Dr. Nadim Z. Baba received his DMD degree from the University of Montreal in 1996. He completed a Certificate in Advanced Graduate Studies in Prosthodontics and a Master’s degree in Restorative Sciences in Prosthodontics from Boston University School of Dentistry in 1999. Dr. Baba serves as a professor in the Advanced Education program in prosthodontics at Loma Linda University School of Dentistry, and maintains a part-time private practice in Glendale, CA. He is currently the President-Elect of the American College of Prosthodontists and an active member of various other professional organizations. Dr. Baba is a Fellow of the American College of Prosthodontists and a Diplomate of the American Board of Prosthodontics. He is involved in the editorial process for several dental journals, is the author of numerous publications, has published a book entitled “Restoration of Endodontically treated teeth: evidence based diagnosis and treatment Planning” and is the recipient of many honors and awards, and has lectured around the world.
VIDEO - DUwHF #997 - Nadim Baba
AUDIO - DUwHF #997 - Nadim Baba
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Howard: It's just a huge honor for me today to be podcast interviewing Nadim Z. Baba, DMD, MSD, FACP. He received his DMD degree from the University of Montréal in 1996. He completed a Certificate in Advanced Graduate Studies in Prosthodontics and a master's degree in Restorative Sciences in Prosthodontics from Boston University School of Dentistry in ‘99. He serves as a professor in the Advanced Education program in Prosthodontics at Loma Linda University School of Dentistry and maintains a part-time practice in Glendale, California. He is currently the President-Elect of the American College of Prosthodontists and an active member of various other professional organizations. He is a Fellow of the American College of Prosthodontists and a diplomat at the American Board of Prosthodontics. He's involved in the editorial process for several dental journals. Is the author of numerous publications. Has published a book entitled, Restoration of Endodontically Treated Teeth, Evidence Based Diagnosis and Treatment Planning and is a recipient of many honors and awards, that he's lectured around the world. My gosh! I don't even know if I'm smart enough to podcast you.
Nadim: Thank you, you're so sweet.
Howard: Oh my gosh. So let's start in Prosthodontics, let's start with the people that listen to podcasts, I always tell them, send me an email firstname.lastname@example.org, tell me where you live, what country you're in, how old you are, what you think of the show. The bottom line is I'm fifty-five, I only get one fifty-five year old person a month, maybe. They're all under thirty, they're all millennials and they're coming out of school $350,000 in debt. I talked to a guy the other day, it was $550,000 in debt and one of their big questions is, do they have to buy a $150,000 CAD/CAM machine to be an amazing prosthodontist like you?
Nadim: No, they don't Howard. The good thing today is you have the major labs that we work with, can outsource the work. So you just don't have to invest too much, if you just out of Dental School or out of Prosthodontics program, you don't have to invest too much into buying a lot of equipment because what you can do, is you can send you impressions to some designated labs that do CAD/CAM milling and they can do the design as much as the milling for you or if you want to invest a little bit more, you can invest into and intraoral scanner or a lab scanner and have your impressions either scanned or you can directly make the impression intraorally and then send it to these labs to do whatever you want to do with this (unclear 0:02:52).
Howard: So what scanner, what do you have in your office or what do you like?
Nadim: I have an intraoral scanner from Dental Wings and...
Howard: Dental Wings?
Nadim: ...yes, Dental Wings...
Howard: Can you send me that Ryan?
Nadim: ...(unclear 0:03:06) it's a company based in Montréal and the reason why I got it because the capturing device is very small. It's the size of the handpiece, it's not heavy and you can either use with powder or without powder and it helps you do whatever you're looking for, from single crown to a (unclear 0:03:33) FPD or to a single implant.
Howard: So you went to school in Montréal.
Nadim: Yes, I went to school in Montréal, I did.
Howard: So did you ever learn how to speak French while you were there?
Nadim: Well actually I am trilingual I do speak three languages before getting into Dental School. So I do speak French, Arabic, and English.
Howard: Wow! Those are three, that's half the U.N. languages, the U.N. only does business in six languages.
Nadim: Yeah, (unclear 0:04:04).
Howard: So you should be at least a half qualified U.S. Ambassador to the United Nations. So which one is the hardest to speak French, Arabic or English?.
Nadim: Actually, I started with Arabic because I was born in the Middle East. Then I learned French in school and the last language I learned was English. So at this stage of my life, I feel very comfortable with English, much more than French. Both, I'm talking about the writing part. Speaking, they're equally fine for me.
Howard: That is amazing. I live a hundred miles from Mexico, so I would give anything to speak Spanish but it was the only D, I ever got in my life, was in high school Spanish. My Spanish teacher, Sam Martine told my mother that I was linguistically retarded, he said and he said you're never going to teach this kid a language. So is CAD/CAM taking off, chairside milling (unclear 0:05:08) chairside milling from lab CAD/CAM. How many prosthodontists are there? About, what is it?
Nadim: There's around three thousand eight hundred to nine hundred prosthodontists.
Howard: Thirty-eight hundred?
Howard: Is that for the United States or the whole world?
Nadim: No, I'm talking about members of the American College of Prosthodontists.
Howard: OK, so just America.
Howard: Just the United States, thirty-eight hundred. How many...
Nadim: There are prosthodontists that are not a part of the American College of Prosthodontists, so they're not members but those who are members, around thirty-eight hundred.
Howard: And how many of them do you think chairside mill?
Nadim: I can't give you an exact number but I know that our colleagues are getting more into CAD/CAM, whether it's fixed or removable and I know for a fact also that we are basically considered the leaders in CAD/CAM dentistry and to the point that the American College of Prosthodontists got an unrestricted fund from Henry Shine to put together a digital curriculum. Because Henry Shine recognized that the ACP has that power to be the leader in CAD/CAM digital dentistry. So the ACP has put together a digital curriculum and we are now trial testing it in five different schools and hopefully, down the road, we'll have a lot of school adopt that digital curriculum and implement it into their daily curriculum because don't forget Howard, CAD/CAM is here to stay. There's a (unclear 0:06:51) a lot of people have thought that CAD/CAM is not going to work because it's expensive because it wasn't very accurate. Don't forget technology goes very fast and the technology's evolving very fast and it's becoming more and more accurate. Now, you remember CEREC came out in the 80s, even before but in the 80s it became popular in the United States and since then the CAD/CAM process has evolved, not only in fixed but in maxillofacial and removable. So it's here to stay and even in implant dentistry, so it's here to stay.
Howard: Well, I remember back in the 80s whenever you were talking to the CEREC people, the limiting constraint was the size of the microprocessors...
Howard: ...they could write, the amount of code they could write was so limited but as Intel went from the, my first dental office in 1987, my office computer, was an Intel two eighty-six. I bet a Motorola flip phone has more power than that darn thing...
Nadim: (unclear 0:08:05).
Howard: ...and then it was the two eighty-six and the three eighty-six, then it was the Pentium and, but as those processors got bigger and bigger and bigger they could just write a lot more fancy elaborate code. But you're even using CAD/CAM in dentures.
Nadim: Yes, we are.
Howard: How is that going? Talk about that.
Nadim: The interesting thing about complete dentures is that you can do two processes. You can either make an impression, send it to the lab and from there using some anatomic landmarks, they virtually set up to teeth for you and they can mill the dentures and send them back to you to get them (unclear 0:08:47) and delivered. Now, and the other process is basically now what we're trying to do is to try to get acquired an impression intraorally using the intraoral scanners and design the dentures from there. So there's a lot of trials being done and all around the United States by different colleagues. At Loma Linda here we've tried couple cases where we use different devices to acquire an impression intraorally and we got dentures made out of these and the dentures came out very nice.
Howard: So a lot of, it's amazing how, it's so American to want to have a instant all on 4, you don't take care of your teeth, you neglect them and you go in there and one day you take everything out, put everything in, it's so American. Watching this for a decade, the people who lost all their teeth and needed all on 4, these weren't vegans who went to yoga three times a day, these were some of the, I would say the more wild Irish drinking, smoking and it seems like a lot of these all on 4's and a lot of these fixed implant cases, when they come in they got a complete ham sandwich underneath their fix. I always wondered if it'd been so much better if it had been like a ball and socket, a removable, a denture with four ball and sockets as opposed to fix. So that grandpa could snap that thing out morning and night and rinse it all off and brush it. What do you think about that and the effect that would have on perimplantitis of fixed versus implant removable?.
Nadim: Well, for sure I can tell you that the decision between fixed or removable depends on many factors. The first is the biologic factors, the economic factors, if you have the amount of bone loss. You get a lot of factors that are involved in there. So the way the media is putting it, an all on 4 for everybody, I don't think it is for everybody. There should be a case analysis to make sure that that patient is a candidate for and all on 4. For some patients given their dexterity, given their age, given the ability, the difficulty to clean, like if they live in a hospital or in an assisted home, it might be easier for them to get something that, as you said (unclear 0:11:33) removable, they can rinse it, rinse their mouth and put it back in. Again, it also depends how much can the patient afford, an all on 4 might not necessarily cost the same as an implant supported overdenture. So there is a big difference there in cost. So there's the cost of the implants, there's the cost of the prosthesis. So it's much more expensive to get an all on 4, than an overdenture.
Howard: Which is, I get it, they just want, I think it's psychological, they just want to have something fixed that can never come out. I totally see the appeal of that but man, you save so much money having an implant supported overdenture and the cleaning. Is there noticeable less perimplantitis around implant supported overdentures as opposed to all on 4's fixed?.
Nadim: Again it depends on the patient and the level of understanding about hygiene. If you look at the studies, it all matters, is how much is the patient investing into his hygiene. Well, you can have a patient wearing a fixed complete denture or a hybrid and not cleaning or not doing anything. Of course, they're going to get into perimplantitis and some other issues. This could be also true for patient wearing an implant supported overdenture. So, it really matters on a case to case basis. But what I can tell you is, I always tell my patients that you can start with an overdenture because it's cheaper but down the road if you save your money, you can have more implants and you can transform that overdenture or you can move from an overdenture to an implant fixed complete denture with time.
Howard: When people go to the orthopedic surgeon and they get a artificial hip or a knee they, around here in Phoenix anyway, it's the only area I know, they set the expectations very low. The doctors always saying, hopefully, you can get five to seven years out of this. What do you think we, these young kids should be telling him. Because some of these kids tell him, oh this implant will be fine, it will be perfect and you'll take it to heaven with you someday and none of the orthopedic surgeons say that about any of the other body parts. What do you think a kid should be telling their patients when they say how long will this implant last? I know there's a ton of variables but how do you frame that?.
Nadim: An excellent question. Usually, the patient ask, so are my implants forever? I said well if they were forever we would be forever too. I tell them there's nothing forever. Usually, what I tell the patients if you take care of your implants, they should serve you between twelve to fifteen years. Well, I think it's probably pushing it to the low side, I know some of my colleagues will say more but I personally, I think it's safer to give them less of a lifespan than more. So if in case something happens to the implant, they don't get disappointed but I usually tell them the lifespan is between, let's say twelve to fifteen but if you take care of them they might last you much, much more.
Howard: I know there's a lot of variables in that. You see, as a prosthodontist, what percent of your cases are treating a failed case, redoing a failed case versus starting a new case?.
Nadim: Well, unfortunately, the area where I practice the percentage of (unclear 0:15:21) failing cases is pretty high. I get around, I should say 65 to 70% of my cases are failing cases that are referred by either periodontists or oral surgeons or sometimes they just come in because they heard about me and it's like a word of mouth but it's a big percentage.
Howard: Why do you think they're failing?.
Nadim: Most of the problems with the failures are below standard prosthesis, whether fixed or removable. Occlusion is always badly designed and most of the time is the choice of the material, the choice of the prosthesis. You notice that some people get engaged into these cases without any knowledge of occlusion, without any knowledge of vertical dimension. There's a lot of things that they omit that causes these patients some issues and unfortunately most of the time the patient have spent a lot of money and then the failure comes in after six month or nine month and they still paying their loans for that prosthesis that they've got and it's frustrating for both the patient and myself because they come to me and they say, I already spent $40,000, I don't have any more money. So what do you do? They've got something fixed that is failing and they end up with a complete denture. It's really frustrating for the patient.
Howard: I know. When you talk about occlusion, I hear the cries of these young kids in Dental School, they basically will say (unclear 0:17:01) say look, when you go into Endodontics, the endodontists hardly argue about anything. When you go into Pediatric Dentistry maybe the only thing they argue about is Silver Diammine fluoride, some just love it and some don't care for it. But man when you go to occlusion, there's five different world religions in the science of occlusion. You've got your neuro-linguistic occlusion, you got C.R, you have all these camps. How do you, and the specific question is this, they come out of school, they say I want to learn more about occlusion and it looks like the universe, the programs are set up either neuro-linguistic programming or C.R., what would you. Do you agree that there's a lot of different schools of thought on occlusion?.
Nadim: I agree with you on that one. There's a lot of thoughts depending on which school do you go to and depending who teaches occlusion to the students or the residents. There are some basic principles that we need to understand. Now if they going with a complete denture, you definitely need to get the patient in (unclear 0:18:03) and now if you're going with an implant fixed complete denture or hybrid's, then you have to treat these cases as if they were fixed. So you have to make sure that the patient gets a (unclear 0:18:15) and protrusive and not to treat it as if it was a fixed case, so and that's the difference. Many times I see all these patient (unclear 0:18:29) hybrids or implant fixed complete dentures and the occlusion is treated as if it was a complete denture and then you can see here and there teeth breaking and popping out and it gets the patient into a lot of difficulties.
Howard: Well said. What advice would you, if a young kid comes out of school. Well, you're teaching at Loma Linda when they come out of school, how is their understanding of occlusion? Where do they go from there? Do they usually come out and they're on top of it or more (unclear 0:18:59)?.
Nadim: I can't say that but I know that a lot of students come out and they have issues with occlusion because it's either under taught and it's a difficult subject. Now one of my colleagues here at school and the previous Dean of the Loma Linda school, Dr. Charles Goodacre developed an occlusion e-book that is available on eHuman and any student or any person can download it...
Howard: Can you find that...
Nadim: (unclear 0:19:31).
Ryan: What is it?
Howard: Say it again.
Nadim: It's eHuman...
Nadim: ...eHuman and it's an e-book that anybody can download but at a cost of course but it has a lot of details on occlusion and it's the best resource for anybody to review occlusion once they graduate from Dental School.
Howard: Nice, how much is it?.
Nadim: I have no idea, honestly, I don't know how much it is but I know it's affordable.
Howard: So what do you think about implant failures from cement left behind, are you seeing much of that?.
Nadim: This is the number one failure that I see in my office. People have issues with cementing crowns. I personally go with screw-retained. So I don't have much of these issues in my office. Again the reason why I go cement-retained because now with guided surgery there is no reason to have the implants off of the axis or in a position that is extremely weird but (unclear 0:20:37) to have a custom abutment and then have the crown cemented. But those people who prefer the cement-retained implant-supported crowns. The thing is, they are using all these composite resin cement and studies have shown that they're very difficult to remove because they bond very well to the abutments. So even if you use scalers, even if you use plastic scalers or any type of other scalers, you're going to create scratches on these abutments that, down the road causes problem because plaque will adhere to these surfaces. And I should say, there is always some remnants of cement that are left in there and then this cement can cause perimplantitis and the loss of integration.
Howard: What do you think the least toxic dental implant cement? I always thought it was funny that the box says dental implants cement, it has a ADA seal of approval but if you leave (unclear 0:21:42) it's toxic and causes perimplantitis, that doesn't. All those things don't seem to go together.
Nadim: No, I agree with you. Having the ADA seal approval doesn't mean that it's an ideal cement to cement a crown on an implant abutment. My recommendation. usually when a student asked me that type of question. (unclear 0:22:03) avoid composite resin cements as much as you can. Now either go with zinc phosphate and we all know and you know more than I do that zinc phosphate is easy to remove after it sets. You can either use a temporary cement like Temp-Bond but there are also some other cement that are easy to remove. The most important part, is choose a (unclear 0:22:28) opaque cement that you can see after you make an X-ray after cementation. Because the problem is that most of the composite resin cement are translucent. So you grab an X-ray after you cement your crown, you don't see anything, you say we're good to go. The problem is, you can't see it but if you use an opaque cement, then you'd be able to see on the X-ray that you have something left in there. Two good ways to avoid cements and (unclear 0:22:56) around an abutment. The first one is to place a cord, so you place a cord like you're making an impression for a single crown and then you cement it and then at the end you pull the cord out. The other way is to do it die, that take some putty material, put it (unclear 0:23:15) surface of the crown and then when it sets you get a die. So what you do is you mix the cement, put it in the (unclear 0:23:22) surface of the crown, (unclear 0:23:23) putty die and then go ahead and cement intraorally. So that will eliminate most of the excess of cement, so it doesn't go into the (unclear 0:23:32).
Howard: But, zinc phosphate, you don't like the resin cements but would, and you prefer to screw than cement.
Nadim: 99% of my implant supported crowns or screw retained.
Howard: But if you were going to cement would it be zinc phosphate?.
Nadim: If I have to do something cement, I use Temp-Bond.
Nadim: (unclear 0:23:52).
Howard: Very, very good. Now you know they're always going to ask you are you a prosthodontist, they want to know what implant system. It's so confusing, like right now the Hinman meeting is going on. We just had the Chicago Midwinter meeting and the biggest dental meeting in the world, is the FDI meeting in Cologne, Germany and they said there were a hundred and seventy five different implant systems at the FDI. So how's this little kid supposed to come out of school and go through a hundred and seventy five systems? What advice would you give her?..
Nadim: The best advice I can give somebody who graduates from school, want to go into implants is to pick a company that has been there on the market for so long. They have a good customer service and they can back you up in case something fails and that's my advice. Then the other thing is use a company that has given to the profession a lot. Now the problem and again, and nothing against any of the companies but you get some of these small companies that are showing up, they're giving some money incentive to these young dentists and they give you a ticket to travel here and there, to get a CE course, they give you so many implants and they want to drag you and God forbid something fails, they wash their hands and they run away. That's the problem that most of the failures that I see, the intention of the dentist was good because he said OK, I'll save couple of hundreds by buying this system because it's cheaper than the other one. But the problem is, once they had the issue, they call the company, company says it's not my problem it's yours. So stick around companies that have a history of success, a long track record that you know that these companies have provided (unclear 0:25:42) for the profession and for the specialties.
Howard: True or false. Some people, first of all, when I got to school in 1987 I never thought I'd see the PFM go the way of the Tyrannosaurus rex, that was the modern cosmetic dentistry over gold crowns and amalgams and, but some people are. I hear some people say that they think zirconium might be too hard for endodontically treated teeth and that when you had a PFM and you bit something hard the weak spot was the porcelain chipping off the metal. But now that their zirconium isn't going to budge, does that mean the weak spot is going to be the endodontically treated tooth and have a root fracture?
Nadim: That's very difficult question to answer but what I can tell you is that the problem with zirconia is to remove it. So, of course, now they coming with new special burrs to remove zirconia but it's still a hard material. And you right be an issue because whatevers going to take the load is your roots, it's not the crown. So but honestly, I still believe there is room for PFM crowns and gold crowns. I might be, I'm fifty years old but I'm not that old but I still believe that some patients given the amount of (unclear 0:27:11) they have, they's be better off with just a gold crown or a PFM crown. I still personally favor having glass ceramic anteriorly, because it blends better with the gums and the translucency that these material have, look nicer and posteriorly, why do you want to go crazy and just for second molar and get something that should be fancy and nice, nobody sees it. So at that stage why not a PFM posteriorly but again, it's debatable, it's.
Howard: It's so weird there's so many cultural factors, I'm in Phoenix, so I'm a hundred miles from Mexico, so a quarter of my practice is Hispanic, a quarter of Arizona's American Indian, we've got a large African-American population. All those girls will go gold. All seven of my restorations are gold but my gosh you tell a European woman to put a gold crown on her tooth and she looks at you like you're from another planet right...
Nadim: Yeah it is.
Howard: ...and it's so frustrating, because she'll have gold earrings, gold bar in her nose, she'll have gold wedding rings, she has gold ten different places on her body and then when I say, God you grind your teeth, the teeth are small, it'll just be perfect being gold and everybody says yes unless they're European American and then they're just like, no way.
Nadim: I agree with you and I know a lot of my colleagues from Europe that I work with, they don't do any, now at the stage they don't even suggest a PFM crown and gold is really out of the question. I hear you, you're right about it (unclear 0:28:51)...
Howard: And we've been talking for a half an hour, have you even noticed any of my gold teeth?
Howard: Yeah, I know. I can vouch for this, I'm very proud of this, and I can't believe I'm saying on a podcast but three times it was a second molar and I didn't have any options and she said no, no, no I don't want gold, cemented a gold crown on her second molar because it was short and far back. To this day they don't even know it. I'm like the only one that knows she has a gold crown on her second molar.
Howard: But that's crazy. So what would you say about, 25% of our listeners are still in school, what would you say to her if she thought, you know what maybe I want to specialize and be a prosthodontist. What what you think of that decision?.
Nadim: I think this is the best time to be a prosthodontist. This is the best time, to be a prosthodontist, honestly. I think we, if you look at the amount of work we have, if we look at the advancement in materials, if you look at the CAD/CAM or the digital world that we're going into, prosthodontists are going to be the leader in that world. We are already and we're going to be more in the future. So I think this is the best time to be a prosthodontist. Yes some people might tell me but it's three years extra and I have to get another loan for three years but it's worth it.
Howard: When they come out of school, a prosthodontist has to pick a business model because some Prosthodontics and their training their programmes, they place the implants. Then I have a lot of prosthodontists and her friend says, I can't do that, I get all my referrals from periodontists and oral surgeons that are placing these implants. What would you say? Should they master placing the implants and then risk not getting referrals from periodontist and oral surgeons or would you just stick to restoring.
Nadim: If you look at the (unclear 0:30:58) and (unclear 0:31:00) has said that prosthodontists need to learn how to replace implants during their residency. Now, to be able to graduate. Now, if after they graduate they have couple options. So if they're in an area where there is no oral surgeons, no periodontists around them, they're the only one in there. Well what's the (unclear 0:31:22), they're not losing anything, so they can put their one implants and even put implants for others and restore them. Now you get some people that say, well as you said, I don't want to lose any referrals because I'm going to be working in an office that relies heavily on referrals from periodontists or oral surgeons. Now, (unclear 0:31:41) have no choice or you can do a combination of both and I know some of my colleagues what they do is they, single implants or easy implants in the posterior area, they do it themselves and when it comes to complicated stuff they refer them out. But again, there's no ideal model, everybody has to work it out according to the area where they going to be practicing and what type of practice they're going to be working in.
Howard: Here's another question, I'm just throwing oddball questions at you but when you're in school you have an articulator and then when you come out of school, what percent of your cases actually do you do a face-bow transfer? When do you need to do a face-bow transfer and use an articulator?.
Nadim: That's a very good question. Now if you're doing a complete (unclear 0:32:30), we usually, 99% of the time use a face-bow. Now if you're doing a full mouth rehab or the maxillary arch or the mandible arch or in cases where canines are involved and you want to work your occlusion pretty well, you better have them mounted on a semi-adjustable articulator. But if you're doing a single clown, a small FPD posteriorly, you don't really need to face-bow but now with the introduction of Digital Dentistry and CAD/CAM. Now, don't forget now what we can do is, they virtually mount these impressions that you make, they mount them virtually on articulator and it's a virtual articulator that can work with occlusion in there. So to answer your question probably down the future, maybe an articulator won't be necessary and I probably see that. Now if you look at the systems that are being built these days for CAD/CAM removable, you don't necessarily need an articulator anymore. So down the road probably we won't have a need for articulators.
Howard: What about Maryland bridges?.
Nadim: Maryland bridges, they still have their own place, not everybody can afford implants if they missing congenitally missing laterals. So I believe that doing Maryland bridges is nothing wrong with it, it has its place and either the patient is too young to get an implant or they can't afford to get an implant. I think this is the best alternative they have.
Howard: When you see failed cases, what is a low hanging fruit mistakes that came from the treatment planning side? Was it too many crowns for too few of implant? What are the most common treatment planning mistakes you're seeing?
Nadim: I think the problem is to see the big picture, so focus on one particular area or they look at one particular tooth, or they look at one arch but they forget that this mouth is part of a skull, of a part of a human being and they have to look at the big picture. So what I say by the big picture is, if you're restoring a case, you want to open the vertical, then you have to make a decision, should I restore only the maxillary teeth, only the mandible teeth or both? And then and sometimes the most of the problems is they don't see that. The other problem is occlusion. So they don't pay enough attention to occlusion and the third problem is the misplacement of the implants, a implant placed in odd positions where they can't be restored. So the treatment plan is extremely important because most of the people and again the mistakes they make, it's either no X-rays, no CBCT's, no surgical guides and the inability to see the big picture and then zoom into the small picture.
Howard: When I got out of school in 1987 my prosthodontist told us that we would witness the extinction of the denture, it was just going to go away and it's funny now looking at that data because thirty years later America does more dentures today than they did in 1987. What are the and for a lot of dentists, here's one of my firm beliefs, that if you don't do something once a week you never really reach critical mass and quality, speed, efficiency, you got to do it faster, easier, a higher quality, lower cost and the dentist are really, really good. We're actually all physicians, surgeons, they're really good if they do it at least once a week. That's fifty cases a year but it seems like so many dentists doing the dentures they get one like every six months and you just really, it's just hard to master something that you do twice a year.
Nadim: But that's what I tell my students and then sometimes they'll tell me, oh you're so good at dentures. I say well, I do an average of ten dentures a month. So (unclear 0:36:43) I have been a prosthodontist since 1999, so you can figure out how many dentures I've made. Well, and then someone of them say, oh I've just made two of them the whole year last year. So it is true, the more you make the better you become. But to answer your question, if you look at the American census, either in Canada or in the United States, dentureless are always going to be here and then the problem is a lot of our colleagues when they say, oh I've never, I don't see dentures in my office, so probably they practice in high-end neighborhood. Well, if you go to some other areas in the United States, people are poor, they don't have money for, to get a hybrid, they going to get a denture. So again it depends where you practice but in general, yes there will always be dentures and the problem is not a lot of schools are teaching removable the way it should be, that's the problem.
Howard: Yeah, and the most common full mouth cosmetic rehab case in America is not the all on 4, it's the all on none. For every person that dishes out $25,000 an arch for a $50,000 full mouth all on 4, there were a dozen all on nones. But if you go to any of these dental conventions all the courses are on the sexy all on 4 and there's no courses on the all on none and they really turn a lot of lives around when they.
Nadim: I'm glad you said that because I personally think that the complete denture is a full mouth rehab. When it's much more difficult actually than doing crowns, it's really much, much more difficult because there's a lot of factors in there that you have to take into consideration to get that denture where it should be. You get esthetics, you get phonetics, you get the vertical dimension, you get the anatomy. So there's a lot of factors that are involved here. So I agree with you, it's a form of rehab but again the problem is that removable is not being taught the right way.
Howard: And there's a lot of business to be made in it too because, if you go to the biggest break manufacturer, Meineke brakes, when you go there, their price (unclear 0:38:56) three. They have the low-cost brakes, they have the medium and then they have the premier and a lot of people when you show them, here's your denture but there's a lot of incredibly gorgeous upgraded teeth you can buy from like Ivoclar and others. Some of these teeth are just, they're gorgeous.
Nadim: Yeah, you're right. You're right, there is also, the way you make the dentures could also be economical to you. Now as a prosthodontist we learn to make dentures in three appointments. So, versus what you learn in Dental School as a five appointments, if not more. So that in itself saves us money because we have the know how to make it three appointments and also as you said you can buy a set of teeth for this much dollars or you can buy a set of teeth for that much dollars, depending on what type of quality the patient is looking for. Yes, I agree with you on that one.
Howard: Yeah, and when you reduce five appointments to three you just cut out 40% of your costs. (unclear 0:40:06). What's that?.
Nadim: Definitely, I agree with you and the thing also is because introducing CAD/CAM into the removable aspect of prosthodontics has also helped us also reduce the cost by itself because (unclear 0:40:23) before you had to make a preliminary impression for the cast, make a custom tray, do (unclear 0:40:30) and final impression and (unclear 0:40:31) the teeth set up and then the processing. Now what you can do is make an impression and then directly go to the teeth (unclear 0:40:40) and if the patients happy you deliver. So that by itself, you using less material, less chair time and it's more accurate. But provided you have to know the anatomy and that's what I tell my student all the time. Yes, technology is going to replace you working on (unclear 0:40:57) and you setting up teeth and you working on all this hard labor but if you don't know your anatomy, you will have issues acquiring a decent final impression, to get a decent final complete denture.
Howard: Do you ever use Valplast anymore?
Nadim: No, I don't.
Howard: Talk about that, why?.
Nadim: Though. But close by itself is a flexible material. So you're talking about full making of these. Well, Valplast by itself is a flexible material. So you're talking for making RPD's?.
Nadim: Well, the problem is the flexibility of the Valplast clasp themselves causes a lot of stress on the teeth and if they are periodontally involved, you're going to end up losing them. So yes it looks nicer, yes it's very popular among general dentists but is not popular among prosthodontist because we know for a fact that it causes damage to the natural teeth.
Howard: So if you come to Phoenix and go down to the Mexican border, Nogales, Arizona. There's a lab company there that all the partials are milled there and then they drive them across the border and they cast a thousand partials a day, a thousand, it's huge. So when I go down there and I look at all these pans, 90% of all the pan just says lower partial. They didn't cut a single rest seat, they didn't write anything on the lab (unclear 0:42:46) it just said impression lower partial. Nine out of ten and these guys are (unclear 0:42:32) and a lot of times, they'd look at me and they say, really what's wrong with your homies and it's like, so what do you, does that make you. When I said that, what does it make you think?.
Nadim: It makes me think that I'm going to have more work to do. Well, the reality is and I know what you're saying, that just grab and impression, send it to the labs, fabricate mandible or RPD and that's it. Well, and again we just go back to the thing that the principles are not being taught adequately. And again we came out at school here with the help of, and again Dr. Goodacre and Dr. Naylor who editors, the came out with an e-book on the removable partial dentures and it's a phenomenal e-book (unclear 0:43:21)...
Howard: This is your second e-book recommendation. So the last one...
Nadim: ...was on...
Howard: ... was on ehuman.com on...
Nadim: ...on occlusion.
Howard: ...on occlusion, how do they find this e-book?.
Nadim: Well, this one is also an eHuman.
Howard: Oh, it's on the same website.
Howard: OK, eHuman...
Nadim: ...and it's on removable partial dentures. There are videos, there are photos.
Howard: Oh, there it is, oh so here's a (unclear 0:43:46). 3-D at ehuman.com 3-D Tooth Atlas 9, 3-D Tooth Atlas 8, 3-D Tooth Atlas and Hygiene edition, 3-D Occlusion Atlas 3, Removable Partial Dentures and Head and Neck Anatomy. So right now you're talking about Removable Partial Dentures.
Nadim: And complete dentures is coming soon. So we're working on it now.
Howard: So are these your books?.
Nadim: No, they not my book. I contributed to some chapters in them but these are, these books have been edited by Dr. Charles Goodacre and Dr. Pat Naylor, who are the editors. Now I only contributed couple chapters here and there.
Howard: Yeah, that's a nice way to learn, a digital format. You know what I thought was interesting...
Nadim: (unclear 0:44:33) exquisite.
Howard: ...when I was learning how to place implants and got my fellowship in the (unclear 0:44:39) Institute and my (unclear 0:44:41). I needed a lot of volunteer cases and you only have so many research monkeys in your family tree, you only have so many aunts and uncles but I was always amazed, to this day how many of my patients that have full dentures they say I don't have any problems. They'll come in and you'll see them and I'll just say, I'll start talking to them about there different options and they're like seventy years old and they've had these dentures for forty, fifty years. They say I, you're talking about solving a problem I don't have and I think it's hard for a lot of people with their full dentition to comprehend that. But there's a lot of really happy denture wearers who wouldn't even get implants if they were free.
Nadim: I think and you're right about it because there is a study where they gave patients the option of having implants for free to support an implant supported overdenture and they didn't want it. So nearly 44% of these people in that study that they suggested to them to get two implants for free, they didn't want it and Howard, the best patients are those who come to you wanting an implant. But if you force them or if you pushed them to get an implant, they are not going to be necessarily happy patients and they might give you a hard time. And again a lot of my patients come in, they say oh I want implants. I said wait until I get you the dentures and then most of the time after they get their dentures, they're so comfortable that they don't want implants anymore. So again the knowledge of anatomy, the knowledge of occlusion, the knowledge of what you're doing is very important in complete dentures and once you follow these principles, the dentures, they are absolutely no problem to be comfortable. One of the major issues that I've seen, talking about occlusion, is the lab remount, 99% of my patients when they come complain about their dentures, it's because the occlusion is off and I know that, I look at it and I'll figure out what the problem is and I get a new one and I make money out of it. But a lot of my colleagues could make their patients happy if they just do a lab remount and that's something that, not a lot of people teach the students to do.
Howard: Yeah, exactly. So, now I want to, again if you're just coming out of school, when you come out of school the first two or three years. When you look at a distribution of all the dentistry done from insurance companies, there's just, you look at millions of things done. It's just four big spikes on the six-year molar. What tooth is most likely to have a MOD? What tooth's most likely to be crowned? Root canaled? Extracted? (unclear 0:47:47) single implant? It's always six-year molars. So I know you're all that and a bag of chips but what advice would you give a twenty-five-year-old coming out of school? Advice on just a single unit crown, the most common procedure done. As they're trying to, they're going to have to do a thousand of them before they even really master that.
Nadim: Well, I think my message to these young colleagues is whatever you do, use ethics and most of the times I see things done unethically. Whether it's a feeling with a lot of voids and I'm sure they don't even (unclear 0:48:09) and if it's a post, they stick in their paper clips, they stick, I've seen crazy stuff being stuck into a root canal and they don't even belong there. All what it is is, it's going to take you five years to get in a comfortable level of your practice, of whatever you do, to acquire the skills of working with an assistant, to acquires working in a dental office, to build up your knowledge about doing all these procedures. It's going to take a five years for anybody to start getting a little bit of experience but my message is within these five years learn to do things ethically and I think that's the only message I have for these young colleagues.
Howard: There seems to be, oh, I don't want to get into politics or anything like that but it seems like trust has been eroding in America for thirty years. It seems like thirty years ago more people were likely to trust their political leaders, their dentist, their physician, their this and that but I think trust is everything because you're selling the invisible. I know when I buy bottled water what I'm buying, I don't need anybody explaining to me bottled water, an iPhone but when you take your car into the dealership because your engine light came on and I grew up with five sisters and played Barbie dolls until I was twelve, so I have no idea what's underneath that hood and some guys looking at you, telling you need a new alternator. It's all on trust and when they come into this dental office and you tell them they have four cavities. How do they know and it all comes down to what you're saying, you're word of mouth reputation, your trust, your integrity. Just slow down and do it right.
Nadim: It takes time to build trust, your right. A patient comes in, you tell them hey, you're going to need a full mouth rehab, that's $40,000. It's a cost of a car, it's a cost of a brand new car. So the guy, as you said, he's buying something that he's not going to see until a couple of months down the road. So you're right, there need to be trust but that trust, you build it, you build it from the first patient you see in the office and you know more than I do Howard how difficult it is to build a good reputation and to build trust among your patients because these people when they trust you and they know you're doing the good job, they going to refer you their friends and the colleagues and the family and then your practice is going to grow. So yes, building trust is very difficult and it takes time and again ethics is very important and unfortunately, a lot of young dentists and colleagues are going into some practice models that are forcing them to do unethical things because down the road they say either you do it or you're fired. And I have a lot of my students come back to me and say well, I went working here and there, I don't want to put names because it's not our purpose here and then he goes, they forced me to do six MOD's for a patient that didn't have any and then they told me either this or you're fired. So it is difficult for these young people as you said, they graduate, they have hundreds of thousands of dollars of debt and they under pressure to perform and make money and pay their debts. Of course, they're going to be pushed but again, you need to have a little bit of ethics and use your common sense.
Howard: Some dentists think that if a patient if they make a denture and the patient needs an adhesive, that it's a failure. Do you think there's a place for adhesive in a successfully made denture or do you think it's a sign that it wasn't done right?.
Nadim: I love that. Well, I usually tell my students, if you deliver a new denture and you give the patient a tooth adhesive, as if you're telling them, hey dude, I made a lousy denture and I want you to compensate for my mistakes using the adhesive. That's how I look at it, honestly. So for me, yes there is room for adhesive but that room is when a patient requirements of retention is very high but they can't afford implants. So the implants are there to retain the dentures in place, so if there's nothing to retain these dentures except adhesive, they can use it. I don't necessarily believe that every denture when you deliver, you need to give the patient a tube of adhesive. That's, really for me it's a signature of failure.
Howard: Another thing, what I love about, one of the things I love the most about America you go to a lot of countries and every, almost all the people are one origin and in Phoenix, I have patients from every corner of the earth...
Nadim: (unclear 0:52:52).
Howard: ...and I'll tell you what, I'm a big fan, oh yeah, you're in California, you have probably every country within a mile of you. But I see these people coming from other countries who are, they call them a spider, so it's a one tooth removable crown. In America, they would make that bar go all the way around or they wouldn't even do it but in America, they say well there's a million attorneys and what if they swallow that and they aspirate it but they all love it and it's just one tooth with, have you ever seen one? A spider?
Nadim: I've seen that in some of my European patients, you're right and some of them come in asking for it and I'm not sure but I think in California it's legal to make these. I think there was a lawsuit that somebody swallowed one of these and after that, it became that nobody does these anymore. Yes in a sense you're right, it's one way to get patient probably, not an ideal solution but maybe for them, it's probably the best solution because they can't afford implants or FPD's or any other alternative treatment that they can come out with. But again I personally don't do them but I've seen them being done.
Howard: Well, you don't want to do something illegal but you're saying they're illegal in California.
Nadim: Say that again.
Howard: You're saying they're actually illegal though in California.
Nadim: I assume, I'm not pretty sure but assume they are.
Howard: Then here's another diagnosing question. One of the things that I have a little cringe in my stomach about is going back thirty years ago, you'd have some sixty-year-old lady and she had a partial and you place two implants and did two, three inner bridges on both sides. Now fast forward ten, twenty, thirty years, she's in a nursing home and one of those implants failed and I'm always looking at these things, my god! why did I do two implants for three tooth. If I would have done three implants for three tooth, then she would have lost an implant but she wouldn't have lost the case. What are you thinking when you see three inner bridges on dental implant supported where it's two implants for a three inner bridge? Do you think that's going cheap?.
Nadim: No, no I think it's an alternative treatment plan, you give the patient two implants for a three (unclear 0:55:15) PFD, if they can afford more, well you can give them three implants with three single teeth, of course, but as you said there's a lot of patients and I'm seeing these a lot, patients that got their implants when they were, let's say fifty and they got implants here and there. Now they are eighty or seventy-six and they losing their natural teeth because they're getting older and they still have the implants intact and then this you have to transform them into an implant supported PFD but, or implant supported overdentures but the problem is sometimes they're retired, they don't have money because what they get from the government is very little for them to be able to afford big restoration. So they have to go with either implant supported RPD's or implant supported overdentures. But again coming back to that patient, let's say received two implants on a three inner implant supported FPD in case they lose one of these implants but there's no contraindication if they don't have any health issues to get another implant and let's say get two crowns in there. So there's no rules of how many implants you have to get and how can you predict if these implants are going to fail or which one is going to fail, you can't.
Howard: So you guys, California opened up a new Dental School. So you had, in Pomona. So you had two up north in University of California and San Francisco, University of Pacific and then you at UCLA, USC, you had Loma Linda. Did you think California needed a sixth Dental School or do you think on the supply and demand equation, was that good or do you think it's overkill or what were your thoughts on the Pomona Dental School, Western University of Health Science?
Nadim: As you say, we don't want to talk politics but I don't know what's the motive, I don't know if it was a government decision or is it at a university level. Absolutely no idea, but what I know is that the problem with California is you're graduating all these dentists but they're all leaving, they're all going to Arizona, Colorado, Texas and rarely are staying here because it's competitive, it's harsh. California is expensive by itself, cost of living is much more than going to Texas or Arizona or Colorado. So and I don't know what's the purpose of having a sixth Dental School but all what I know is that now you've got the same cake but instead of, I'm talking about Southern California instead of having three Dental Schools take from that cake, they will have now four Dental Schools, digging into that same cake. So it has probably reduced the number of patients in all the Dental Schools because you've got more going now to Western.
Howard: How close, I'm not good on my geography out there, how close is Pomona from Loma Linda?
Nadim: You can say probably thirty-seven, forty miles...
Nadim: ...(unclear 0:58:31)...
Howard: ...pretty close.
Nadim: ...yeah, it's pretty close and Western to USC, it's pretty much the same distance. So, and then USC to UCLA, they're pretty much close to each other, the only ones that are further apart are UCLA and Loma Linda because one is on the west, one is on the east but all the others are just pretty much close.
Howard: I can't believe we went over an hour man, that was the fastest hour I've ever done in Dentistry. I could talk to you for forty days and forty nights. Was there any questions I wasn't smart enough to ask you?.
Howard: Or that you wished we had talked about?.
Nadim: No, just what I really want to stress for these young colleagues and I wish I could talk to each one of them personally but my advice to them is, do you work ethically, keep working hard, keep learning and there's a lot of opportunities for them to learn what you guys did and Howard specifically you with Dentaltown and the opportunities that you're giving these kids, it's priceless. So, again they need to take advantage of that. When it comes to treatment planning, look at the big picture, don't only focus on these little things, don't forget it's a whole mouth your looking at and when you're talking complete dentures, remember your anatomy because people have the tendency to forget the anatomy that they're registering and where is the denture need to sit. When it comes to implant make sure you use genuine components that fit on these implants. I know there's a lot of material that you can buy for cheaper to restore your cases but it will down the road fire back. So use genuine components, make sure your occlusion is nicely done, avoid cement on the surface. So this mostly what I can do and for the CAD/CAM, embrace technology, it's here to stay. I think CAD/CAM removable fix, they are going to a place, the traditional way of doing things but it doesn't mean they need to forget the basics. Basics are very important regardless of what technology you going to be using. It doesn't matter if it's an (unclear 1:00:42) or if it's a CEREC if it's whatever, it doesn't really matter, you can buy anything you want, provided you follow the principles, understand where you're going and you do it right.
Howard: Well, old guys like me, we always went to bricks and mortar conventions and we learned everything in a convention but these Millennials, we put up four hundred and eleven online courses on Dentaltown, their views are coming up on a million. It would be an honor if you ever wanted to create a online CE course on any of this...
Nadim: (unclear 1:01:16)
Howard: ...it would be a huge honor and they're watched all around the world, it's so cool to see them listening to these things in every country on earth but hey, it was just a huge honor for you to come on the show, thank you so much for accepting my invitation.
Nadim: I'm humbled that you've asked me to be there, I'm really humbled and I thank you very much for the opportunity and I'll be looking forward to do that, probably another time, be more than glad to do that.
Howard: Thank you so much. And what's really romantic is when these kids say, from South America, Africa, Asia they say, it'd take two months wages to buy a plane ticket just to L.A. to hear someone speak and now they're on their Samsung watching this stuff and they just, it's so neat how the world's two million dentists now all live within a smartphone. I did not see that coming thirty years ago.
Nadim: (unclear 1:02:10) there's a lot of opportunity that I'm going to be coming out with a lot of e-books and a lot of, and again one more thing I wanted to say about CE, about CEE, I know you have credibility and you doing the right thing. So I'm not talking about you but I'm talking about, there's a lot of CE courses that are there, they need to scrutinize before getting into any type of CE courses. They send them like a weekend course, they take their money and they make them feel that they know a lot of things and unfortunately they go back to their practice, place the implants in the wrong position because they haven't been taught how to do it right and they get in trouble. So again, they need to understand that not everybody is capable of doing CE courses and they need to look at the history of whoever is giving that CE course and how long has it been. You have been there for so long, you're doing an amazing job educating young dentists and they should definitely stick to something that you're presenting because you guys have credibility there but there's a lot of people who don't (unclear 1:03:25).
Howard: I've been, lately, I've been getting all of my advanced diplomas off of eBay, the other night I bought a black belt in Karate and I'm an oral surgeon and I got a Eagle Scout all for $9.99 on eBay.
Nadim: Yeah (unclear 1:03:39).
Howard: Thank you so much for coming on the show.
Nadim: (unclear 1:03:44)
Howard: ...great podcast and Ryan thank you too. I hope you have a rocking great evening.
Nadim: Thank you, same to you guys.