Thomas: A bunch of missing teeth. I'm going to be doing either bridges or implants and a bunch of or a lot of wear. I've got to restore a worn area.
Howard: Then you'll take study models with Alginate? You'll pour them up yourself?
Thomas: Staff.
Howard: I mean your office.
Thomas: Yeah.
Howard: Talk about your ... What percentage did not use a facebow one time last year?
Thomas: Oh God, I don't know. I think it's pretty rare to use a facebow.
Howard: Why don't you go into detail because you've been educated, you've done post graduate programs, I'm a big fan of your 6,000 posts. Talk about which cases and why you would used a facebow. I want you to talk in detail so that this kid driving to school who doesn't even have a facebow, he left it at dental school. He dropped it in the trash can on the way out. Why would ...
Thomas: If you're going to be opening vertical, if you have a lot of wear, you've got to use a facebow. You've got to know where that joint is. If you're going to open vertical. If you just have missing teeth, the occlusion's okay you're not going to have to change vertical. You probably don't have to use a facebow at that point. If you're dealing with wear or you're going to change the patient's vertical, then you better be doing that on a hinge. I just did that with a case. I had a lady practicing in my area who was doing really a lot of cosmetics. She went to an institute down South of here.
Was doing a lot of cosmetics and not very well, got into trouble with it. Serious trouble where the state board gave her the choice of going back to school or giving up her license. She had a very small boutique practice just around the corner from me. We merged that practice with mine. I have a lot of these cases where she restored the upper arch but not the lower. Again upper arch is porcelain but didn't do the lower and didn't protect the lower from wear. I have a lot of these cases now where she had done relatively poor dentistry in the upper arch, with significant wear in the lower arch.
I just finished one of them where we redid all of her upper crowns. She had to go have a lot of crown lengthening surgery done. The lower where the lower incisors and the premolars and molars were probably 50 percent of the lower incisors were gone. Were worn away, 50 percent of the length was gone. We mounted the case up waxed everything to ideal which opens the vertical up. Brought her in, it took my 4 hours. I brought her in and I rebuilt in composite each one of those teeth just in composite.
Opened her vertical and as she's going out the door, I said, "We'll see you next week for photos, we'll take pictures of this next week when the tissue's better." As she's going out the door she says, "How long til I get used to this bite?" I say 20 minutes, 30 minutes, it'll feel a lot better than it does now." She came in this week for the photos she said, "You know how long it took me to get used to the bite?" I said, "I don't know." She said, "@ minutes." That's because we opened it on the hinge, brought her back to where she was , brought her vertical back to where it was at age 16, where it should be. That is so comforting to patients to do that.
Howard: You bought this woman's practice?
Thomas: I merged it in.
Howard: Was it a merger and acquisition? Did you buy her practice and took all her charts and not the equipment? What did she do? Did she go back to school or?
Thomas: She retired from ... Moved to Hawaii.
Howard: She retired. What do you think her actual mistake was? Do you think she was ...
Thomas: She was working with minimal staff. My staff bails me out like yours does. My staff saves me. She was working with minimal staff, she had bought into this theory of all the teeth have to be paper white, you don't want to see any margins. You want all your margins under tissue. Then figured out from there that she could do this stuff pretty easily with using very basic techniques. Not using articulators, not using ... Through the labs that this group down south of here works with. She was not careful about taking impressions. Most of the margins are short, long, open.
Howard: What do you think is wearing down the opposing teeth the most. Do you think a lot of it's the material choice? Do you think some materials wear down the opposing teeth more than others?
Thomas: Yeah. Porcelain certainly does wear down.
Howard: You think feldspathic is a lot more brutal than E-Max?
Thomas: Yeah. Obviously. We see that. We're trying something new now, we've gone into a lot of E-Max stuff, I still do a lot of porcelain bond with the high level. I do a lot of E-Max stuff on anterior's we tried some E-Max stuff on posterior, had some fracture. We were starting doing for second molars, lower second molars now. I will only do gold or monolithic zirconium. Monolithic zirconium doesn't look all that great, now they've come up with something new. Dave Nakanishi at Nakanishi Dental Lab does my lab work for me.
Howard: Plug him, what's his www? What's his URL? Do you know?
Thomas: nakanishiDentalLab.com
Howard: Can you spell that?
Thomas: It's N-A-K-A-N-I-S-H-I, Naka Nishi.
Howard: Can you spell it one more time N-A.
Thomas: N-A-K-A.
Howard: N-A-K-A.
Thomas: N-I.
Howard: N-I.
Thomas: S-H-I. Naka Nishi.
Howard: Nakanishi.com where's he out of?
Thomas: In Bellevue.
Howard: In Bellevue, you were saying he's talking about a new zirconium?
Thomas: He's got something new, he calls it Imagine. He says that the strength of this material is not as strong as monolithic zirconium, but it's 3 times stronger than E-Max and it looks great. We're going to try some of that.
Howard: I only have 7 restorations in my mouth and they're all gold, but so many women always tell me but you're an old bald man what do you care. It's just so hard to get ... I tried to draw the line with women on maxilar second molars. I said, "I swear to God if I do a gold crown on your maxilar upper second molar I'm going to be the only guy that ever knows. I don't think your ENT will even know. Naka ...
Thomas: Nakanishi.
Howard: I don't N-A-K-A-N-I-S-H-I, is not getting it. Anyway what else did you want to talk about? I've only got you for 9 more minutes.
Thomas: I love the posts on Dentaltown that are about practice management, because everybody has the same issues in practice management. Whether it be with patients or with their staff. You all have the same issues. It is kind of hilarious to read the posts from the young guys who are just getting started and they're trying to deal with staff problems. Whether it be just the behavior issues or somebody's going to test or somebody is going to do it their way. The staff starts to fight amongst themselves or maybe the other thing is when patients come in and start talking, start dictating treatment to you.
A couple of things I always say on Dentaltown is that whenever somebody comes in and tells me what an idiot the last dentist was, I know who the next idiot is. At that point I get very, very cautious and I go very, very basic. The other thing I always say is that patient directed treatment has a high failure rate. It doesn't mean that you don't want to exclude your patient from your treatment decisions. A lot of times patients will come in and try to tell me how they want this stuff done and yeah, you can do some of that but some of the things that they want just can't be done.
Howard: I've only got you for a few more minutes. I want you to give your closing remarks on ... You've been doing this from 72 to 2015, 4 decades you've seen this industry 5,000 kids just walked out of dental school a month ago in May. They're scared because they have 250,000 dollars in student loans. They're scared because they see corporate dentistry. They know that in the old day, 50 years ago when I was a kid, every pharmacist was an individual, like a dentist now they all work for Walgreen's. What are your predictions? Do you think in 50 years we'll all be working for Walgreen's? What did ...
Thomas: No. No. No. The market's changed the market in dentistry has changed significantly, but what didn't change is the patients. The patients are still the same. What the patient wants, there's categories of patients. The type of patients you really want in your practice, what they want is that individual one to one intimate relationship with the dentist, with somebody who they trust who obviously knows what they're doing. Develop that interpersonal relationship with the patient.
That's certainly been the most joy for me in my practice is seeing the kids and the grandkids come through and talking with them. The graduating senior hasn't changed since I graduated. I just hired a young man for an associate position here because I need some help. I want to cut back a little bit. He graduated right at the top of the class and I'm here in the classic suburb of Bellevue with Nordstrom's right next door and all my patients are basically all Caucasian and everything and I hired a kid from Persia.
Howard: Iranian.
Thomas: Iranian. He's been in the United States 9 years and he graduated right at the top of his class, Arman Abetti. Right at the top of the class and won all the awards, so I've got to patient [crosstalk 00:55:42].
Howard: Where did he go, did he go to your school? University of Washington?
Thomas: Yeah. I said, "Okay, here you go." This guy's got a loose implant. I don't know what it is, it was done in Argentina. Bellevue now is people from all over the world coming here to work with Microsoft. I don't know what this thing is, he was supposed to bring some information because he was going on a trip. See if you can find the screw axis and take that thing apart and just see what happens, put it back in. It turns out it's an implant made in Holland, Dymo was the brand, I'd never heard of it.
Howard: Was it made in the Red Light District?
Thomas: I don't think so. That's where the engineers lived. It had a stock abutment that had an integrated screw in the stock abutment and used a slotted driver so you couldn't torque it. This crown on top of it was cemented on with temporary cement but it had been there for years, s I couldn't get it off. I put him in a room with this patient and said, "Figure it out." After a while he comes out and his eyes are big, he doesn't know what's going on. I had to go back in and finish the thing to get it off and get it back on.
Howard: That's what I love about Dentaltown, because guys like that will take a picture on their iPhone and they've got the Dentaltown app and they'll go post a picture. I see people everyday say, "Should I do an E-Max or a Zirconium on this the patient is getting numb. Before the anesthetics get off 5 people like you, bless your heart have answered him.
Thomas: 5 responses on it.
Howard: I also think that's interesting, you're saying you live in Bellevue where there's people from India and Iran and Argentina and everything. It's amazing, I've lectured in so many countries and almost all the countries. If you go to Vietnam, they're all Vietnamese. If you go to Korea they're all Korean. If you go to Japan, they're all Japanese. If you go to Poland, they're all Polish. If you go to the Ukraine they're all Ukrainian, but gosh darn the United States, Canada or England. It's about the only 3 places in the world.
Thomas: I can't tell you the number of times I walked into a room and I'd have to tell them, "I'm a mono-linguistic idiot, what's your name? How do you say your name?
Howard: That's what I love about it. That's why America and England and Canada and Australia, have such rich cultures because you've got food and music and entertainment and wine from every corner of the Earth, it is amazing. I still think the only city I've ever been to in the world where you can actually eat authentic food from v corner in the world is only New York City. Maybe [crosstalk 00:58:42] and second to that would be London. You can't do it in Hong Kong, you can't do it in LA, you can't do it in Africa, Latin America or anywhere like that. Okay, I've got you for one minute. In one minute what is your graduation school advice to the 5,000 graduates?
Thomas: Just get out and try everything. Get out and just work and this young man working for me works, when he's not working for my office then he's at a community center doing mostly walk in patients. He's like, "God, I had to do so many extractions my arm was hurting." He's a great big guy, "So many extractions my arm was hurting." My advice is to try everything. Get to tough. Go to work, get tough. Do this stuff, til you're tired. Keep your eyes open, what you learned in dental school is some of it's correct, but only some of it there are so many other products and techniques and treatments that are successful. You just have to go out and try everything. See what works for you. When you see something that works, remember it and repeat it.
Howard: I'd like to tell those graduates that at my age, nobody gets to the top in under 10 years.
Thomas: Oh no.
Howard: You're going to have to do 10,000 units of everything before you start doing good. Number 2 remember that you can answer a lot of questions by saying money is the answer, what's the question. In this country of ours as opposed to all the other 6 continents, you're always going to have 25,000 specialists saying, "You don't need to learn that." If you want to do that, you should send that to one of the 9 specialties. I always want the young kids to say, "When you were in specialty school, did you ever do your first case? How come you were allowed to do your first case, I'm not allowed to do my first case." Just try it, what you're going to do is you're going to try stuff and if you don't like it you can throw in the towel. You find out why you don't like it, you probably don't like it because you're not good at it. Do more [crosstalk 01:01:08]. Do more CE's.
Thomas: We have to function. The standard of care in my community is set by the specialist. If I'm going to do a procedure, I have to do it at that level. There are procedures I no longer do.
Howard: The ones I don't do is because I learned how to do them, I just don't enjoy them. I used to do a lot of ortho, I don't anymore. I've done pediatric dentistry because I have to, I have to do it all the time, but I'd rather seriously be a underwater basket weaver than a pediatric dentist.
Thomas: I don't do any pedo, I don't do any endo. I love endo, I can't make money at it. I can't do it as fast [crosstalk 01:01:50]. I love it.
Howard: That's what I came to the conclusion with ortho. They're flipping these chairs in 15 minutes. If you're flipping them in a half hour.
Thomas: Scare the hell out of you.
Howard: Okay. We are out of time. I just want to say Thomas, seriously, seriously the fact that you're so giving and humble and sweet and nice and have answered 6,000 questions on Dentaltown over the last decade. I always smile when I read your posts. You give Vince Lombardi advice on subjects from A to Z.
Thomas: I don't think so.
Howard: No. No. I just think you're a hell of a great guy. Thank you so much for spending an hour with me on your Friday.
Thomas: Thank you Howard, you're the best. When I retire and get down to Phoenix I'm knocking on your door for a job.
Howard: Please do. Please do. We've got everything from clinical, to websites, to CE, to magazines. I'll be your buddy in Phoenix. I can show you where all the good drinking spots are.
Thomas: You're my buddy now. Thank you for everything you do. It's wonderful.
Howard: All right. All right. Tell your lovely, lovely wife Linda, I said, "Hello."
Thomas: Oh yeah. She remembers you.
Howard: Okay. Have a great day.
Thomas: Okay. Take care. Thank you.