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1491 Dr. Jean C. Wu, DDS on the Art of Prosthodontics: Dentistry Uncensored with Howard Farran

11/2/2020 3:00:00 AM | Comments: 3 | Views: 392

Dr. Jean Wu is on the Executive Council for Pacific Coast Society for Prosthodontics and a Past-President for the Academy of Microscope Enhanced Dentistry. She is also a member of the American Dental Association, the California Dental Association and the Orange County Dental Society. She was a Board member of the Orange County Dental Society in 2011 and Senior Delegate in 2012. Currently, Dr. Wu is Partner in the Sheets, Paquette and Wu Dental Practice and on faculty with the Newport Coast Oral Facial Institute, a non-profit international teaching and research center. She is also actively involved with several research projects on dental implants and materials and has published articles in several dental journals.

VIDEO - DUwHF #1491 - Jean Wu

AUDIO - DUwHF #1491 - Jean Wu

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*Please excuse any typos as this was digitally transcribed.

It is just a huge huge honor for me today to be podcast interviewing Dr Jean C. Wu DDS if she was in china she would be introduced as dr Wu jinn Ching she's a prosthodontist at sheetz paquette and Wu and I’ve been trying to get her on the show since the day we started four years ago and finally my dream came true she's on the executive council for pacific coast society for prosthodontics and a past president for the academy of microscope enhanced dentistry she is also a member of the American dental association the California dental association and the orange county dental society she was a board member of the orange county dental society in 2011 and senior delegate in 2012. she is a partner in sheetz paquette and Wu dental practice and on the faculty with Newport coast oral facial institute a non-profit international teaching and research center she's also actively involved with several research projects on dental implants and materials and published articles in several dental journals experienced prosthodontists with a demonstrated history of working in the dental practice industry she's skilled in endo research everything sleep apnea she's an incredible entrepreneur and uh my gosh uh she's joining us from a hotel because you're Beverly hills a fire the fires made you evacuate yes we we my residence is in Irvine orange county California um my office is in Newport beach so we're probably about um six miles from the fire i because it was getting quite smoky this morning and there was a mandatory evacuation anyway so my kids luckily were at home doing online schooling because of this covered um situation so we took our dog my mom and uh we're here in a hotel in the Hyatt hotel wow that is uh crazy so what do you make of all these fires um is it just a part of being in California i know when um i grew up you know we live in Arizona yeah so we're just like wow we don't get hurricanes we don't get fires we don't get tornadoes we're kind of we're kind of a uh just it's kind of boring out here but is it just a part of life in uh California that well i guess it's um it's been dry so with the drought we've got we we're by the canyon so there's a lot of brush it started as a brush fire this morning and then we've got Santa ana winds i heard it was 50 to 70 miles which is i don't know a hurricane level wind um so when i woke up this morning a lot of trees and um you know the backyard furniture was toppled over and then um we started to see the cloud looking a little uh the sky looking a little cloudy but it was actually smoke so when i turned on the tv i could hear that there was some fires behind us and then with the wind it just turned from 50 acres to i think 6 000 or something like that in a very short time span so it got a little scary and then we got the amber alert saying um there's a mandatory evacuation that's when we packed up and left wow well uh my gosh uh so what what was worst news uh the fire or having to come on my show well i thought as long as I’ve got wi-fi i have um an ability to connect with you so i didn't cancel because i um most hotels obviously have free wi-fi so i hope i don't uh lose connection but it seems like it's pretty strong so no i was looking forward to this Howard i think uh because your podcast has such a wide reach especially to young dentists i think as um now in my fifth decade i feel like an elder now even though i used to be the junior member of the sheets because practice uh actually i still am I’m the youngest of the three partners i still feel um it's important to obviously contribute in fact the first year after i graduated from the university of Melbourne in Australia i was invited to come back and teach so i you know volunteered for half a day a week and went straight back into teaching so i think we have a lot to offer whether it's clinical experience which obviously we've grown to have more of as we get older but also wisdom and business experience which they really don't teach you in dental school so i think it really is important to share our experience because as a younger dentist i always treasured those times when older dentists and professors and the you know more experienced dentists would take the time to give us you know their advice or guidance and i think that um goes a long way it's just kind of a full circle and you know there's there's that human mentor guidance that's so real but at uh I’m 58 i i just can't help but notice that um like all the Americans who are born in America and never left America i mean when they talk about economics macroeconomic anything you can just tell that they're they're not worldly or they they don't get it and it seems like whenever i find really really sharp uh business people dentists whatever they've ever either been international business people traveling the world or they were born in different countries you you were born in china lived in Australia lived in California and let me make an example uh this i noticed that in the six dental schools in California if you were born and raised in the united states you will come out of ump say 400 000 in debt and then you will say that san fran has too many dentists because there's this many dentists um you know the ratio but it's all dentists from like Monday through Thursday to five and then you'll see someone who uh was born and raised in Vietnam and they'll come out of dental school the the American will after 400 000 in debt will go buy a house and buy a car and then rent a dental office i mean they own the place they sleep and they rent the place they work my god if you were born in uh Nigeria you know anywhere in Africa Asia south America they um they'll go buy a dental office they'll live in that dental office they won't even get a house or a car and they'll be open as long as they can answer their cell phone and you come back in five years out of school they've got their whole student loan debt paid off and they've got 200 000 in cash now the American you catch up with that guy 30 years later they gone from 25 to 55 and he just upgraded to a bigger house on a 30-year mortgage he's driving a land a range rover and it's on a five-year lease i mean i mean i just think when you tell me you're a dentist in America that you weren't born here i mean you're just scale more worldly and full of wisdom and since your name in china uh Wu jin jin gene is crystal and chin is clear do you see that crystal clear like i do well i think I’ve um i i always knew that i had the best of all cultures um i was raised quite strictly by i was actually born in Taipei Taiwan but nevertheless the the work ethic is very strong so you were always um just from example my parents ran a restaurant so i lived above the restaurant um and so after school i was obliged to help you know work in the restaurant until after dinner was when i could go upstairs and do my homework but um i you know as soon as i got home you had chores and you're obliged to help with a family business so i think from an early age i knew the value of hard work and how that would pay off and my my parents operated the restaurant seven days a week um dinner seven days a week lunch five days a week we closed on good Friday and Christmas day we never really went on vacations I’m not saying that is a good balanced lifestyle i don't think it was i think they worked really really hard but i think in order to get ahead they had to do that because um you know my mom had no college degree but my dad was a diplomat with the Chinese government so he was bilingual and taught himself how to speak English actually by reading the dictionary and so that's why he was sent from Taiwan to Australia and he saw an opportunity to be a chef and have his own business so he left politics and opened up the restaurant because he knew that if he was his own boss he could keep all the money instead of working for somebody so i think that instilled in me that in order to get ahead you have to work hard um try and be your own boss invest your money save your money and make the money grow so they invested in real estate and i i realized that there are other ways obviously to invest but it was always that you don't spend all your money that you try and keep enough money to make it grow and spend wisely within your means and so you know i was a waitress during high school and all the way through dental school in order to earn some pocket money and um my my parents obviously helped me um as most Chinese families do to help you with your school uh um you know paying your school and my dental school but i paid for myself for my American degree because once i came from Australia to America i had to go back to dental school i met my husband at the university of Pittsburgh when i did a fellowship in maxillofacial prosthodontics and after we got engaged it was quite a sacrifice to move from Melbourne Australia to Memphis Tennessee his uh with FedEx and so i realized after teaching at the university for a few months and volunteering that i couldn't not do any clinical dentistry and just be a faculty member with my Australian degree i was not allowed to treat patients i could only teach in the clinic and not put my hands in patients mouths but i could tell them what to do so that was obviously not acceptable so i went back and did a DDS degree at the university of Tennessee after i had already obtained a master's in prosthodontics and a five-year dental degree in Australia but i realized that not being a clinical dentist and just being a faculty member was not enough for me so i knew i didn't feel confident in just being faculty without having clinical daily experience so it was quite a sacrifice to do the dental school in two years instead of three i finished in two and after that then that's when i came to California from Memphis Tennessee um and that's when i met uh shaolin sheets and Justine paquette through an endodontist so just in your intro you said that i can do endo i actually don't do endo I’m just a prosthodontist but i met them through a very good friend um Gary car who's an endodontist in san Diego yes i know Gary he's the only uh dentist on earth who kicked me out of his class because me and mike diastole were not endodontists it was for endodontists only so we had to sneak in and uh so uh thank you Gary he was very kind to me because uh i spent a day with him and he said you've got to go and meet Cheryl and sheets and Justine picket um and so i drove up i was living in san Diego at the time and that kind of changed my my trajectory because i was ready to buy into a practice in san Diego well i don't like to ever talk about religion sex politics or violence but i have to bring it up when it's fair when i got to school out of school in 87 um there was a um about a 85 year old 85 probably uh Jewish woman who escaped Nazi Germany um before um um hitler uh took over and when she got to Arizona they you know she was a dentist in Germany i mean this isn't you know a dentist in you know uh some crazy country this this is Germany where they make mar cities buns she comes to the land where they make Chryslers and they said you can't be a dentist and she was married she just left everything she had in Germany and but the uh the lawyer said but you know the loophole is you can own a dental office so it forced her to own a dental office but can't do it and so by being that way when i got here she had a north south east west she had a driver like a limo literally a limo driver and she just drive around she just had the high life and but i was sitting there thinking um you know i underst i i i just don't think it's what America is based on i mean she came here from Germany i understand that the Arizona state board can say well Howard uh went to dental school in Kansas city Missouri where dr jin Chen Wu went to Australia we only license Howard because you have to go to an American dental school but but they don't say well gene is not licensed or approved by Arizona they say not only not licensed you can't practice and if you do we'll hire the mob the police to go arrest you kidnap you put you in a cage and deport you and then they did it with the person that i bought my mcmansion from uh some poor lady that owned her own business made millions uh just the epitome of the human and she got brain cancer and an American pharmaceutical company had a drug but it was in fda trials and she said well why are you doing on rats and monkeys I’m volunteering no no you're not allowed and so she had to sell the house to me moved it moved to Scandinavia where she could get the American drug and it's like it's like okay the FDA has not approved this drug i understand that but I’m dying from the disease and they said I’ll be dead in six months and you're spending years on rats and monkeys and mice can i just try it on me and the government says no so now that you've been here and been practicing for decades do you think that the board should just or the FDA should approve a drug or not approve a drug or license you or not license you but not use measured violence to keep you from selling your drug or doing dentistry on someone who wants you to do on them yeah i think i understand um now you can be licensed or um by credentials so at the time uh they did not accept my credentials but now if you've been a dentist i believe for five years in your home country you can pass a series of examinations and be you know accredited or be eligible to sit for the the state boards so i at the time felt that it would be a maybe a weakness if i just got my license in California because i could have done a series of examinations to obtain my license in California but it would have taken almost just as long so i decided to get a dds in case we went to another state because if i just obtained licensed here in California and we decided to move to another state i would have had to overcome that state total or that regional boards so i decided if i was to stay in America i better get a an American degree and not be at a disadvantage to you know uh you know if we wanted to move or if i wanted to make a change so i took that route but i could have done part one and part two of the state requirements and then be eligible to sit their state boards at that time but i figured it was more powerful to get the DDS degree and be recognized in America so i think you need to protect the the public from um and maintain a standard of care for dentists uh wherever you're from i mean i felt that Australia was part of the commonwealth equivalent to Canada England you know Singapore many um first world countries so it's not like i was from a third world country and so i think we should have been able to show via our transcripts and maybe by equivalency accreditation of my school which was a main school in the city of Melbourne which is a you know 4 million people population in Australia we should have been able to compare the credentials and accreditation of the school but maybe now i think it's a little easier for foreign dentists but at the time i just didn't want to be held at a disadvantage uh you know to be able to transport or move if i wanted to um so i chose that route but in order to answer your question i think the safety the public whether it's drugs whether it's clinical dentistry there should be some measures and certain criteria to keep the public safe and then some sort of you know common sense and sensibility has to come into play as well if you have a dental school in a first you know developed country like Australia which is equivalent to Canada and England although some could argue that the dentistry in those states or those countries are socialized and maybe inferior but i i would beg to differ i think it's first of all safe and those countries use kind of the same materials the same textbooks the same philosophies of safety and clinical standards we should be able to compare them and and be able to still keep the patient public safe i am i you know i grew up in Kansas and uh went to dental school in Nebraska i mean uh Creighton and Nebraska for undergrad in dental school Missouri and i gave my first lecture august 4 1990 in new York city only because this little country boy wanted to see new York city and i still can remember to this day like it was just a looking out the window then all of a sudden realizing that black canyon over there was buildings just blew my mind and i i i think the the single greatest thing i got out of uh lecturing was to go meet other dentists in other countries and i i am so impressed by Asia i mean Taiwan japan Korea um i got to speak at the the world dental conference in china and um again i don't want to go into politics and honestly but um man asia is just so exceptional like Taiwan has the same freed Zakary was talking about this on Sunday um Taiwan and new York state have the same population and Taiwan had seven deaths from coronavirus and new York state had 34 000. you're live you you you born in taiwan you're in California um what what what is the difference why why why did 34 000 more people die just a new york state than in taiwan and taiwan was right across from wuhan i think they they they realize the the transmission the mode of transmission early and the public um you know followed the uh guidelines of you know wearing mass and social distancing and they were willing to be um controlled i guess by the government in terms of their movements and um businesses with screening and temperature and tracking and testing so i think um obviously in America with we're very protective of our um our rights and freedom of speech and so i think that comes at a disadvantage of just people feeling uh unable or unable to accept that the government has certain implied restrictions that keep us all safe and so you know it doesn't need to encroach upon your freedom of speech but it's just common you know society uh protection and and empathy for your fellow man to to try and do what we can to keep each other safe so in asia there was no disagreement about having to wear a mask and being trapped and tested and temperature taken at every business and you know maintaining a certain restriction on people's movements and travel because they knew it was for the common good so in those countries who are accepting of that the population was safe so in America it's harder to police we've got a bigger population people don't want to be tracked people want their freedom people want to be able to express themselves and so i think that is a more difficult task for the government to control us we don't want to be controlled but but then they go out and get married i mean come on come on talk about hypocritical um but but do you agree that they wear the mask differently in china because i remember the first um time i went there i thought for a couple days that they were wearing it for health reasons for them for pollution whatever and then my friend edumacated me saying uh no she's probably worried that maybe she has a cold and she doesn't want to spread it to everyone else yeah i think a lot of people in asia do wear it for pollution and air quality but i think they are also aware of whether it was sars or other flues or swine flu other um contagious disease or even tb and um that it could be communicable with uh you know saliva and so in order to maintain personal hygiene you know that is probably a good idea to to protect yourself and others yeah so you're um in newport beach so for international lectures um where's newport beach for the international people is that just a suburb of l.a you can imagine um south of la north of san diego along the coast uh you know a lot of people have heard of probably Laguna beach because there's some some tv shows you know reality shows based in Laguna beach so we're right along the coast of uh you know the pacific highway um it's a very affluent uh part of orange county which is south of la it's probably about 40 minutes without traffic from lax airport in international airport it's also maybe an hour north of san Diego which is another very beautiful part of the coast along California and then maybe another hour to the Mexico border so if you can imagine two hours from the Mexico border one hour south of l. A okay now if i got in my car at the Mexico California Tijuana san Diego border and drove all the way nonstop down that big interstate to the California Oregon border how long of a drive would that be um California Oregon border uh i don't know i know from here to san Francisco it's about eight to twelve hours um depending on what part of north you know um northern California is so i i don't know I’ve never i mean it's just it's just a monster stairway so it is so uh big um that that uh yeah i mean just just crazy big so um another question i gotta focus on is um when you came to the united states or when you became a dentist in your lifetime first in uh Australia and the united states did you feel like it was a man's profession did you feel like being a woman was um a minority to talk about those days compared to 2020 yes i graduated in 1990 in Melbourne Australia my class was about 50 50 female male ratio it had just be begun to be about 50 50. um i did feel when i graduated that the the practicing dentist was still predominantly male um that most female dentists were working part-time because of family at you know the age that we graduate we're usually married and child bearing age and many women and my friends included would probably suspend their practice to go and have a family and some came back part-time and some actually never came back unfortunately because of various reasons whether it was child care or whether it was because of um interest they felt that their priority was their family and they could go back to practice later i always felt that i could do both and when i first graduated 1990 i was not married and did not obviously have any children so i threw myself 100 into my practice and was very involved with uh you know the the curriculum council at the school with some the ada and my local branch with the prosthodontics society i just knew that in order to learn and to grow my business and my network i had to be out if i was just in my practice nobody would hear of my name so i luckily had some very strong mentors people who were president of the prosthodontics society people involved with the ada who nurtured and encouraged me because i was never afraid to speak um i think a lot of people who are shy who don't like public speaking or who don't feel comfortable standing in you know or in even in a group of people and to have a voice may not be as actively involved but i was never shy i always um i guess i had a very strong father figure when my father knew that i wanted to be a dentist he said just whatever you do whether you're a dentist whether you're anything whatever you do just be the best and and be special don't be average so i never wanted to be average i always wanted to stand out and do something to make myself be special whether it's in what i do what i could contribute whatever it was i knew that i wanted to be above average so when i was involved after dental school i just found it interesting as well as a good networking practice builder to go back and just participate whatever it was that i did so i was out nearly every night whether it was going to a meeting going to a continuing education meeting going to a study club i just knew if i sat at home and watched tv i would not get ahead and so um doors would open so the more you get yourself out there the more people you may feel more opportunities for in your lap and if you say yes enough times people you have a reputation of being a contributor so people would then ask me to participate and nominate me and and encourage me to join their groups and so moving myself up from you know a secretary to a vice president to president of the prosodic society at a young age before i left australia was all through just participating and being available and just saying yes and doing the best that you could when you did say yes and where did where along the way did prosthodontics come in your mind i mean uh there's there's now 12 specialties um where did that come from i was always very artistic um growing up i love i love art and sculpture so when i first graduated from dental school i did life drawing i did sculpture i did ceramics i was always visual and very tactile so i felt that i didn't like endo sorry endodontics out there because i couldn't create beauty and form and function um i knew it was very important for obviously disease and pain control and i critically you know appreciated how important that profession was i didn't particularly like scaling and root planning i liked oral surgery but i felt that i could do more with my hands in creating a change in terms of somebody's function and and presentation and aesthetics with prosthodontics so that always interested me whether it's carving a simple amalgam or doing a wax up or setting some dentures that excited me more than other things orthodontics is interesting in moving teeth but i like to change shape and and utilize that for also functionality so prosthodontist always spoke to me so i did a general practice residency my first year out where i i had a taste of oral surgery trauma you know perio endo and i that's kind of one year out where i did a little bit of everything cemented my interest in prosthodontics and then that's when i went back and did a two-year master's in prosthodontics and then a further one year in maxillofacial prosthetics and right now we're in the middle of a pandemic I’m sure you got the memo on that um a lot of kids are sitting there thinking um maybe it's better to just stay in school and specialize and unlike you when you and i got out of school there was only eight and they've added a whole slew of now we're up twelve so now there's um and I’m gonna put these in uh most demand as far as uh for enterprise dsos uh all that oral surgery endodontics perio pediatric ortho pros dental anesthesiology or facial pain oral med oral path oral radiology and then last but not least dental public health um first of all i want to back up a question um there was a lot of controversy um with these new specialties oral facial pain oral medicine um did you think that was a good thing or did as being a specialist did you think it was diluting the water um how did you weigh in on those new specialties i think those new specialties that if it's complex and requires further education and more training i think it is worthwhile i don't know that it dilutes our profession i think it only elevates the degree of sophistication and education and research in that arena because dentistry is only getting more complex i don't think it's it's easier to be a master of what your of your craft so if we have more highly educated um more uh specialty trained dentists i think that only helps a profession in elevating the standard i think what's key and important is that we are not too narrow in our vision so even though you're a specialist i think you should be obliged to at least practice one year out of dental school so that you know at least what all the other specialties do because if you go straight into your profession or your specialty outside a dental school you have no idea what the practical real world uh you know dentist dental experience is and so if you're treatment planning or discussing a case with other specialists it's difficult to do that if you've never experienced just general practice um when when someone tells me like you that you're a prosthodontist um is it when someone says I’m a prostitute is it mostly fixed prosto i mean is removable um just kind of going the way of you know uh you know or would you would you say what percent of your world is fixed versus removable i would say probably 90 percent is fixed but it would be a shame if we lost the ability to be able to make a removable partial denture or full denture because if you're doing all on four or all on six or you know all on whatever um you need to be able to set the teeth in the right place people don't come in with a perfect dentition and need all their teeth out and and have it and transfer or transition to an implant supported prosthesis if you don't know how to set a denture if you don't know how to identify the occlusal playing and where to set your two fronts uh two centrals you're not going to be able to make any implant supported or even be able to digitally design a denture if you don't know those parameters so you need to have some sort of uh ability to even make a provisional appliance not everybody can have a a fixed provisional transitional appliance sometimes you need a removable appliance so if you don't have any training in that or ability to to service your patients with a removable appliance i don't think you can adequately treatment plan or be able to you know set the occlusal design for their fixed uh prosthesis so i think it would be a shame if dental schools don't continue to teach you know how to do removable uh prosthodontics because that is an essential part of transitioning to a fixed prosthodontic solution well you're not going to like my answer to what you just said the reason i got into implants in 1990 is because when i went to seek my upper denture i i couldn't let go of it because i i didn't know if it was just going to free fall or have suction and i was so scared i finally got an implant because i figured the only way i could make an upper denture was to nail it down with a bunch of titanium by the way kyle just sent me it's a 12 hour and 30 minute drive on an interstate from uh mexico to oregon my god that's a huge say but you know um here's my theory the i think the people that get a's in math and physics and chemistry and biology uh they they didn't they're not the you know they're they're not extroverts they're not people person they they're they're they when they're alone they get re-nursed and when they're out with people they get drained and on dental town you know since 1999 it seems like the number two thing to stress out people our dentist are patients and their staff i mean i i think dentists are the happiest when they're in the lab the door is closed no one's in there and it's just them in their bunsen burner or in the library i mean um so um so when i tell them you were talking about how important it is finding mentors but i know my homies and she's she's just too shy but where i think um your mentors can give you the most is not in helping you oh you broke off the root template or let me help you get it out it's in diagnosing and treatment planning and my gosh you're young and you want to network um with with um you know a very um distinguished prosthodontist but if you called her up and said can i go over some x-rays and a study model whatever that might be an icebreaker and that's why I’m um i see the concern again not undergoing politics but like take global warming i mean you know the first thing they wanted to do of course the mob the first thing they want to do is shake you down for more money and do this carbon tax and all this stuff it's like whoa wouldn't the first thing you do is get all the scientists in one area and figure out exactly what's going on and get a diagnosis and treatment plan and then implement it and i see i would rather the dentist gets an a on the diagnosis and a c on the work than a c on the diagnosis and an a on the work i mean um what would you and they're so young when they come out of school they don't know what they don't know and diagnosing and treatment planning i mean i i don't know how you would understand that for the first 10 years out of school what are your thoughts on how they could accelerate diagnosing and treatment planning i think uh if they're working with an elder or a senior dentist that would be a start i did review my cases with my mentors a lot when i was first starting out and i was i never wanted to practice alone i actually like being around people um i like to talk and to feel to have con affirmation that what I’m doing is correct um and what i when i don't know something it would be nice to be able to have somebody there to to run a case by so um when i first started i always had other dentists around me who were more senior and more experienced that i and if i didn't have somebody that i knew was able to counsel me or guide me i sort that out so whether you go and join a study club a local study club or whether you go down the street to the specialist in your area and make a introduction i think the specialists when you when you pick up the phone or you reach out to them by whatever means most people are very obliging because they know that if the case is too difficult you will give them and refer them to work so they will get business um in a roundabout way but even if they don't make any money uh from helping you which most people are not focused on that to tell you the truth i think most of us who've been in practice long enough do want to help the younger people coming up below us and i think um most people find it refreshing and and most of us are not that busy that we can't give us you know give somebody a few hours of our time and it's not that often and if you get um a relationship with those people it actually is quite um enjoyable to help young people because makes you think so i always knew that when i was coming up you learn one you know what do you do you watch one teach one do one you watch one do one teach one so when you teach somebody it makes you go back and think how can i transfer my knowledge does it make sense and why do i do what i do it makes you think about what you do and it actually helps you cement and clarify your methodology or your rationale your philosophy so i think it keeps us on our toes when we actually mentor somebody and makes you really stop to think why do you do what you do and what is the rationale and makes you keep up with the literature as best as you can and uh makes you want to participate and and sometimes when i go to a meeting even if you don't hear or learn anything too different it's reassuring to actually see that what you do is actually the current standard of care or the state of you know technology and knowledge that it's um reaffirming so you that was uh just amazing you said see one do one teach one yeah and so basically what you're saying is that when you're mentoring a young kid going over uh cbct and models and treatment plan that you're actually benefiting from that too yes because i think it makes you organize your thoughts it organizes your protocol your methodology your philosophy so that you can express it and verbalize it and you know explain it so if you don't know what you're doing it's hard to come across and explain it and make it sound like it makes any sense so it helps you organize your rationale and I’m going to play the spoiled entitled brat syndrome children that I’m having to go over now with a seven grandchild my four boys have turned into uh uh seven grandchildren but it's always the oldest one he's already saying but I’m never gonna need to learn i never need to know algebra I’m never gonna need to know this so right now she's saying i don't want to do dentures i i don't need to learn dentures I’m not going to do dentures and you're like okay you're not going to do them but you need the knowledge and she's saying no I’m never going to do this the people who say i don't need to know dentures they're relying on a technician you give them a model without any teeth or very few teeth or a deranged male occlusion that you need to restore and you're asking that technician set the teeth do the wax up for me and then give it to me all done but that is not as the dentist you should be telling the technician this is the occlusal plane this is a midline this is a just on the canines this is a smile line this is the occlusal vertical dimension this is the mold and the shape of the teeth that i want this is the shade now set the teeth for me you shouldn't have the technician find the landmarks the midline the occlusal plane the retromolar pad the the vertical dimension how does the technician know without having met the patient a they're also not a dentist they don't know anything about occlusal vertical dimension of occlusion freeway space neutral zone lift support how is a technician supposed to tell you where the teeth should go because when the where you know when you know where the teeth will go then you know where the implant should go it doesn't you don't put the implants in the bone and then just hope that the teeth can go over it mechanically aesthetically the exit points with the actual loading for the implants nothing's going to be correct you need to know where the teeth where the smile line whether the phonetics whether where the occlusal dimension of occlusion those are the basic fundamental guidelines for setting the teeth the teeth have to be set first before you can do your implants so that's what i would say if you're relying on your technician to set the teeth that is not why you went to dental school the technician is not the the quarterback the technician should be part of your team that is told and or you collaborate and say these are the guidelines um you know some technicians have a um a true talent for shaping and setting teeth and and obviously for ceramics I’m not the expert on that but i need to tell the technician a where to set the teeth where the incisal edge should go where the smile line is that is not the role of a technician right that's what i would say to somebody who says i don't need to know dentures yeah um so when you um or so i want to focus on the kids in school because i i feel like you and i got out at a great time we've benefited immensely from this profession and um you know they they came out of school in 2020 um four hundred thousand dollars in student loans um the um to put in perspective dental town has had free classified ads since like 1999 and there's always been about um 1 000 practices for sale and about 5 000 associate jobs needed now it's 2 000 for sale and just 1 000 jobs um a lot of the dentists you know if if they haven't been divorced if they've never divorced they can cash out and retire 60 no problem at age 60. if you get divorced once you push that back a decade and if you get divorced twice you die at the chair okay so a lot of the dentists when they start hearing all this ppe and all this stuff they just said I’m done selling it what would you say to the class of 2020 where they're texting me and emailing me saying right here in Arizona saying dude i can't find a job i got 400 000 student loans and and but here's the thing about the entitlement here's what really is just just um they say oh well i said really you can't find any job they go oh yeah if you want to go to some dso medicaid clinic in south phoenix and there's this other one where he's on all the ppos and I’m like okay okay and and this one's only going to pay 20 I’m like so you'd rather be home unemployed than working at 20 of collection at a medicaid clinic because i mean that's just finance you're still getting to practice people skills and trying to get a kidnam and do your art do your craft what advice would you give these kids during the pandemic i think i agree with you that there's always a need whether it's in a a clinic that may be not the type of business structure that you're uh obviously ideally interested in um you've got to start somewhere so whether you get a few part-time positions um you you as you say you get real world experience you get your speed up you get clinical experience you get business experience you get people management skills and so just start doing something it's not your forever job my first job and and I’m sure everybody's first job was not your your last job so you learn from every life experience that you have um you you chalk it up to experience good or bad and when you do have a bad experience you know the next job you take you don't want that in your job description or you don't want to work with people or a business structure like that so you get to to kind of develop your philosophy of how you want to practice what sort of person you want to be what sort of manager you want to be what sort of clinician you want to be and what sort of dentistry you want to do and so i think the more you see the more you do the more you know what you want to do next specifically so i I’m I’ve been telling them you know if you can't find a job go specialize because not number one i mean uh my gosh the average net income for dentist for dental specialists average all us general our dental specialist um is netting 320 is showing 320 000 income whereas the general dentist is 197. general dentists who own their own practice um averaged 244 000 dentists or employees at 147. um when you look at oral surgeons 448 periodontists 330 endodontists 307 pediatric 304 ortho 289 prosta only 219 but it's still um it's still extremely high um would you um would you recommend prosthodontic as a specialty do you think it's needed do you think um yes i would endorse it go become a prosthodontist or would you say no i do i do feel it's needed i mean in our practice we it's referral based whether it's from other specialists or even patients refer because many of our cases are re-treatment and so it many of patients have gone to whether it's a general dentist or a cosmetic dentist or dentists who say they specialize in implants or reconstructions and don't know enough about what they're doing enable to be effective so whether it's a lot of the time it's a collusion um sometimes it's due to poor um execution of the dentistry whether it's preparation design you know encroaching upon the um the zone of um you know attachment and and sub-gingival margins and causing uh chronic perio whether it's a fit of restorations and cutting corners and having open margins recurrent decay and um soft tissue problems there are multitude of complications that it can occur when you don't have the the big picture um anybody can prepare the teeth and cut them down and remove enamel it's it's the application of the occlusion is understanding the the vertical dimension the phonetics the um the setup of the case and knowing why the case needed a reconstruction in the first place which goes back to the treatment planning and diagnosis it may seem easy to do a mouthful of preparations and just you know have some pretty ceramics but if the occlusion is not correct or if you don't understand what led to the breakdown in the first place whether it was disease process whether it's para functional process it it's it's not going to last so i do believe the specialty is important because we have further training in the more complex uh male occlusions and occlusal derangements and so with you can't get that in dental school so there are some super generalists who go out and do continue education who sign up for other additional institutes whether it's panky or others who help further their education process after dental school and they're very well qualified but most people who come out of general school don't have enough training and background to be able to take on the more complex cases without further education so therefore um it is an important as a specialty because there are um other additional uh you know didactic um training that has to be performed after dental school you just can't cram it in and know about everything sufficiently after general school and with implant dentistry whether it's um you know cad cam dentistry it still goes back to the fundamentals as you uh correctly said out of fundamental diagnosis and treatment planning and then how you execute it whether it's analog or digital the diagnosis and dream planning is still critical and so i don't think we get that adequately in dental school if you come out of school and you're four hundred thousand dollars in debt and then she wants to grow up and be just like you and she thinks to do that i need to go by she starts her own practice and she sees i gotta buy a cbct there's a hundred thousand i need some fancy millennium laser there's another hundred thousand a chairside milling there's a hundred another hundred thousand for a cereal machine she can make three purchases and double her student loan technology so I’m gonna hold your feet to the fire and try to get out of you what high-tech equipment does she have to buy to practice just like you um well I’m I’m a little biased i would say the clinical microscope because i think that that automatically will elevate your standard of care because just to practice with loops with a headlight um just to go and start your examination and diagnosis you can see a lot more if you're magnified greater than two three four five six times magnification so in my opinion the microscope was life changing you can always refer the patient out for imaging whether it's a cone beam or a panoramic radiograph you can always take a analog alginate or polyvinyl suboxane model and have that scanned if you want to do some you know digital male dentistry but if you don't see and you miss a diagnosis if you don't know that your restoration is not fitting and there's recurrent decay or micro leakage or um you know inflammation or retain cement uh your dentistry is not going to be doesn't matter how high-tech you are your dentistry is not going to last and it's not going to be pain-free um even simple things like just checking occlusion uh the microscope tells you a lot about wear facets about you know wear patterns diagnosing you know cracks just seeing how the overall dentition appears magnified um diagnosing microgaps or you know open margins overhangs open contacts it is immeasurable how much i think the clinical microscope has elevated my standard of care and that came from seeing dr sheets and dr pickett's practice i thought my two and a half times loops was great until i sat down at a microscope and saw how much more i could see and it keeps my tooth preparation conservative it it elevates every ass aspect of my practice from examination and diagnosis to the execution of the clinical dentistry to the delivery to the final check of the the cement removal adjusting the occlusion i think that would be my advice because all the other technologies you can you can farm out whether it's that the the lab can scan your model you can send it to an imaging when we started we didn't have a panoramic radiograph um facility we had to ship it out to the imaging center down the street so you can still do that without having to spend a bunch of money trying to have your own convenience ct having your own digital you know impression system uh i think being able to see properly to do your dentistry even if your 20 20 vision is not as accurate as a clinical microscope and a magnified vision so that would be my advice that changed my practice so a microscope is a a life-changing deal and oh i still think that was the neatest thing about when i got the cerec machine and samara puri came out to her office and was showing it and everything and i got to see the first time i did a prep under 40x and i thought i thought um i should have my license taken away and dr prairie agreed i mean imagine if Stevie wonder had been practicing dentistry for 30 years and he just got his vision back i mean it's just uh there's there's no simpler way to increase your quality than with magnification whether it be loops microscope um and the endodontists are using it for before they obturate um it's just but but i want to take a step further and the the assistants have to have it too i mean um you know your assistants yeah yeah your assistants uh assisting you and making provisionals in the the hygienist and et cetera et cetera um your most laboratory basic uh lab they have those um you know countertop microscopes but a lot of labs have other microscopes that they check uh things and and as you correctly stated cad cad designed dentistry relies on a scanning and if your margins are not clear you're not even going to be able to adequately scan it because there's so many steps and so many irregularities but that automatically magnifies it on the computer screen for you or the technician so if that first step is not adequate then every step along the way is going to be a challenge and microscopes are not expensive you can get one probably for you know 10 a very basic one or even a used one and even a very good new one uh can be twenty thousand so compared to all the other technology it's actually not that expensive and it and it doesn't break it's like a good mercedes you you used to have to change the light bulb but now it's led it could last you for your whole practice we've got microscopes in our office that are in place for 30 years and you know we've eventually switched them out because they get a lot easier to maneuver for the new mechanics but if you have a good led lighting source they just keep turning on they don't break so there's um you said mercedes-benz uh the german one is zeiss and then the American one is uh global out of uh st louis um which which one of those do you specifically have well we have global microscope but uh we've utilized many other microscopes in our teaching courses i think the key for any uh anything you purchase is follow-up and service so if you can't reach the supporting technical team or the salesperson if you have a question or if something needs to be you know modified or if you need to buy an attachment or have some assistance it will be frustrating if you can't reach the customer service person and in in this day and age a physical person is still important for business so i would say whatever system you buy all the objects are very similar their lighting sources is very similar you just need a dial that changes a few steps of magnification from maybe three to five to nine to 12 to 14 i mean you don't have to have many steps you could just have three magnification levels if anything is better than just having one set of loops that you have to put down and and put back on and i think in this day and age they're all very reliable nothing really breaks you need somebody to help you with installation with attaching a video camera for documentation it's the best teaching tool for patients if you can show a patient what a crack looks like if he can show a patient what a deep pocket and a bleeding calculus pus draining pocket looks like the patient immediately understands what periodontal disease if you can show aware facet and the occlusal scheme with the balancing interference and mobility and and recession and bone loss the patient gets why their bite is so critical for their health um so i think if anything uh you can take from this it's not only does it elevate your quality of dentistry it helps you communicate with your patients it it helps you if you want to put it crudely sell your dentistry because once a patient sees what um disease process looks like what pus looks like what calculus looks like what a pocket looks like what a crack what a um a recurrent decay what an open margin or overhang looks like they will understand why they need that restoration replaced you don't have to sell them anything they will want to change it because it looks terrible if they know the disease is present um so i always tell patients your mouth does not have a separate entry to the rest of your body it is a communicating railroad system the blood vessels communicate with your mouth so if you have a point of disease with bacteria that can go anywhere in the whole process in your body um most people think you know the mouth is separate from the rest of the body it is is this is such a source of biofilm and bacteria for our overall health it is critical to your overall health and inflammation and and chronic level of disease so if you can demonstrate to a patient what is going on in their mouth whether it's basic hygiene um they will get it and they will want to floss they will want to come back for that route planning and and you know pocket reduction they will know what is going on in their mouth so they will want to uh proceed with you know um getting that rectified and when you said um you you uh embarrassingly said um to sell dentistry and I’m one of those unappalled i mean business business you know it's it's supply and demand and if you can't sell it you're not a good dentist and i keep trying to tell these dentists that some of the people who think they're the best dentists in the world they don't even realize they're not at all because if you tell 100 kids that they have a cavity and you can only convince half of them to come in and trade you a coin to get it fixed and the dentist across the street told 100 kids and 80 got it fixed the dentist who did 80 amalgams is better than the dentist who did 50 composites and better than the dentist who did my eight gold inlays and onlays i mean i mean there's something about selling dentistry and i always thought like on your website this is a class example you gotta check out our website um her website is uh sheets and paquette.com paquette is uh fr is that french or french or from paris yes so um but anyway you show your own work and i mean my gosh my plastic surgeon friends say that the reason they crush it is because they'll go to all the plastic surgery doctors and all they have is brochures and posters and all this and when you go to his office this is my work and when you're you know doing something and and i think the little digital camera which i don't know what a digital camera cost but it's got to be probably about the same price your iphone under a thousand dollars 500 whatever but when they go to your website and they see your work before and after i i think that's the greatest sales deal and then to put that in perspective like sometimes I’ll be having dinner with a friend who in in town who like i know like really loves implants and that's his his whole passion he just loves implants but man you go to his website you'd never even know it yeah and and uh you know but if he if he showed me if his website had half the before and after pictures that he's showing me at a bar on his iphone yeah i think he'd double his practice yeah i think um in this day and age people want the visual uh and and so that that is a fast way to communicate what you do and so we even have to update our website more and have more interaction and more click on hyperlinks because uh the worst is not where it's at um people want movement people want visual and and fast information and transfer so um where we need to kind of continue to evolve and our website is a little uh dated but still we are a visual visual profession um i think people also believe that uh obviously pain pain gets people in the door as well but um beauty is a a large part of what we offer our patients as well but we hope that what we offer is not only beautiful but pain-free and gives people the longevity as well so you know visual is i agree very key and that's why we videotape the end of our examination at every new patient or a re-examination appointment because i always say to patients I’m going to videotape the highlights from our examination today in order for me to communicate with you what i see in your mouth and what the situation is so you can better understand the condition of your dentition and and know what your level of health is and where the issues are that we've been discussing because as i videotape their mouth through the clinical microscope i am describing on purpose what i see a for the patient to hear the b for my assistant to know that what i want to uh capture is a disorder of number two the six millimeter pocket and the and the bleeding and the drainage i want to capture the mesial of number five to show the marginal ridge fracture and the micro leakage and the cracking knee um in the truth i want to show them the lingual aspect of number nine where there is some you know recurrent decay around this margin of this restoration because if I’m not centered and I’m not capturing that distal aspect when i come back to play it it's either out of focus or off center and i don't have that information so my assistant knows I’m trying to capture a certain area they and they'll say move to the left move up move down because what i see is a wider field of vision than what the microscope will capture which is right in the center so when i play it back my patient says oh yeah that's what you were talking about there was decay there oh you were talking about that bleeding and they get to see and hear one more time for a second time what i had just described so it's very important for them to get the verbal while I’m recording it and then the visual as a playback i never got um on who has better support in person on a dental microscope i must admit global does and i don't uh want to talk badly about any company but global has a a bigger support team um in the united states because zeiss is not um us-based and so they're getting better and they're hiring more people and then now sullivan shine is i think uh the parent company so i think that will further improve their ability to support um the consumer so you're saying stan bergman is scheinbach global or zeiss i believe stan bergman bought zeiss or they're the exclusive distributor for i believe they are yeah huh that is amazing amazing amazing yeah but uh um yeah it's the same thing i mean you call these companies and uh there's a lot of people who when they get an automated deal push one for this push they just hang up and terrible and then you're on hold forever and you never get anywhere yeah there's a lot to be said another question they're going to have is um a lot of people who sell chairside milling um are saying that there's cosmetic dentists out there um top of the line cosmetic dentists that are chairside milling their anterior veneers um maybe I’m old but aren't really the best looking porcelain veneers still like stacked porcelain or in a lab or whatever or are you i mean you're um you're about as elite as they come out there in California do you do anterior veneers yourself chair side milling or do you still use a lab tech we still use a lab tech um if we if we do mill we do uh in many cases have to customize whether it's a shade or whether we cut back and do some veneering porcelain i think in our practice we're not uh the run-of-the-mill um single shade veneer it is um we're known for our customization and and to do a single veneer i think it's impossible to have a monolithic veneer that is going to match your other central i I’ve never seen one um so if you're doing six or you know four veneers maybe you can be monolithic and just have one shade and mill it um but to milk to e-max or lithium disilicate is extremely difficult um it i i think that the pressed lithium disilicate is far superior in terms of fit and uh reliability a lot of the time when we try to mill uh the lithium diasilicate the burrs often break you can definitely mill zikonia and then center it more reliably than milling a e-max or lithium-silicate material and but i don't do many zirconia veneers i know it can be done but i still think the beauty and the translucency of lithium disillicut or emats is far superior and then when we have a really challenging case as i mentioned we cut it back and we veneer with a overlaying salespathic porcelain and in some very challenging cases we'll still go back and do false pathetic only if you have underlying enamel to bond to for optimal strength if you're just on dentin um it's going to be challenging to use file spatic and have the reliability of the and the strength and are you um are you scanning more of your impressions digitally electronically or are you still old school vinyl poly siloxane um if the case is super gingival and the scanner will be quite reliable and so we will scan if it's um a limited you know segment if it's a full arch case we're still old school for sure polyvinyl siloxane it is extremely difficult right now to have a full arch accuracy for just a digital impression um if it's a sub-gingival margin it can be challenging unless you use electrosurge or a laser to really expose your margin in order for the scanner to read it even if you zoom in so in my in my opinion if it's a equi gingival or a super gingival finish line you can scan all day and as long as it's a limited segment and not a full arch if it is sub-gingival uh difficult to see margin or a more comprehensive cross-arch case then i would do polyvinyl siloxane okay when people say that prosthodontists are so expensive and it costs an arm and a leg don't you say no it costs a tooth i mean we're prosthodontists i had one patient Howard a very intelligent businesswoman who had stopped around she was losing her dentition due to her past history of perio she went to clear choice she went to several cosmetic dentists and then she came to our office and what she said to me was she saw our facility she interviewed us and she said in my opinion i want to pay it once do it right and do it once so when she went to interview other officers for whatever reason she felt that they were not either good communicators or their facility didn't give her the confidence that they were able to do the job she had been to a cosmetic dentist for many years and and she made the decision to leave because she knew that her dentition was falling apart that they were doing piecemeal if one tooth broke down they would fix that one tooth then another area broke down that would fix the other area and then her clue her occlusion was not stable the colors didn't match the embrasures were packing food she knew that there wasn't a comprehensive approach and so when she interviewed us she met our technical team she knew that there was support she knew that what we offered was a more methodical approach and she knew that clear choice was not for her because she felt like they were too much into selling her that they could fix it quickly and they could offer her a solution that was immediate but she didn't feel confident that it would last and so every day when nice every time i see her she always says to me i know you're expensive and i know what i what i have in my mouth is not for everybody not everybody can afford this but i am so grateful that I’ve proceeded with your office in that i know that i do it once i do it well and i don't have to touch it again um and so i think that's when when people say you're expensive i always tell them we want to do it right we take the time to get it right and we will stand behind obviously our work that it should last you i'd never say a lifetime but it should last you a long time and um whether it's biological health whether it's aesthetics whether it's functional um comfort uh it has to be all of the above so i want to teach the kids a um term about channel conflict I’m pretty sure about a quarter of our listeners are still in dental kindergarten school the rest are under 30. um and by the way um please send me an email Howard at dentaltown.com or leave the message in the uh the comments under youtube i i love getting that feedback um but a lot of times they don't understand like they're thinking if I’m a prosthodontist well i may want to surgically place the implant and restore it but then they learn in the real world that when they start placing an implant now that oral surgeon or periodontist who used to place them and had you restore them they lose that revenue stream and then they have to decide well will the revenue of placing implants will that counteract the revenue lost and then there's just the specialty um some think there's so much time and knowledge needed to surgically place it and a totally different set of restoring it so my question is you you have a three-person team do you place them and restore them or do you only restore them and why we used to only restore them and uh dr sheath is still the restorative part she's not interested in the surgical part dr piquet and i and also david gashe who is one of our associates as well in our office um we're interested in the surgical aspect and we've further trained in the surgical aspect i think there are some cases where there are no um compromises with the uh the heart tissue and the soft tissue anatomy where there could be um an ability for the prosthodontist if they're trained to do the surgery to do the surgical and rest restorative part of the rehabilitation and in most prosthodontic training programs they are teaching the students or the residents how to place the implants but in other more complex situations where there is a bony defect whether there is complications with the soft tissue and maybe whether it's in the high lip line um kind of aesthetic zone we understand our limitations and we will definitely refer to a specialist so it's just like invisalign or minor orthodontic treatment um we do invisalign and clear correct and other aligner therapy too before we reconstruct the case because we understand there are in certain situations where the skeletal structure is a class one malocclusion we feel confident that we can set up the case using minor aligner therapy before we do the veneers before we do the tooth preparation because it will be more healthy for the patient but there are other situations where we refer to the orthodontist because it's out of our realm of um training so i think it's case selection it's further training and it's also whether you're interested in surgery there are people who find that that is an interesting aspect of what we do and want to pursue it and then go and have further training but we need to understand our limitations and select the cases appropriately and we still need our other co-therapists because there are many situations that are um you under you need to understand is out of your area of expertise and you need to refer now your father-in-law um is a very famous prosthodontist correct uh justine paquette's husband uh father-in-law is niles gashay yes oh okay my gosh david shea david gashay's father is niles gashay okay i uh messed up but who was the uh okay so dr picat married dr niles gashay's son david david all right um but who was he the you said there's you have an another dentist working for you what was his name what was that david comes to us uh a few times a month to treat us tmd patients david gashe oh him yes him oh my gosh i did not know that and he does quite a lot of surgery he loves to do surgery and he does a lot of full mouth reconstructions with him yeah okay i did not so um so niles gazette's son david is also they're both prosthodontists yes and also his brother greg geshe is a prosthodontist so greg and david work together in the city of orange niles has now retired their father but they used to all three of them practice together so that was a um an amazing answer um to implant surgery here's another thing you know i love cynics i love it when you tell them about a rose garden and they say that that ain't roses those are dandelions um in this country it seems like all the implant training is sponsored by a manufacturer so then the kids and ask i think very logically do you have to pick your implant system because that's where you're going to get all the training do you pick the implant first and then go get the system or how do you get training on implants how would she's saying i want to i want to be like you i want to get more training where can i get more training i mean obviously if i go to nike they're not going to tell me the advantages of reebok or puma so how do you how do you get training that's not manufactured bias in fact i think the ada is going to come out with something very very um controversial and and a lot of people are for it um that um the continuing education hours doesn't count from manufactured sponsored courses it's got to be accredited through an institution not a sales rep i think ada serp guidelines are very strict whether it's from the advertising whether it's um sponsorship um uh the pacific coast society for prosthodontics I’m on the executive council we have very strict guidelines from ada on how we advertise how we uh devise our courses how we're sponsored how we have the disclosures it's very strict so i think that is very good for uh the profession to separate um the sponsorship i know we rely on sponsorship for many of our physical meetings and because of covert we haven't had one for a while but when we do resume these physical meetings the sponsors have an important role to help us hold these courses but we need to understand that the education component has to be independent and so what i would tell people if they want to learn um how to do more dentistry we started mentoring with an older oral surgeon who we used to refer to we would sit down and treatment plan we would review the cases together in the beginning it was because we were treatment planning together as we learned more from him he would say well why don't i come and do the case in your office you can look over my shoulder and then the next case was well why don't you do it and I’ll look over your shoulder and watch you do it and he would just um guide us and then there were situations where he said this is too difficult I’m going to do what you watch and in the future you may never do a sinus lift and we never i mean i never do but justine and others um there are certain cases where they can uh do their own complex surgery because they've continued to develop their craft but we mentored with an oral surgeon and then we also went to continuing education courses independent of a company and their companies don't get me wrong do have a role to play in understanding their system but you the the rationale and the fundamentals have to be in place first in order for you to discern whether that company has a design and the type of prosthetic components that you're interested in you you shouldn't be told by their representative what is good about the implants you should be able to seek them out and say well i like your implant because of this design i like your implant because of this um this component or this type of you know support or this surface design or this morse taper or this thread system so you should be able to understand what they're telling you and what the literature says about the you know the micro gap and bacteria and the mechanics of their uh connector um so in order to be able to be a discerning clinician you have to get the fundamentals first and that has to be independent and there are many ways you can do that you don't have to have a full-time you know uh postgraduate degree you can do a residency um you know for a few weekends and or whether it's a week or two weeks and then build upon that step by step but i think it's important to start with a mentor first um we i cannot believe uh we already went over an hour my god i feel like I’m uh cheated I’ve been looking forward to this all weekend and my time's already up can i keep you for a little overtime or i know you're in the middle of the fire um and then the other advantage now is we're over an hour so if i get too controversial we can just cut it off no big deal um but um all on four um a lot of young kids ask very you know um obvious questions um that you know is an all on four you lose one implant is now is it all on none um um would it have been better maybe all on six um and then the other thing they ask about is the fact that how do you draw the emotional line where you know if you could snap it out that grandma can put under the sink and brush it with her hands and she can get it all clean but if you make it fixed where that can't happen every time she comes in she has a complete ham sandwich underneath her all on four so what do you think of all on four versus all on five or six or seven or eight and woody and how do you draw the mental health of saying i don't want it to be able to come out of my teeth versus the dental knowledge is well the reason you lost all your teeth is you don't really brush and floss and all that so so i know i threw a lot out there at you um how do you want to approach that well i think that what the patient wants is a huge driving factor uh there are patients who don't care that is going to be a challenge they if they can come in frequently for us to maintain the case and if they do some basic things such as water picking whether it's putting any biologics whether it's a clorox bleach solution in the water pig whether they will use some sort of you know other device whether it's a you know basic electric toothbrush or supplemented with water picking um there are some patients that come to us once a month for maintenance because we know they're not physically able to maintain their plaque control um there are other patients that come once every two months because they're you know they're a little bit better so i think the maintenance program is key for those patients who insist on something non-removable for other patients um that probably is their best option is to have a removable you know over denture and retained by a few implants whether it's because of hygiene sometimes it's financial it's much cheaper to do an overdenture than do a porcelain fully fixed case on multiple implants i think all on four if it's well designed and it is well maintained and mechanically engineered appropriately obviously can work but it is a little risky in certain situations where if you do lose one uh what do you do then can you have somewhere where you can place a replacement and then the cost of that so we do more all on six because we know the spread of the um occlusal load is more distributed um but there are some situations where maybe you can't do six maybe there's not enough bone just or to the canines and you have to do just for so i think it goes back to treatment planning it goes back to the biological health of the the type of bone and the um the level of maintenance that you can foresee after the reconstruction because that is going to be critical for the long-term or the longevity and the maintenance ability um sometimes it is the patient dictates most patients don't want something removable how can you design something that can be maintained and uh is structurally um sound in good healthy bone and mechanically well designed so you don't have a huge cantilever i think there are multitude of factors so so you have to give patients what they want or they'll go elsewhere and get it somewhere else and have a maybe an inferior you know design or um you know what it what last is not as good quality as what you can offer so i think we need to create a balance between giving the patient what they want but knowing that they are not the educated person in the room they just know that what they want is something that is as natural as possible how can you get them to that point in a safe manner it's your responsibility as a clinician to be able to advise a patient and if it's really not a good idea whether it's because of bone structure whether it's due to anatomical restrictions whether it's because there's such a poor hygiene risk then patients will probably accept if you can present the case in a in a manner that is uh understandable why it is not responsible to give them a fixed case um and they will accept if you can get something stable enough that it is going to be the best for them and be the best way that they can utilize their funds and have something that will last and be healthy and how much of what you do is cosmetic versus form fit and function i think you can't separate the cosmetics if you want a patient to be satisfied when they pick up the hammer at the end of a delivery it has to all come together it can't be well functioning and strong and be ugly in this day and age nobody wants something that's not attractive so i think it's our responsibility as the trained specialist to give them the form and function that they don't understand they don't know what centric relation is they don't know what vertical dimension means they just know that it looks better when they're not collapsed they just know that their bite feels better when they have a stable occlusal scheme and that's mutually protected and that nothing breaks and they don't have any interferences um if they just know that it has to be comfortable it doesn't they don't want things breaking and chipping and falling off or coming loose and they just want it to look decent so i i don't think you can separate how much of the importance i would say that it has to be an even split um if something looks great but doesn't work and it breaks you failed so i don't see that one is more important than the other the the aesthetics the stability the biological health the form and function it's it's like a venn diagram it all has to intersect very very very well put so then the um i i almost didn't want to ask this because it just uh it's just so many cans of worms but why is occlusion so mystical why do they come out of school and they know streptococcus mutants causes decay and pigeons violence but man when it comes into occlusion they come out of school and it's like it's like the this mystery wrapped in enigma i i i don't know how it i i i guess it falls back to the teaching i think once i had it explained by you know um dr ockerson there's a book i think it's called occlusion um when i saw the diagram of what it means for centriculation to have the condyle seated in its most retromolar um superior position i just think of it as home base and i explained it to patients i can try to take your bite just with you biting together but if you have an interference or if you have a tooth that is out of place you'll you'll slide to get your teeth into fitting into a good fit but that doesn't mean that your jaw is in a home base beginning position i i think of central galatian as the beginning position like home base from there we can move to excursive movements to to chewing motion to speaking but you've got to have a reliable home base to be um reliable to come home to so i give the analogy if somebody came in with no teeth how can you get them to bite together you can't just gum it you have to have a stable physical position to put the mandible in and so then you use your wax rims to find that home base which is centric relation it's not centric occlusion because they have no teeth so when they do have teeth teeth doesn't mean that it's in the right place it could have a crown that is in an interference or they could have a malocclusion it doesn't mean that the condyle's in the right place so i think if you had a visual like bite fx is a really helpful program to teach people what occlusal slide what um you know a occlusal imbalance what uh you know an interference looks like what a cost fracture could mean if you have a balanced interference i think if kids had a interactive 3d model that was visual and they could spin the mandible around they could look at what the condor does when you have a mutually protected occlusion when you have guidance when you don't have guidance and you have balance interferences um then they'll prob when they'll probably see a slide they'll be able to understand what a bennett's movement is they'll be under able to understand why you set the condyle with a condolence inclination and then you can see how the cusp angles fit in with the condylar inclination that's when i actually got it because I’m very very visual as well and when you physically have a skull and you can move the mandible on a skull and you can see how it translates um down the articular eminence then you actually understand why you have to have centriculation because it's a repeatable position with no interferences from teeth because teeth are not always in the right place and if you just restore to fit in with the occlusion that somebody walks in through the door that could be an incorrect setup and you're just perpetuating an incorrect bite i remember when we got out of school uh the scariest thing in the world was that you were gonna open someone's bite i mean they were just like i mean it just it seemed like we were always thinking with their breaks on because if we did that you knew their arms and legs would fall off the next morning um what would you say to someone who's uh very very afraid uh that they might be opening the bite i think when you open somebody's bite it doesn't really matter how much you open them because most patients can accept within within um limits if you opened up two millimeters three millimeters four millimeters however much you needed to open them to create restarter space to um to level their occlusal plane if it's um uneven uh as long as it's even and balanced and it's uh you have some sort of guidance and that's protected it'll work many times we'll test it whether it's with occlusal splint before we actually start the reconstruction in order to get their muscles and their tmj comfortable in order to find the centric relation because many times their muscles are in spasm they're in pain they're bracing they're uneven um many times an occlusal splint will help you test the occlusal vertical dimension of occlusion but we also test it when they're in provisionals and many times patients will come back and say oh that actually feels quite comfortable i actually like it because when somebody is over closed it actually puts a lot of strain on the muscles and the ligaments and it also looks very aging and most patients like to look you more youthful so when their occlusal dimension is open it actually supports and keeps the condyle from over closing and impacting the soft tissue but it also looks good not only feels better but as long as their um bite is even on bilaterally and they don't have any interferences and they have some sort of guidance most patients will accept what you do we've opened up to eight millimeters um occlusion that that would be very concerning um initially to a young dentist because you think wow that is so much how can they tolerate that how can they accept that but the neuromuscular adaptation is actually quite um receptive as long as everything is balanced if you just have them hitting on one side whether you open them up one millimeter or eight millimeters they're going to be in pain if they're hitting evenly bilaterally that is heavier in the posteriors lighter and anteriorly and you have some sort of anterior guidance so that you're not um overloading the posterior teeth during function they're actually going to be quite pain free and comfortable um i just want to remind the uh kids when in school that when i was in dental school they were telling us that the uh the denture was just at the brink of extinction and that they would just um you know they're just going down and almost never down and to be honest 32 years later the united states does more dentures in 2020 than they did in 1987. um did that surprise you and the other thing is um everybody wants to be you know when you go to a cda meeting everybody wants to go to the sexy speaker talking about all on four no one's gonna go to the some ugly guy doing all on none i mean you know the if you want to be sexy superman do all on four uh but man god it's it's like the all on nun is this embarrassing thing we keep in the closet and all that kind of stuff like that um what do what do you think about dentures are they are they dying and going away or do you think they're going to be here till your grandchildren have children i think they're always going to be there Howard because there are not everybody can afford an all-on-four but even not talking the economics of uh because you shouldn't uh diagnose with somebody's pocketbook anybody who comes through the door if you don't know how to set up teeth on a denture i don't think you can do all on for as we go back to what we were saying before are you going to have the technician tell you where the teeth should go and you just place the implants and tell the technician to design the case i don't i don't see that that is our professional responsibility it is our responsibility to diagnose and set the teeth first in order to know where the force should go i mean obviously there has to be bone and there has to be some sort of um fundamental you know foundation for the implants to be integrated but uh how how do you know how to put the teeth on the four implants that you've placed that has to come before you actually place the implants so whether it comes with a surgical guide the surgical guide has teeth on it the surgical guide has to be made on some sort of diagnostic setup before you can actually do the surgery so if you don't know how to set teeth and do the diagnostic wax up in order to do whether it's even digital on the computer if you don't have any fundamentals and you just have a technician set the teeth on the computer i don't know how that is how that can be acceptable you're a dentist you should know how to set the teeth you should be able to work with the technician and be able to review what the setup is and say okay this this is not correct this this occlusal scheme is not going to work this is off the ridge this is not the correct occlusal dimension you've got to test it you you can't design a surgical case and not have a try-in or at least know that the denture that they walk in with is acceptable or if it's not acceptable you need to modify it or remake it it's very rare that somebody comes in with a perfect dentition and then you just follow that and convert it to an all in full case many times you have to change their occlusal scheme or modify or improve upon what they come in with before you can deliver or have a surgical plan and and deliver a case um the American college of prosthodontis um has a advertising campaign and they're trying to build the brand it's called a go-to um go to i mean their website is go to a pro and i love it because pro that's kind of a pun go to a prosthodontist go to a pro uh florida was big on uh florida orange juice um you know um do you think the go to a pro with 331 million Americans do you think they have established a brand where a lot of them people know the difference of a prosthodontist versus a general dentist or do you think it needs a lot more money and a lot more work it needs a lot more money and needs a lot more work i think um also everybody knows what an orthodontist is everybody knows what an oral surgeon a lot of people know what a endodontist is but very few people know what a prosthodontist is they don't even know how to spell it i think it is probably always going to be a struggle because most people will say well why can't my cosmetic dentist why can't my general dentist do it and there are some general dentists and cosmetic dentists who do an excellent job just as well as a prosthodontist but then there are other cases where it is more complex and there are other people who may not have had enough training even as a general dentist in order to do it so i think to go to a pro is just like if you had open-heart surgery you don't go to the internet you go to a cardiologist i had a patient actually tell me we did a marketing campaign for the American college of personalities and she said if i needed heart surgery i don't go to a general dentist i don't go to my family doctor i go to a cardiologist i go to the heart doctor if i need a complex full mouth reconstruction i will go to a specialist who does that i know the general dentist may not have the training in order to do that now there are obviously some very well trained dentists who can do everything but i know for one i can't do endo i can't do wisdom teeth i can't do um complex periodontal plastic surgery and reconstruction uh you know rebuild a papilla or root coverage or free gingival graft i know i would go to a specialist so if i had cataract surgery i don't go to a foot doctor i go to an eye doctor so in order to go to the pro if you have a very simple crown you can go to a general dentist if you have a very difficult hard to match central veneer i might want to go to a pro because it's going to show if it's not right or if i have a full mouth reconstruction with many problems i think it's too complex for a general dentist so there are specialties in medicine for that very reason in order to avoid complications in in order to know that the person who's doing your case has had more experience more training more knowledge in order to encounter or actually avoid problems if you encounter a problem that's a little late you need you need to plan the case so that you don't get into trouble very very nice um my gosh so um so this last question I’ll let you go i know you're uh on fire out there you're calling from a hotel I’m so honored to have you come on the show but i um i see something very bizarre where um you look at league of the trend 1900 no specialties healthcare is only one percent of gdp by the end of the century it's um you know the physicians have 58 specialties the dentist have nine it's now 14 of gdp you go out to 2020 dentistry's up to 12 it's now 17 of the gdp and yet these kids come out and they're gonna they're not gonna specialize they're gonna do endo and perio and pedo and implants and veneers and cosmetics and they just want to be everything and although i applaud their youth and in enthusiasm and i think it's so exciting and fun i mean we're not going back to the 1900 where one doctor does your eye ear nose throat and delivers your baby and amputates your foot how do you train the mind of the young kids that says okay if you're going to add implants to your curriculum i mean are you going to add bone grafting or and you also said in the same sentence that you're gonna you want to go into invisalign and align technology and then you want to learn silver diamine chloride for pedo and you don't you don't do you know how can she be at 25 when she walks out of school can she be wonder woman and do it all i think you probably have to take it in a stepwise manner do the basics well examine the patient well um communicate with the patient um maybe do some basic perio well do some single restorations well and then add to that module and say well maybe I’ll do you know a quadrant next time I’ll be able to do multiple because i understand the uh maybe the occlusion better if you're doing a single tooth it's it's probably the occlusal scheme is set up for you you're not going to change the occlusion you're not going to change the occlusal vertical dimension so i think if you do a limited case well then you can add to that and and always we're still undergoing can um continue education we never will stop until the day i retire because there's always something that i can do better there's always something that um i need to understand more or something that needs to be refreshed or um just to collaborate and say oh there's another way of doing this i can hear from somebody else maybe there's improvements in materials or methodology i think you shouldn't feel in your first few years of practice that you will do anything well um even if it's just a class one restoration it takes time to do that well whether it's your anatomy whether it's your you know carey's detection whether it's your dexterity whether it's your handling of a material i think whether it's your adjustment of the occlusion at the end of the restoration i think you need to understand that you can keep building on your ability and there are some things that you do well and some things that you don't do well and that you will understand you need to refer or some things that you don't like to do i think in order to be one person for everything is extremely challenging um and i think that is is dangerous to think that you know it all and most people come out of dense schools thinking they know enough and that is so far from a reality as soon as you enter practice um if you are humble and if you have a um a questioning mind you will very quickly realize you know nothing and you need to talk and learn and watch and continue to learn and there's so many ways we can learn now whether it's youtube whether it's on you know dental town whether it's on um any you know just google a procedure there are many ways that you can educate yourself and then there are more structured courses that you can participate in so i think you need to always be questioning how can i do that better how can i learn more and how can i keep building on my knowledge base because it never stops it was such an honor to podcast you i mean i like say i i contacted you guys the the first when we started doing it four years ago and um I’m glad you waited because now the audience is so much bigger for what you deserve um i just think you got you've um you've opened up so many doors for so many people you're on every committee i mean you guys the the three all three of you are legends and to think that you're in one building is uh just uh crazy crazy was there anything you wanted to talk about today that i was uh uh didn't bring up no i think um dentistry is not a dead profession i think what i what i am surprised about is how exciting dentistry can be um there are many challenges whether it's covered whether it's the economics of maintaining you know a common economically viable business but i think you should never forget that if you're honest and you give your best every day and that you treat patients and people that you work with well and that you have integrity uh that you strive to be the best that you can be you will do well don't be um don't be scared and and um uh depressed by the world affairs by clover by you know having to wear two masks and a shield and a gown we can overcome all those obstacles as long as you know that you're providing a valuable service to your patients and it and if you do a job well you will make money you will make a good living but you need to do your best continue to strive for excellence and the people will come because you are providing a good quality service and until the end of time people will need dentists and so you will you will be a survivor if you provide quality and have integrity and honesty so don't don't take any shortcuts and lose sight of that so basically what i heard you say is if uh integrity and sincerity and honesty is so important that once you can fake that you got it made yes and be able to communicate that and get it once you can fake that that was that was another attempted joke hey um thank you so much uh for coming on the show I’m so sorry are you in harm's way or are you um I’ve got um my phone is uh I’ve got 18 messages people are asking me how we are i don't know I’ll have to check the news and uh see what's going on out there it it i think the fire is still uh not contained but um I’ll have to see how close it is to the homes well if you run out of beer i can get to the ocean in la in six and a half hours so remember the most you'll have to go without beer is six and a half hours thank you so much for coming on the show today it was just an honor and a privilege to be able to podcast you my pleasure all right have a great day good luck on that fire thank you Howard

Category: Prosthodontics

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