Dentistry Uncensored with Howard Farran
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819 Occlusion & Evidence Based Dentistry with Dr. Mike Racich : Dentistry Uncensored with Howard Farran

819 Occlusion & Evidence Based Dentistry with Dr. Mike Racich : Dentistry Uncensored with Howard Farran

8/22/2017 2:39:41 PM   |   Comments: 0   |   Views: 254

819 Occlusion & Evidence Based Dentistry with Dr. Mike Racich : Dentistry Uncensored with Howard Farran

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819 Occlusion & Evidence Based Dentistry with Dr. Mike Racich : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #819 - Mike Racich
            


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AUDIO - DUwHF #819 - Mike Racich
            


Dr. Racich, a 1982 graduate from University of British Columbia, has a general dental practice emphasizing comprehensive restorative dentistry, prosthodontics and TMD/ orofacial pain. Dr. Racich is a member of many professional organizations (current AES Past President) and has lectured nationally and internationally on subjects relating to patient comfort, function and appearance. He is a Fellow of the Academy of General Dentistry and the American College of Dentists as well as a Diplomate of the American Board of Orofacial Pain and the International Congress of Oral Implantologists. Dr. Racich has published in peer-reviewed scientific journals such as the Journal of Prosthetic Dentistry and the International Journal of Periodontics and Restorative Dentistry and has authored the books: The Basic Rules of Oral Rehabilitation (2010), The Basic Rules of Occlusion (2012), The Basic Rules of Facially Generated Treatment Planning (2013), and The Basic Rules of Being a Dental Patient (2016). Currently he mentors the didactic/clinical FOCUS Dental Education Continuum (study clubs, proprietary programs, coaching, 2nd opinions only) in Western Canada.

www.DrRacich.ca



Howard: It is just a huge honor for me today to be podcast interviewing Mike Racich all the way from my favorite city in North America, Vancouver British Columbia Canada, that is the coolest damn city. He's a 1982 graduate from University of British Columbia as a general dental practice emphasizing comprehensive restorative dentistry precedents and TMD orofacial pain. Dr. Racich is a member of many professional organizations. Current AES past president and has lectured nationally and internationally on subjects relating to patient comfort function and appearance. He is a fellow of the Academy of General Dentistry and the American College of dentists as well as a diplomat of the American Board of orofacial pain and the International Congress oral implantology. Dr. Racich has published and peer-reviewed journals such as the Journal of prosthetic dentistry and the International Journal of periodontic and restorative dentistry, and has authored the books, The Basic Rules of Oral Rehabilitation, The Basic Rules of Occlusion, The Basic Rules of Facially Generated Treatment Planning, The Basic Rules of Being a Dental Patient. Currently he mentors the Didactic Clinical Focus Dental Education Continuum Study Clubs for Podiatry Programs Coaching Second Opinions only in Western Canada. Man, you are so accomplished, and I wanted to get you on this show so bad because I'm just going to, this is Dentistry Uncensored. So, let's get raw that the bottom line is these kids come out of school and they say they didn't learn much about TMD or occlusion or facial pain, and they want to learn more but it seemed that the kids tell me, remember we're on a podcast so it's all millennial stuff, all the baby boomers are reading your textbooks, the Millennials only read books if they’re audio files and, but anyway, if they went to 10 and orthodontic lectures, they're all mostly no controversies. They went to 10 pediatric dentistry courses on a pulp oddity, there'd be almost no controversies and they're like, man, these occlusion camps are like world religions. Do you agree with that assessment or is that not the real reality?


Dr. Mike: I think that everybody means well and I think that everybody is out there, the various institutes or the camps, whatever you want to call them. And they're basically trying to tell the information and simplify it as best as they can and that's what prompted me to write my first book is, "The Basic Rules" because what I realized is that no matter, whether you've got one group talking way over here and another group talking way over there, at the end of the day they're all talking about the same thing, and essentially that's what my first book is about. It's just trying to distill down everything into simple, simple practical terms. For example, you mentioned endodontics, I mean, success with endodontics is not obturation, it helps to do good obturation. Success with orthodontics is cleaning it out, that's the basic rule. So there's basic rules with occlusion and TMD and all that sort of thing, and I think that nobody is doing; I call it Institutitis, there's a noun form of Institutitis and a verb form. And I'm a general dentist and as a general dentist I was guilty of Institutitis, too. I went to a continuum and that was the noun form where I, of course I have to learn it and so I listened to what the instructors had to say and I gathered as much information as possible. When the Institutitis becomes dangerous is when it becomes the verb form and when somebody puts on their blinders, and as you say, they lift the camp and they fail to realize and they stop to realize that there's more than one way of accomplishing something. To put it another way, I never ever, ever knocked success, so if I can see one group over here having success and having another group over here having success and they appear to be doing things differently, well, wait a second here, there has to be some common variables. And I think at the end of the day for the people that are listening to this, the Millennials, as you say, and they want to get started. Go get started, take somebody's program but don't drink all the Kool-Aid. Remember that you take the good information and then go listen to someone else, someone else that you think might be diametrically opposed. Just sit back and listen and try to think to yourself, what are some of the common elements. I mean, if you want you can push my book, of course, or give me a call anytime but that's.


Howard: How would my homies find your book right now?


Dr. Mike: Well, my publisher's Palmieri publishing, they're a Toronto based company, Markham Ontario and it's palmieripublishing.com or they just call my website.


Howard: Your website is Drracich.ca?


Dr. Mike: Yeah, and you can just go on the link there. But that all being said, let's go back to your question.


Howard: Well, I want to sell some books for you.


Dr. Mike: Well, I want to sell them, too, but the main message here is go out and learn it but eliminate the blinders and try to keep open-minded.


Howard: Trying to find which, okay, now I found it. Publications.drracich.ca. You told me something interesting, that your name Racich, that you're Croatian and the first C in a Croatian name is pronounced an S.


Dr. Mike: Yes.


Howard: So, it's Dr. Racich but he's Croatian, so it's spelled D-R-R-A-C-I-C-H-.-C-A and you have all four of your books there. What would be there, first of all are these books in audio?


Dr. Mike: The books aren't in audio yet. Books number two which is Occlusion and book number four The Basic Rules of Being a Dental Patient are now being translated into Polish.


Howard: Nice, you got some Polish friends?


Dr. Mike: That and I've lectured over there, and I'm going again this Summer to lecture, so there it's a little pre-emptive move to try to.


Howard: Do you know, do you know Marcin de Lucky?


Dr. Mike: Not yet.


Howard: Email me, howard@dentaltown.com and I'll reply back with Marcin de Lucky, he's the Godfather of Dentist in Warsaw. He's the most connected man. He just, he's the most lovable guy but yeah, Amazon says that audiobooks are outselling textbooks and I came out on my book, and it was a hardback book and sales are doing great but I finally one day sat down on Skype and read my entire book for five and a half hours and the audio version blows away the print.


Dr. Mike: It's a good suggestion and I'm on it.


Howard: Yeah because it's kind of like, I thought it was weird that movies and music were separate. There were silent movies and music separate for forty years before one human puts a deal in, and then the next thing that came along was to add popcorn because monkeys are two eighty-eight A.D, too hyper to sit there and just watch a movie. So, they got to eat while watching a movie with sound and you would be surprised at how the millennials, when they read books, they like to be commuting to and from work, an hour on the Stairmaster, a long bike ride and since everything, but I don't want to get you in trouble but I feel like I'm going to get you in trouble right now. Their specific question is, they can just go to any Indo course and go to any pediatric dentistry course but they feel like they got to pick between like Neuromuscular or CR and some of these courses also promote expensive toys, and maybe eighteen thousand dollars for the equipment and they're like, I'd like to learn this faster, easier, higher quality but lower cost. Do I need this? So, answer that round of questions? Or are you going to piss off all your friends? Are you going to have to move to Croatia after this podcast?


Dr. Mike: Like I said, I think everybody's out there giving very, very good information. Just remember there's a noun form of Institutitis and a verb form, and I think that everybody has to be very careful that they don't get locked into a camp, keep an open mind. All education is good, I would encourage any and everybody to go out and seek and go and listen and keep an open mind, and of course I've written three books, I've distilled things down; obviously if somebody wants to contact me, I coach, I lecture, blah, blah. I'd be more than willing to share my information and how I think that there's more similarities between all these different groups and there's not. So, for example, you mentioned Mile Centric and you mentioned traditional CR, well at the end of.


Howard: So just for the kids, Mile Centric you're using that interchangeably with Dural Muscular?


Dr. Mike: Exactly.


Howard: So, you can basically split the whole occlusion world into two just by saying Mile Centric Neuromuscular and CR. Is that oversimplification?


Dr. Mike: It's an oversimplification but it's a good one.


Howard: Okay, remember my brain is only the size of a walnut, so I got to go slow.


Dr. Mike: Well, you and me both but CR, no, it's Mile Centric and Centric Relation, there's more similarities than people think there really is because at the end of the day, what the restorative the dentist has to achieve at the time of definitive records is a consistently reproducible position. So, I call CR not Centric Relation, I call CR Consistent Reproducibility. So, whether someone's using a Mild Centric Technique or a Neuromuscular Technique or a Traditional CR Technique or whatever technique, at the end of the day the dentist has to have a reproducible position that they can treat you and that's really distilling it all down, that is the basic rule. That's like cleaning out the Endo tooth, that's the most important thing, get it in as clean as possible and then we can Obturate in any way that we want to.



Howard: I really like that Centric Relation CR to you means Consistent Reproducibility, that's very, very cool. But in that Consistent Reproducibility, all that stuff, some people go back and think there's a brain activity to all this and that it's not so mechanical, and then some of the elder statesmen like Dawson says, "that's not true, it's all mechanical," and some are saying it's all, some of it's coming from the brain.


Dr. Mike: Oh, boy, you're just walking into these questions beautifully for me.


Howard: Am I?


Dr. Mike: Oh, I'm loving this. When I teach Occlusion because my focus study clubs are didactic and clinical. What we mean by that is we meet all day and there's at least four or five hours of hands-on, okay? So, when I first start working with a group of dentists or a dentist, I always tell them 50% or more of the Occlusive Collaboration is done in the consultation room. 50% or more the Conclusive Collaboration or Fat Fact Restorative Dentistry or Prosthodontics is done in the consultation room and not chairside. It's all about discussing things with people, educating with people, getting that so-called placebo effect with people, building that trust and so on and so forth. How I can guide a mandible is not, sure it's a mechanical guiding that we do whatever technique somebody wants to use but if the person is sitting in the chair bolt erect, good luck trying to get any kind of position. The more relaxed and more confident the person with it is with us, the more that we're able to work with them, educate them, they're listening to us, they trust us and so on and so forth. So, at the end of the day, yes, it's a mechanical thing that we're doing, there's various techniques that can be shown but it's getting in line with the patient, and most importantly is finding out what that patient wants. So, for example, when I'm guiding a mandible and if the patient is telling me that I'm pushing them back and they don't want to be there, "hello, they don't want to be there,” so I have to then develop a technique or work with that patient to get them into a comfortable physiologic position that's not only mechanical but it also works with the, what's going on upstairs here with the patient as well.


Howard: I do it but they don't want to put the mandible back, I use the United Airlines approach, just start beating them and drag them out of the operatory until they do what I say. Do you recommend that? Or they send off flying in Canada, is that something that only happens in redneck Arizona?


Dr. Mike: You know how it is.


Howard: Well, another, back to sell your books because my job is to, I think the most successful dentist that I watched in my thirty years were the ones who, and that's why we're doing a daily podcast show and I'm trying to motivate them to read your books, a great way to read books as we put four hundred and seventy online CE courses on Dentaltown, and they're coming up on a million views and if you put a one hour course on this, it would build your brand, sell those books, fill your glasses, I would give anything if you do an online CE course .


Dr. Mike: Yeah, I'm in.


Howard: You talking about the hierarchy of dental care levels one through six.


Dr. Mike: Yeah, that's an important one. The basic level is the elimination of infection and pain. The level six is, okay, inter and multidisciplinary dentistry are two different terms. Interdisciplinary dentistry means within the profession; multidisciplinary dentistry means Dentists, Physical Therapists, Dermatologists, Neurologists, Plastic Surgeons and so on and so forth. So, the top level is level six. So, level six is really being as, I think, I don't know who coined this, maybe it's an old expression but it's being a true Physician of the mouth, in other words, we're treating the whole person and not just the tops of the teeth and so that's, and really, I haven't listened unfortunately to any of your podcasts, sorry, Howard.


Howard: No, that's fine.


Dr. Mike: I'm pretty certain that someone's probably spoken to this and that we’re one of the places that dentistry is going, and it's going quickly is into, patients want more than just toothpicks, they want to go to offices that are looking at their, maybe what their diet is? What their diet composition, maybe give them some diet counseling and other things to give them a more, broad Medical-Dental based model of care when they walk into their office.


Howard: Well, what would that term be because you said interdisciplinary was within Dentistry and multi especially was the whole body, is that what you said?


Dr. Mike: The whole part and all the other different specialties.


Howard: But seems like the consumers call that holistic, but when you say the word holistic to a Dentist, he thinks you're a quack and runs out of the room.


Dr. Mike: You notice how I try to avoid that statement when I just gave you that explanation.


Howard: Yeah, I know. I mean, people who put on their website Holistic Natural Dentistry, fillings without any GMO modify, whatever, they get patients driving an hour away but the dentist would think of their peer as a quack. So, the consumer worships that word and the Dentist thinks it's quackery. So, what's your word for holistic?


Dr. Mike: Whether Dentists markets himself outside externally that way or it's just an internal marketing, I think that the Dental Office that embellishes multidisciplinary care. In other words, they network, their network just isn't Endodontists and Orthodontists and everything else. Their network, whether they want to do Botox or not, for example, is Plastic Surgeon and Dermatologists, their network is if they're doing T and D and orofacial pain is Neurologists and other people like that, Physical Therapists, Massage Therapists and so on and so forth. So at the top level of Dentistry is multidisciplinary care, inter and multidisciplinary care. At the beginning level is what we were taught in dental school, elimination of infection and pain. Level two is simple treatment, again we all graduate knowing how to do that. Level three is we're now trying to treat Sextants and Quadrants, so most of us can get to that level in five to ten years quite comfortably, some of us are more talented, get there a little faster.


Howard: Now Sextons and Quadric, is that Metric or is that Imperial Math. You're going to confuse all the Americans are like, wait a minute, is that a Metric term?


Dr. Mike: It's all the same, well, no, no, no. What I would like to say is Oral Surgeons think in inches, Orthodontists think in millimeters and Restorative Dentists and Prosthodontists think in microns in terms of.


Howard: Say that one more time, Oral Surgeons thinking?


Dr. Mike: Inches or feet sometimes, Orthodontists think in millimeters and then lastly, Restorative Dentists and Prosthodontists think in terms of microns.


Howard: Nice.


Dr. Mike: That's why at the end of the day when we have an Occlusal problem, trust me, it's not millimeters, it's usually microns as we've all been down that road, we all know that one really well. So then, level four is basically what the Institutes can help people do and they can treat Complex Aesthetic Restorative Dentistry, not in maximum intercuts patient or have it bite, maybe they've learned to joint position. It kind of goes back to our discussion that we had earlier, this is the level four. Level five is what we consider Interdisciplinary Dentistry, so the Dentist is now moving past the Institute or maybe the Institute is encouraging them to go to work with Orthodontists and all that, but the Dentist at level five is maybe starting to bring in other concepts, like I tried to talk about earlier, not just the one Institute but get other people's ideas and then they're really branching out to try to look at their cases and definitely encouraging the other Dental disciplines to be involved, and then of course I mentioned level six.


Howard: What do you think of the current use of the term evidence-based Dentistry? Do you think it's a good thing that has a long way to go? Do you think it's misunderstood? What are your thoughts on evidence-based Dentistry?


Dr. Mike: Yeah, evidence-based Dentistry, there's, we're all practicing evidence-based healthcare, I'm sixty years old right now and I'm having a few medical afflictions happen now, and I practice evidence-based healthcare. I go on the internet, but I just don't go on the internet, and for all our colleagues that are listening right now, we can go on Google and just type in some keywords but it's just so simple. I mean, there's so many Medical databases out there and of course the easiest one to get first involved in a PubMed, all we have to do is go on whatever we want to use, Google or Yahoo or whatever else, type in PubMed and then in comes this Library of Congress or whatever it is, the Health Institute or whatever it is and then all we have to do in the search box because they made it really easy, and all we have to do in the search box is just type in the key terms and the most important term to type in is review. So, for example, if I want to find out about a new composite material or what type of white material I want to use, all I have to do is type in composite review and hit the button and a whole host of pretty decent articles are going to come up that people have taken the time to sit down and think, and then maybe they've been pre-reviewed. I'm not saying that there's anything wrong with anecdotal and articles that are written as editorials and all that, that's all good learning. But if somebody really wants to look at the evidence and look at articles that at least somebody's tried to sit down and maybe do meta-analysis on or statistical analysis on, it's a simple way of doing it but that's not the main point here. The main point of what evidence, Dentistry is not the evidence, evidence based Dentistry is three-part and I have this actually in my book, it's actually a Venn diagram. Venn diagram with those three little circles and one of the circles is evidence, the other circle is the team values, the Dentist's values and the third circle is patient values. So, two thirds of evidence-based Dentistry has got nothing to do with the evidence, two thirds of evidence-based Dentistry is got to do with patient values and Dentists values, routine values and if these two aren't in sync then who cares? But that's just common sense, I mean, it doesn't matter what level of Dentistry or what anybody that's listening to this thinks of this or they've got the ability to access it. If we do not get along with our patients and our patients don't understand us then what is the point of going forward? It doesn't really matter what the materials are or what the so-called experts say at the end of the day. It really comes down to the two thirds being in sync before we even look at the evidence. So, when I practice evidence-based dentistry, Howard, the first thing that I'm trying to do is connect with the patient, when a patient comes in for the first time and meets me, the first thing I'm trying to do in our team, of course because it's a team, it's, they're just not meeting me by the way, it's a team they're meeting. When they first come in and meet the team, the whole idea is to try to get this little module working that the patient will feel comfortable and feel, give us honest answers and will listen to us and we can get open to this line of communication, then and only then do we really look at what the evidence is saying and there's a hierarchy of evidence, too. The review articles, like I tried to suggest, are a good way to go but it goes all the way down to just expert opinion, too, which is nothing wrong with. I mean, it's all good information but we have to temper it as to which way we might want to lean a little bit more when we're looking up some information.


Howard: So, let's do summaries of your four books. The Basic Rules of Oral Rehabilitation.


Dr. Mike: Yeah.


Howard: Summarize that, how long would it take to read it? Six hours?


Dr. Mike: That could be read. It depends, it could be, the books were written deliberately short, each chapter, each rule is written a thousand words or less and they were written in such, and with only ten references and they were written to be a very quick overview of the subject but they're also written in layers because as you know, you write and as you know, we can use a lot of terms to solidify a lot of concepts. So, in one sentence I could maybe write a concept down that maybe could be expanded easily into a chapter in a book, and so depending on the sophistication of the dentist and how deep they want to go into the books, those books can be read in an hour but then a person could go back and spend, oh, a long time reading certain aspects of the book and thinking about it and then maybe go into some research on their own.


Howard: Summarize the basic rules of Oral Rehabilitation. Can you answer that, an unfair question?


Dr. Mike: It's just straightforward, it's broken up into sections, it's written, it's called The Patient, The Plan, The Process, The Payoff. So, the basic rules of Oral Rehabilitation is broken up into four sections: The Patient and the Plan, The Process, The Payoff. The patient is the patient, kind of just what I was talking about when I was talking about evidence-based Dentistry, get to know your patient plus SIBO, all that sort of stuff. The plan is the plan, we have to have some kind of sequential way of going through, introducing a patient into our practice and then working through whatever way we're going to sequence through. The process is the process, in other words, how do we go from A to B, in other words, taking records and all that sort of stuff and then the payoff is the payoff, you know what the payoff is? Being able to go to sleep at night.


Howard: Nice.


Dr. Mike: It's priceless, the payoff isn't making $30,000 a case, the patient, the payoff is making some money, paying our staff and then being able to have a good night’s sleep.     


Howard: Let me make an analogy like if, when people start getting into Endo, the Endodontists say, start off with Incisors, maybe then do, work your way to Bicuspid, don't start with Second Molars. Orthodontists say, you don't start with a high angle long face. What basic rules or rehab would you tell these young Millennials when they get started to stay out of trouble? What are red flags and say you need to be five years down your journey before you start doing that. Are there any of those that you can think of to keep them out of trouble?


Dr. Mike: Oh, yeah, definitely, find out what the patient wants and always ask the patient what they want. So for example, I'm going to do a Posterior Crown, first question I ask him, "Do you want a metal biting surface or a white biting surface?" White biting surface. "Do you want it layered porcelain over metal or a high-stress zirconia core?” What's the difference, they both can chip. If you don't want to, you want to minimize the potential for chipping then maybe you just want the high-stress Ceramic Core and then I look at the patient, I let them make the decision. If they're talking about a more complex case, I say to them, are you interested in Orthodontics? No. So then we have to explore something else. If it's a, maybe an implant case where their dentures are in the Maxillary Posterior and there's Minimal Crestal bone height, I say to them, "Are you interested in potentially doing some Bone Augmentation in your science?" Yes, no. If they say no, slam, the door gets slammed and then we have to think of another opportunity. So I'm always encouraging, I'm always asking questions but the question that I gave now were good questions because they were yes and no, they were closed-ended questions, they weren't open-ended questions. I would recommend that always ask questions that's more than, gets, elicits a response more than yes or no. It gets the patient talking about what they really want, so the first step with everything is to get the person's consent, their informed consent, that's a medical legal term but it's just common sense. Get the patient talking and find out what the heck they want and then we have to know what we want to do before treatments, but most importantly is what are we going to maintain this patient lifetime. I'm sixty years old, I probably got another ten years left practicing. I've already cut the practice down, I practice a couple days right now but you Millennials out there, and you've got a few decades, and with the communications ability of people nowadays, the patients are going to find you, okay? You might be practicing in Seattle Washington right now and you might move to Paris, France but guess what, they're going to find you, they're going to find you. And so at the end of the day, what are we going to do and how we going to maintain that case, no matter what we do, whether it's a single composite or something more comprehensive, and so it's the maintenance of the case that has to be thought up along with the beginning of the case, in other words, all the stuff at the beginning. How we're going to educate the patient and so on and so forth, and then what we do is we have to have a systematic approach to care, well, I call my systematic approach that carries the one, two, threes of Dentistry. We have to have a stable starting position, CR consistent in reproducible position at a workable vertical dimension. We have to know about the anterior parameters, both sagittally which is Function, Envelope of Function, Procels Envelope of Function 1951, Coronal Smile Dejour and then we have to make sure that the teeth all look like teeth in the Posterior and we have to have a sequential way of doing that, and we can follow that through, no matter how difficult the case looks. How do we eat an elephant, one bite at a time, and it's the exact way that we have to approach these cases. Oh, and one thing I should definitely emphasize here, it's extremely important for everybody to take meticulous records before we get started, meticulous, and it doesn't matter whether they're conventional, good old alginates mounting on our articulator photographs and all that, or people want to do it virtually, you can get your scanner out and scan and whatever way you want to do it. But the records have to be meticulous because in taking those records, it's more than just the medical legal, and taking those records we start to visualize, we start to conceptualize what we're really going to, where we're going with these, with these patients and whatever we're going to do in these cases.


Howard: Well, you brought up, did you say tax scan?


Dr. Mike: No, any scan.


Howard: But when you say meticulous records, do you recommend any of these high-tech electronic scans? What is it called, a T-scan?


Dr. Mike: Yeah, I mean, they're adjuncts. They're not doing any harm, just be careful that you know what you're actually going to do with it. Patients love it, by the way, again I would never just, like I said with a contingent education before, I would never tell anybody not to buy any technology, but all this technology, I would encourage you to know exactly what your endpoint is going to be and most importantly, most importantly the question I have for you is, what are you going to do if this technology doesn't work? Then what are you going to do? For example, when that aircraft took off from New York a few years ago and they had the bird strike and they no longer had any power, it's a good thing that pilot that day really knew how to fly that plane and landed in the Hudson River, so when the technology, in other words, he knew the basic rules, right? Of how to fly an airplane.


Howard: You're talking about Tom Hanks, right?


Dr. Mike: Yeah, but the same thing goes with Dentistry, so the technology is great but if the technology, for whatever reason doesn't work, all of a sudden, we've got a patient that's looking at us and they're going to be saying, "Okay, what are you going to do next?” Okay, and if, you better know what we're going to do next, and then it doesn't, it's not a bad thing if you have to go back to conventional ways of doing things, for example, if it's a Tech scan obviously the conventional ways is using our hand, the patient doesn't already know what we're doing but the thing about it is that, just be aware, the technology is good but just what are you going to do if it doesn't work or use or you're at a dead end? Again, that tunnel vision. Make sure that there's more than one way to make chocolate cookies, okay? You can add different things to chocolate cookies when you're making them.


Howard: You said something very interesting, like I remember when Diagnodent came out, a lot, all the old timers are saying, "Well, hell, I can just look with a mirror and explore, I don't need a diagram," but the patient, it was very powerful.


Dr. Mike: Oh, definitely.


Howard: So, text scan, and by the way, when I talk about products, I have no financial relationship, they're not advertisers, this isn't a commercial but do you think it does have a high wow factor with patients or not really?


Dr. Mike: It gets your attention, again it's the wall factors, the clinician that believes in it.


Howard: Okay, this is Dentistry Uncensored, I want to ask you.


Dr. Mike: Just like you, you're a great public speaker and I'm sure that.


Howard: You must have never heard me.


Dr. Mike: Oh, but I know you are. I know you are because I heard people that have told me about how you speak, okay?


Howard: Were they drunk and Irish?


Dr. Mike: And I can almost guarantee that one on one with a patient, you've got an amazing rapport. You've got great body skills or great communication skills, and if a Dentist really believes in what they're doing, whether it's evidence-based care or whatever we're talking about here today, the patient can actually feel it. They can see it in our jugglers, they can see it on our face, we're using that great eye contact with the person. It just exudes confidence, we, they can see we're confident about it so the patient buys into the placebo effect, everything else kind of effective of what I said earlier, the explanation is the key to all this and the treatment is just, these things are just tools to get to the end result that we're trying to do. So, if somebody wants to use a T-scan, go for it. The key is that as long as they end up getting the end results that they want and they end up with a happy patient. And a happy patient, by the way, is someone, patient, isn't it true our patients talk with their feet, right? All customers, I mean, I'm a customer in hotels and that, we talk with our feet, or restaurant, we either walk out and never come back or we walk back in one day. So, every time a patient keeps on walking back in we're the best dentist in the world, right? I mean, as in their eyes we are the best dentist in the world and so if we can get the end result big smile on their face, and most importantly they're referring patients to us, why change?


Howard: Yeah, and the young kids, I was talking to a very young girl yesterday and she was really, really sad that one of her patients left and went to another office, and I got to tell you, after 30 years of this, she might have gone to another office because that's where her husband goes, it might have been closer to her work, it might not even have been you, she maybe just did like another team member. I mean, you can't take that stuff personal because humans are so damn complex. I mean, look at you, you try to say that you're all for Oral Health but then you watch Hockey where all they do is knock people's teeth out all day. How do you morally justify that in your head to support beating your teeth out and Oral Healthcare?


Dr. Mike: Howard, I'm a businessman.


Howard: You support Hockey to drive business. This is Dentistry Uncensored, we've all heard Dentists say things in restaurants and bars, and I want you to opine on because I hear it a lot, they say things like, how does Occlusion even make sense when we spend, send all of our kids to the Orthodontic factory and they level align the Curvus Fee, the Curve of Wilson and they don't really leave it in great Occlusion, and number two, a lot of times when people have TMJ Orofacial Pain. The Ortho is saying, "Well, the best way to get out of that is we'll put you in braces because we'll let your Condyle relax, we'll straighten your," they say this, they say, if I straighten my arm, my elbow determines where my hand is but when your teeth come together, your elbow’s just wherever, it's left up so I'm going to balance your elbow with your hand and the best way to treat TMJ and Occlusion, Oral Facial Pain is put you in Ortho, then a lot of the referring dentistry say, "Dude, you blow out the Curvus Fee, the Curve of Wilson and you don't even equilibrate them at the end." So that was a lot of ranting, did you find any good questions in that rant? Anything you can opine on?


Dr. Mike: Oh, definitely. It all goes back to the famous Gibson Lindy study, remember the study that was done where they studied chewing and how people chew my analyst 1960s and 70s. What they did, just, I'll say it real fast. What they did is they got people chewing and they hooked them up with the leads in the day into mainframe computers and then they took the data from the mainframe computers, took whatever articulator it was hooked up, motors, mounted casts, and then watched all the chewing actions. So, what they did is they first analyzed people with different worn Occlusions and they saw the various chewing motions, whether they were straight in and out or more of a grinding motion, and then what they did is they restore them and saw what the different benefits, positive, negative work. What also came out of those studies and other people have supported this or at least found these as well is what they started to quantify, not just qualify but quantify was that for the most part and I've been even watching you since I started talking about this with you, you were just talking to me about it is, most people have their teeth apart during the day the only time teeth come together is when we bite down for a split second and or maybe we bite through food, if I'm eating a banana it's unlikely that I'm biting through and hitting my teeth. So at the end of the day, whereas for the most part wearing a dentition is abnormal and so if a person's got, you're going to love this one, if a person's got their teeth apart, guess what? Occlusion is irrelevant, okay? So if I can educate my patients to keep their teeth apart during the day and they wear a piece of plastic at night just to protect whatever we got inside there from moving or destroying it or whatever else, then for the most part it's a mute discussion and so that, now we go back to, you’re talking about going back to Institute's and all that sort of thing, after I spent a lot of money, Millennials out there, listen to me, after I spend a lot of money trying to learn all this, which I did, and I, many great mentors that I am honored to have been associated with and to learn this but when I finally realized what I just told you, it was a very humbling moment.


Howard: And what's like, when you said that you mentioned Donald Duck and you mentioned Cookie Monster's, and young kids have to realize that all those initials have to remain, mean nothing to the patient, it's how you communicate, how you make them feel, and the guys and girls with an awesome chairside manner that can, even Einstein said you need to explain things simple and if you can't explain a simple, you probably don't understand it yourself and I just..


Dr. Mike: There's just a quote in The Vancouver Sun this morning, our local newspaper, one of the, we just had a provincial election or state election in the United States, our provincial election and we have a minority government but anyways, one of the candidates that's going to help form the minority government right now, he was asked about some initiative that they had put forward and he said to himself. He's being asked about, he says about, it's quite complex to explain this but he said it's a good initiative, if I can explain it simply and my grandmother will understand it and I thought, "what a great quote, what a great, it's so true," if I can't explain something simply to my patients that their third adult, that their teenage child can't understand then that's not good.


Howard: Back to Millennials again because seriously, almost every email I get on my podcast is they're either in dental school or they just graduated or they're working as an associate, when they go to the big dental conventions, all the Crown and Bridge courses are full mouth rehabs and they come out of school, they've got to learn how to do just a basic Filling and a Crown, and if you look at the lab data then I say it's, 96% of the Crown's go in as a single unit. I mean, look at the insurance data, all the treatments done, they're just for huge spikes on the six-year molars. And so back to the basic rules of occlusion, if you're just some kid that got out of school or you're in dental school and you're just doing a first Molar and you're doing Crown and Bridge, what are the basic rules of Occlusion or red flags when you're doing a single Molar with a triple tray and an Emprogram Impression? Is there anything you can add value to the simple stuff on their journey before they start doing full mouth rehab someday?


Dr. Mike: If it's a single tooth, just do the single tooth. Don't mess with the other teeth because the person's Occlusion is stable, we're assuming now, okay, Occlusion is defined as the static relationship of teeth, this is Occlusion, okay, when I'm thinking of Occlusion I'm thinking of systematic and system in a Physiologic position which means, so assuming that the person got their teeth together, if we only work on one tooth and we don't touch any of the other teeth, even if the person says all of this. If they only do the one tooth that could be the only thing that goes right or wrong, and then just be a meticulous dentist, a single tooth, doing exactly the standards of care that we were all taught in University and it should go just fine. The way, what I do want to add about, you're talking about the Crown of Bridge courses and everything else kind of going back to what I call the one, two, threes, of dentistry, Occlusal Equilibration just isn't a subtractive procedure, it’s additive, too, and so composite makes everyone an Oral Rehabilitationist. So, my favorite provisional restoration is direct composite. So I do a lot of Composite Rehabilitations and Composite Rehabilitations do a number of things, they're cost effective, they're durable, patients can afford it, even patients without insurance can afford it or they can be, it's not like it's $50 000, it's still expensive but they can be, they can be financed in a way that they can afford it and then it's a template that we can copy exactly, whether we do Intraoral scanning to taking images of our, what's working in the mouth or doing the conventional ways because there's conventional ways of copying it and it becomes very, very, very predictable. The other thing that's nice about doing Composite Rehabilitations is even if the patient leaves us, adios, Miguel, even if the patient leaves us, all we've done to another dentist is the Composite buildups, and so from even a medical legal point of view, it's definitive care in terms of a direct Restorative material but these patients are usually going on to either Gold or Ceramics or something like that, and it's a great Interim Restoration and for you Millennials out there, it's a great tool to try to get to master. And then, and then you can slowly segmental, the word was, however you remember this one, Segmental Reconstructions, what they really meant by Segmental Reconstructions is then taking our Provisionals and Segmentally converting them into definitive Restorations, ie. Zirconia, Porcelain, whatever you want to do, Gold, whatever you want to do.


Howard: So let's go to your third book, The Basic Rules of Facially Generated Treatment Planning.


Dr. Mike: Oh, yeah, that's everything. That's the old, Howard, you know this one. That's the old mantra, the old Prosthodontics Mantra, meet the person, meet the face, meet the mouth and meet the teeth. Meet the person, you have to know what the person wants and so on and so forth. Meet the face, there's Aesthetic Dentistry and there's Cosmetic Dentistry and Aesthetic Dentistry and Cosmetics Dentistry are two different things. Aesthetic Dentistry is working with the person's natural beauty, Cosmetics and Dentistry means whitening teeth diamonds and teeth and so on and so forth. So Cosmetic Dentistry can't always be made Aesthetic but Aesthetic Dentistry can always ways be made Cosmetic. So what we mean by that is as follows, nail salons are very popular right now, got tons of them here in the Vancouver area and I usually, like when I'm walking by I usually slow down and I'm amazed at how full they are but I can see all the therapists there, or the nail designers or whatever you want to call them. I can see them working and sculpting the person's nail, they're working with the person's aesthetic and then they put the Cosmetic on. If that same person was to go to the local supermarket or wherever and buy the nail and just go, they would get the Cosmetic but it might not look Aesthetic. So Aesthetic Dentistry should just melt into the face, it started facially, just melt into the face no matter what Cosmetic the person wants. So if the person wants to go from a dark shade to toilet-bowl white, if it’s done Aesthetically it doesn't look as in the face as if somebody just goes in and it goes from a wax up one end, one shade or a1 or b1 or super white shade, and bang, when the person smiled all you see is teeth. So that's what we mean by Facially Generated Treatment Planning. So we meet the face and usually with the face that helps, what helps us design it is facial third is one, two, three. Vertical dimension, we then meet the mouth and meeting the mouth, it's got a lot to do with their skeletal position or the skeletal one plus two, plus three. It helps us align the vertical dimension and then we finally meet the teeth and by meeting the teeth we just get in there make sure that we're good Restorative Dentist.


Howard: Man, you're an amazing surgeon but you still didn't answer the main question, do you pay $5.00 extra down the sea salt rub in your calves? I mean, they always ask you every time, do you want the sea salt in your counter?


Dr. Mike: Sounds good.


Howard: Sounds good? Will that help with the Occlusion if after I get done doing the Cosmetic Dentistry, I ask him if they want an upgrade for the sea salt?


Dr. Mike: Why not? If that's the vibe in the office, why not?


Howard: So then you go from.


Dr. Mike: I never knock success, Howard.


Howard: So in your fourth book, The Basic Rules of Being a Dental Patient.


Dr. Mike: Yeah, that book was when I wrote the first book. Why we wrote the first book, what motivated me was right off the bat our first, when we started this discussion today was, it occurred to me that we needed a Dentistry for Dummies book and what I noticed was all these Institute's and GP’s trying very hard to learn various techniques and everything else, and I just wanted to distill down what I thought were a lot of common concepts, like we talked about right now. I was asked to write the second book by my publisher, he wanted me to do something on Occlusion and then the last book, Facially Generated Treatment Planning was actually, came from my study clubs because when I'm actually teaching hands-on, we talked a lot about Facially Generated Treatment Planning. So in hindsight I kind of just fell into all of this and they really should all be blended together, the three books, but that all being said, my patients, when I came up with book number one they always asked me, could you write a book for us and so the book is actually written, the fourth book is, I've actually written the book as if I'm a patient and as I alluded to earlier, I'm sixty years old, I'm starting to use medical services now and so the book is written, is what do I look for when I go for medical services? Who am I looking for? and the book is about being proactive and it's about trying to educate patients on how to look at the Internet and possibly get in some more scholarly type education by utilizing services such as PubMed.


Howard: It's really weird because I'm at a crossroads on water fluoridation. I have almost, the businessman of me tells me, listen to the people, one-fourth of Americans think it's just crazy, communist, toxic, everything's wrong with it and those people, and that's why the Internet is frightening because if I go to the Internet and type in water fluoridation, what percent of the sites are misinformed scare tactics sky-is-falling?


Dr. Mike: I would think a lot.


Howard: Yeah, it's 95%.


Dr. Mike: Yeah.


Howard: And then when you say, "Well, you should just go to websites like PubMed or the CDC or Mayo Clinic or Cleveland Clinic," they always think those are conspiracy, CDC, well, they're in bed with the government and the government's taking kickbacks from the fertilizer manufacturers, and the fluoride is so toxic they can't put it anywhere so they bribed the government to pour it in the water and it's like, you can't even have a conversation on half of these topics with one-fourth of America.


Dr. Mike: Let me respond?


Howard: Yeah, yeah.


Dr. Mike: I always try to do a positive spin on things and so rather than tell a patient, for example they're a slob and they don't do their hygiene very well. I don't say, jeez, if you don't do this, this is going to happen. I try to highlight the benefits, well, the benefits of flossing is less bad breath. Possibly if you do a little bit more of this, you get less decayed, the benefit, the benefit, the benefit. So, if somebody used to bring up a topic like Mercury and Silver Fillings or Fluoride or something like that, I said, what I say to suggest is, for example, Silver amalgam, I say it's been a loyal material, we've got a lot of good results out of it over the years, it's a controversial subject, I know it's an emotional subject, I would encourage anybody, I never go “you”. Oh, by the way, “you” is always a bad word whether it's capper  “you” is always a bad thing to say, I always try to talk in terms of “I” and “we”, so I would say that what I would encourage myself to do if I was doing this is, I would try to go to many sites as possible and then I would sit back with my and think about what my value system is and my family value system is, and I would weigh out the options, what I think is best a choice to make myself. So, it sounds like I'm basically telling the person do whatever you want but what I'm doing is I'm trying to plant seeds in a positive way, that possibly there might be some information out there that they might find enlightening that might sway their opinion a little bit more. We all know the Rogers Adaptation Curve, don't we? The Rogers Adaptation Curves, how people move along with concepts, we have our innovators which are out here, it's a Bell Curve, we've got our innovators out here which are usually considered the idiots, they're considered the wackos and the nuts. We've got our early adopters, they're the ones that see a really good idea and jump on to it. So for example, you have your innovators out here, maybe those were the people that were thinking about personal computers forty years ago, and then you have your early adopters and they say, oh, wait a second, these, no, maybe Dell would be a good example. Oh, we like these personal computers, I'm going to start making all kinds of personal computers, this is going to be a good thing and then you have the top of the curve up here which those are the people that tend to say, okay, this looks like a trend, we're going to, we're going to be riding along it, maybe about your late adapters. It's damn it, I guess I do have to buy an iPhone now, everybody else has got one, damn, I don't really want to do this and I better do it, and you have, we’re always going to have our laggards. I mean, we're always going to have our laggards and so even when it comes to topics, no matter how emotional people might get about them, we're always going to have people that are going to not even be interested at all, unfortunately.


Howard: And what percent of Canadians and Americans would you consider to be just batshit crazy?


Dr. Mike: It depends where you talking about.


Howard: So when you go to your website drracich.ca and you have four sections. You have Focused Dental, Dental Coach, Second Opinions Only, Media Publications which has the four books. So let's start one by one, what's Focused Dental?


Dr. Mike: That's my continued education, that's my hands-on programs. So focus, I run study clubs, I like writing study clubs, so those are groups of getting groups of Dentists together and then we run it, first couple years are run very structured because talking about topics, like you mentioned earlier, usually takes a very structured approach to go through things like what's the Joint Position and Vertical Dimension and all that sort stuff. So the first three years are very structured. So the first door explains how I run my study clubs, they're hands-on, we get groups of Dentists together.


Howard: Are these all mostly in Western Canada?


Dr. Mike: They're mainly in Western Canada but they could be done anywhere.


Howard: And how many, how many sessions is it usually to get the get them from A to Z?


Dr. Mike: The first year is basically what we talked about earlier, Centric Relation, Records, Making an Orthodontic that we can get into the mouth predictably, at a predictable vertical dimension. So the first year is six or seven sessions and we space them out about two months, six weeks to give everybody a chance to go back to their office, think about it so on and so forth. The second year is Facially Generated Treatment Planning and what we do in the second year is we do a Denture because the easiest way to learn Facially Generated Treatment Planning is put something in there where we can move the teeth around very easily, lip support, jaw relationships and so on and so forth and then what we do in the second part, a second year is the Dentist Mount Aesthetic cast at a Workable Vertical, the Vertical Dimension that they want to work at and then they do a Wax Up or a Composite Up on there. Just to give them an idea what the stages would be to literally reconstruct somebody's mouth, applying the basic, applying Facially Generated Treatment Planning and then we just keep on going on from there. My first study club is still going, we've been going for 19 years.

Howard: Wow, now Phoenix. I don't know if you're, you got to be aware of this, 10% of Phoenix is from Canada.


Dr. Mike: Oh, easy.


Howard: Yeah, 10 % and there's other ones that.


Dr. Mike: The Winter, but might even go as high as 50, you never know.


Howard: Oh, my God, there's more Maple Leaf flags flying in the retirement communities and there are American flags because it's their way of communicating each other where they're at. But anyway, thank, both of the Orthodontists across the street from my office are both from Canada but if it's six or seven, it's six or seven classes a year, two years?


Dr. Mike: No, each year is about six or seven.


Howard: Yeah, but it's basically two years long, though, to get through all.


Dr. Mike: Well, yeah, it usually takes about three years.


Howard: Okay, well, I'm just saying, if you ever consider doing that in Phoenix during the winter months, of course you don't really have Winters because you're in a rain forest, right?


Dr. Mike: That's right, tropical, a temperate rainforest.


Howard: Yeah, most people don't understand this about Canada but it's Vancouver, you got to go in the Alaskan cruise, the only same cruise I did twice. I mean, if Canada where you live is a tropical rainforest. What is it like, eighty inches?


Dr. Mike: Temperate rain forest.


Howard: Temperate rain forest. How much rain do you guys actually get?


Dr. Mike: I don't really know how much we get a year but it rains, but it mainly rains, but we have rain all year, of course. The heavier rain is November which is bad news but then it's good news is because that's when all the local hills around us and Whistler, our big resort get all the snow. So that rain and the Wintertime brings snow to all our ski resorts which is really nice, and in downtown Vancouver we get snow in the city but not a lot of snow there, most of the snow stays up on the hills. So year around people can golf, that sort of thing.


Howard: And then tell me about the third part of your site is Second Opinions Only. What is Second Opinions Only?


Dr. Mike: It's mainly a site for medical-legal, I do medical-legal work plus I do, I'm on the college inquiry committee, the discipline committee so I do medical legal work but the Second Opinions Only is actually just that, too, it's for any Dentist that wants to send me some various cases or whatever, or it's also for the public. So for, public just wants an opinion on what to do, it's strictly an opinion, I’m not soliciting work, in fact, anybody that comes through that site, any patient that comes through site I won't take them as a patient. I'm strictly there to give them an objective opinion, give them the facts, let them go away and think about it and then they’ll hopefully seek care with their dentists or whatever dentists they choose. I want to go back to how many years it does, takes to do the programs clearly with study clubs in Western Canada run from September to June and so that's why it kind of gets, the six or seven sessions get kind of expanded out, if you like, but clearly these can be condensed. I mean, the six sessions could be condensed into one month, so that whole three years, for example, could easily be done in one year, three months. If it was a Graduate Prosthodontic Program that would be just be vacuum packed very tight.


Howard:  Interesting. Man, I think you're amazing, I hope you make some online CE course, well, Dentaltown is interesting, so we have an annual meeting where we meet every year, the first fifteen years was in Vegas then we plan the next two years, the next two April's will be in Orlando but you can't really have a department that has one meeting a year, so the only way it works is you got to have other meetings during the year. So we have that big annual meeting but now we put other meetings on, we like to put other meetings on and of course there's four million people in the metro of Phoenix, so when we put courses on right here at Dentaltown at the Indian Reservation Casino, I mean, shit, there's three thousand eight hundred Dentists that are in driving distance just to that core. So I know you Canadians love Phoenix. My gosh, I love Phoenix. It's funny because if you're from Canada or the northern Midwest you come to Phoenix but once you cross that Mississippi River, you go to Florida and I don't know if there's a, but yeah, this place is so Canadian, that's why I thought you might do that. But man, I hope you make some online CE courses. Can I ask one overtime question because I've been looking at the message boards under TMD and there's one recurring question that is the biggest frightening ghost in goblin in all of Occlusion, and that is, "if they open up someone's bite,"?


Dr. Mike: Oh, no, don't worry about opening up anybody's bite, the most you're going to, most of Dentists, obviously we've got the Denture Cases where they don't like that but Dentate people usually don't come in, and so our jaw is like a nutcracker and it's a one millimeter here, it’s about three millimeters here. So if we've got even a class-one Occlusion and we open it up three millimeters, that gives us a lot of room for Restorative Materials. If we open up the Posterior two millimeters, that's six millimeters, the clinical height of Essential Incisor is ten millimeters. If we've got a skeletal class two person because, oh, and by the way, when the jaw opens up, the jaw just drops down, it doesn't drop down, the jaw auto rotates back. So if we've got a skeletal class two person, where am I in this camera, a skeletal class two person here, I mean, they're going to even auto-rotate further away, so the amount that we have to open someone up, we're talking a millimeter. A millimeter is like nothing, two millimeters is like, whoa, three millimeters, oh, my God.  We just don't do that, so opening up a bite is not a problem, okay? It's making sure we have a stable position and again what I call the one, two, threes of dentistry and then, and if you think about it, if you really stop and think about it, if someone's got a 50% overbite and we continue to work with them in that case and if by some chance we restrict the envelope of function when they're functioning, they may start pressing against a little bit more which might cause a few problems, you might create a problem. If we open up someone's bite, one of the things that we're doing is we're giving them a little bit more freedom but what we're also doing is that their Bruxers, we're giving them less porcelain to smash. So opening up a bite isn't such a bad thing to do, it almost makes people, it also makes people look a little younger. It's almost like free Botox, help get rid of the wrinkles and it comes back to this Facially Generated Treatment Planning, so when we're treatment planning someone, we're looking at the facial thirds and we're looking at what their lower facial third is, and can we open them up a little bit, and depending on their skeletal class we can get away with a little bit more a little bit less, class threes can get away with quite a bit because, class ones we can get away with a fair amount, class twos are little trickier, skeletal class two is depending on how more, where they're at and all that sort of stuff but it's not insurmountable.


Howard:  And just for a total disclaimer, I want to know that I have not used Botox, this is all natural. This is totally natural, everybody thinks I have photoshopped my face but it's all natural. Hey, man, I could listen to you for forty days and forty nights. I think you're the bomb, this is a very, very difficult subject. It takes a long time to learn it, I think you’re, I can't believe you wrote four books, you are so prolific. I mean, God, that's like having four kids on the side.


Dr. Mike: There you go.


Howard: Yeah, but man, seriously, thank you so much for coming on my show today. I do think if you did a one hour.


Dr. Mike: Thank you everybody out there for listening to me, too. Hope you haven’t dozed off halfway.


Howard: I think that if you did a one-hour online CE course on each one of your four books, it'd be the best marketing you could do for those books.


Dr. Mike: I'll do it! Let’s get it done.


Howard: Alright! Next time I see you I hope we're having a beer at a bar before I get on that Alaskan cruise again.


Category: occlusion
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