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AUDIO - HSP #170 - Rok Stern
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VIDEO - HSP #170 - Rok Stern
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Listen to Dr. Rok Stern share details about Microdentistry, and how telescope techniques help dentists in Slovenia and Germany.
Dr. Rok Stern:
Born in 1985 in Slovenj Gradec, Slovenia.
Graduated dental school from the University of Ljubljana in 2012.
Working as a GP since 2013.
stern.rok@gmail.com
Howard: It is a huge honor today to be interviewing with who I call the Rok. His first name is R-o-k, last name Stern. I'm just going to say he's from Slovenia. I've been there, but there's no way I could pronounce the city. Is that the capitol you live in?
Rok: Yeah, it is.
Howard: How do you say it?
Rok: Ljubljana.
Howard: They say if you know two languages, you're bilingual, and if you know one language, you're an American. For our American friends, say it again slowly a couple of times. They might try to attempt this in their car as they're commuting to work.
Rok: Ljubljana.
Howard: It's horrible for me to be interviewing this morning because I'm short, fat, and bald and you're rocking red headset and all that gorgeous hair. I'm telling you, you're dental cases, you are a rock star, whether you call it R-o-k, your name, or r-o-c-k, really you posted a thousand times on Dental Town and it's just an honor to be talking to you today.
Rok: The honor's likewise, thank you.
Howard: Slovenia, I've been there with my son, Greg. When I was lecturing in Venice, we drove up. We rented a car and went up. You boarder on Italy, where I entered from, Croatia, we went down there, Austria, Hungary. That's a cool part of the world. It's just Gorgeous. Where I live in Phoenix, an old historical building is about 50 years old.
Rok: Yeah.
Howard: How old are some of the structures in your country?
Rok: I don't know, at least 500 years old.
Howard: Yeah.
Rok: At least.
Howard: It is so gorgeous, I mean unbelievably gorgeous. I'd like to start out with, first of all, we have listeners from all 206 countries listening to this stuff, so for people around the world, I think a lot of people are just wondering if you could just describe what's it like being a dentist in Slovenia? How many people are there? How many dentists are there? Do you they have water fluoridation or not really? Do they drink a lot of sugar water, coke, soft drinks? Is there a lot of decay? Talk about, to people around the world, what's it like being a dentist there?
Rok: Well, we have population of about two million people and Ljubljana, the capital, has about four to five hundred thousand. We have about 1,500 dentists. I think that includes all the specialists like periodontologist, surgeons, and stuff like that. We're pretty spread out around the country. Most dentist work in Ljubljana. If you say person that lives in Ljubljana, there are probably the most dentists, the most saturated market.
We have water fluoridation, but not as much as in the United States. The concentrations are lower, but we don't have a lot of decay because of that. It's enough. The children usually don't drink a lot of candy or soft drinks and stuff like that, but they drink natural juices, so they have a little bit of decay from that, but not as extreme as the Mountain Dew mouth that you see in the States.
I'd say the overall oral health isn't as bad as you would think it would be. I'd say the worst is periodontitis. Most dentists that are in the public sector, which is something like Medicaid in the States, don't really treat periodontitis. They just treat decay, that's because they're old school. They didn't even teach. The last 25 years, maybe, they started teaching about periodontitis and periodontal disease here [inaudible 00:04:03], but they get really low reimbursements from the insurance companies, so they don't treat. It's like less than two dollars per tooth treated, so that's why they don't do it.
Howard: Do you think they have a lot of periodontal disease because it hasn't been treated or are there other factors that ... Do you think Slovenia has more periodontal disease than some other countries for some reasons?
Rok: No, no. I don't think that, but it's noticeable that most people have problems I'd say. I don't think ... I think if we compared it to Swedener's or the northern countries, we have more, but if we go more south like Albania and Macedonia, then they have more than we do.
Howard: Some things are sensitive to talk about, but I had an older periodontist tell me that he thought there were three types of teeth, more associated with races, that caused gum disease. He said the Chinese and he Asians have the most constricted cervical neck to where the tooth really constricts and that precipitated more calcium and phosphorus and calculus. Then the Europeans were in the middle and the Africans had the most bulbous and they didn't really as much calculus. What was funny is years later a pedodontist told me that it was harder to keep a chrome still crown on an African child because they didn't have the under cut from the constricted cingulum, but I never see many people talking about that.
I do notice when I am in China, it seems like everybody has gum disease in China.
Rok: Yeah, I haven't been to China, couldn't tell that.
Howard: The other variable in China is the joking is in America they have a smoking section and a nonsmoking. In China, it's the smoking section and the chain smoking section. I'm sure, like most things, they're multifactorial to where it could be a constrictive cervical neck, a big increase ...
Gum disease, how many dental schools do you have in Slovenia?
Rok: One.
Howard: One?
Rok: Yeah.
Howard: How many hours does it take to drive from one end to the other of Slovenia?
Rok: If you go straight across diagonally, it takes about, I'd say, a maximum of three hours.
Howard: Okay.
Rok: It's pretty much highway from end to end, so you can drive fast.
Howard: Right on. What did you want to talk about today? Your cases are ... First of all, wouldn't you say that you're ... I mean, you're really into dentistry. What type of dentistry gets you more excited? What is your core competencies or specialties or what type of cases do you like to photo document and post the most on Dental Town.
Rok: I do pretty much everything, except surgery. I don't document surgery because it's messy and I don't have anybody to take pictures for me because I just put another pair of gloves over my gloves to take pictures and I can take all my pictures myself. There's a great course on dentists done by Jason Olitsky and I've learned a lot from that. I don't do it between surgery because I usually have the sterile gloves on and I don't want to put another pair gloves over them.
I like the posterior composite, anterior composite, and for mouth reconstructions, I do a lot of telescope work. You don't do that a lot in the States, but ...
Howard: What do you mean by telescope work? You mean a microscope?
Rok: No, no, no. Telescopic overdentures.
Howard: Oh, telescopic overdentures.
Rok: Yeah. Microscope, I'm buying til the end of this year. I had the pleasure to test a prototype of [inaudible 00:07:52] microscope for a week and I think I'll buy it one of his scopes when they officially come out at the end of this year.
Howard: Now, do you work with a dental assistant?
Rok: Yeah.
Howard: You like to take your own photos?
Rok: Yes.
Howard: You don't like to delegate that out?
Rok: No because we ... most of the dentist over here don't have the same relationship with their assistants as you do in the states that I've seen from other people's post on Dental Town. They don't ... They can't do a lot of stuff over here, like provisional or cleanings, like you have those assistants who can actually make fillings. We don't have anything like that over here. They're just chair-side assisting and it's easier for me to snap a picture than tell her what I want from the picture every single time.
Howard: Legally, can they do expanded functions or is it a law that says no?
Rok: I think they can make nothing permanent, they could make provisional, take pictures and stuff like that, but anything that is invasive, no. Most dentist over here only have one assistant.
Howard: How many chairs?
Rok: One, two, maybe three.
Howard: What would you say the average dentist has? One chair or two?
Rok: One chair, one assistant.
Howard: One chair, one assistant. Would they have a front office person too or just one dentist, one employee, one chair?
Rok: Over here it's like that. You have the a system that is controlled by the government and a private practice, that's separate. In the public system, you are delegated by the insurance company what you have. Everybody who works in the public system, and that's probably at least half of all the dentist, they only have one assistant and one chair and no front office, nothing. Then you have people who work for the insurance companies, but out of the system, they also have one assistant, one chair, maybe two chairs if they really have enough production. Then you have private practice and some people in private practice have two or three chairs and two or three assistants and a hygienist. Our hygienic school for hygienist is only producing hygienist since, I think, the first graduate class was 2012 [crosstalk 00:10:21] 2015. We didn't have nay hygienist because dentist clean calculus. Now it's starting to develop a little bit.
Our periodontics professor made the school for hygienist because he saw it in the United States and he decided he wants to do something about that, so he started the school for dental hygienist.
Howard: That is so amazing. This is like a walk about through time for when I first went to Australia. I think it was, I forgot what year, it was 90s, but there were no hygiene schools and most everybody had one chair. Now I just got back there last week and now hygienist are really getting incorporated and multiple chairs. That's amazing.
What percent of the dentist live in their dental office, where it's their home and their office?
Rok: I'd say it's a really small percentage.
Howard: Really small percent.
Rok: Yeah, maybe five percent. I actually, if I think about it, I maybe know one and they don't even live in the same house. They have a separate house for the office and their house is really close by, like hundred meters apart.
Howard: I love lecturing in different countries. My goal is to lecture in every single country and I want to podcast in every single country because so much of this is cultural. Like in the United States, in the west, they're day off is Friday but in the northeast, they'll do two days, Monday, Tuesday, then they'll take off Wednesday, and then they'll go back and do Thursday, Friday, Saturday. You only see dentist living in their house in the very northeast, like New York, around the area of New Jersey. Many, many countries, the dental offices is the first floor and they live upstairs. Very, very interesting.
You said ... Let's talk first about telescopes. Talk about that and why you think you love them and why you think you do see them used as much?
Rok: Well, they are used a lot but not in the states. They're used a lot in Germany. If you go to a German forum, dental forum, there's probably at this moment probably at least 20 cases up about telescopes, how to do it, what to do, what teeth to preserve and stuff like that. I just think that you ... It's a technique that I think was developed in Germany about 30-40 years ago. I think you had [inaudible 00:12:51] on your podcast.
Howard: Right.
Rok: He knows about that. He wants to do that more in the States, but the dentists don't know about it, so I made that post on the removal prosthodontics sub-forum and I think it explains a lot [inaudible 00:13:08] somebody will try it.
Howard: Can I push that piece out on social media like Facebook, Google Plus or is that more private for Dental Town?
Rok: No, you can.
Howard: I never post a private case on Dental Town on social media unless I get the doctor's permission and I like to do it because I think a lot of people have no idea. There's two million dentists on earth and it blows my mind that only two hundred thousand have found Dental Town. It blows my mind. The four million post on Dental Town from guys like you are just amazing.
Okay, but start from scratch. We're throwing around the word telescope and you got a lot of people listening, like okay what does that even mean. Start from scratch and explain it because I know all Americans are interested in anything out of Germany because when you think of Germany you think of Mercedes-Benz, Audi, Porsche. When I think of making something high-quality, I pretty much only think of Germany and Japan. When I think of American manufacturing, I just think of a really good marketing and advertising department. The Americans can sell snow to Eskimos, but the Germans and the Japanese, I mean God Dang, they're just the land of engineering.
Talk about the telescope and what it is and then what would be the equivalent to the Americans doing it and why do you think more Americans should look at this German technique?
Rok: Telescopes are basically a process you conserve pretty teeth that would be lost in most American cases. I see all these cases on Dental Town where people just go all in four or all in six. They extract everything and go full implant. Maybe it's because of money over here, implants are real expensive, so telescopes are a way of using the teeth that are left, let's say two to six teeth per arch, and cover them with an oral denture. By covering them more denture, you get nice esthetic because you don't have the transition between the white and the pain esthetic. Pretty much if any of those important teeth fail, you just make a simple repair to the overdenture and the patient has their teeth [inaudible 00:15:24] they are made the next day. It's similar like cone assist. You know cone assist?
Howard: Yes.
Rok: The main difference is the telescopes are zero degrees. Cone assist friction lock. They're like [inaudible 00:15:43] on implants. They have four, five, six degrees. I think they are just staying with the four degrees now and they interlock and the connection is really rigid and the patient usually has a hard time removing the such overdenture. With telescope, it's zero degrees. It's patient fit, but the path of insertion in just one, so the patient usually easily removes the overdenture, but there's no way that it will fall out unless there is maybe only one tooth remaining for the whole arch.
Howard: Okay, if there's zero degree and you got two or three or four or five or six of these things, how would you ever get them to be parallel? How would you ever get them to line up?
Rok: You need a great technician. When you prep, prep for a telescope is pretty aggressive. You remove pretty much a lot of tooth structure, but especially on the anterior teeth because you need room for the primary telescope and then a secondary coping and then the tooth that covers everything, so we need more room to produce esthetics. You don't need to align the teeth at zero degrees. You just prep them roughly in the same direction and then the technician who produces the primary copings, he then makes them parallel to each other. If he can't make them parallel or something is wrong ... I had a case where I had six teeth remaining, one molar was a bit out of line. He sent me back the cast, he said, "You need to remove a little bit more from there and then I can fix everything."
I think that's why it's not really made a lot in American because you need a great technician and they usually cost a lot. In America, it probably cost the same as a full implant overdenture.
Howard: Most of my listeners are an hour commute to work, so when they get to work and they log onto Dental Town, what would they type in on the search bar to find a tread? Did the tile of your case have the word telescope in it, so if they did a search on telescope?
Rok: Yeah, I post a lot of case but they should search for the 101 telescope thread.
Howard: The what?
Rok: The 1-0-1 telescope thread.
Howard: The 101 telescope thread. Ryan, I'm going to add an additional monitor so that when I'm doing these podcasts I can actually pull it up. That would be rad. I also want to switch from my boring black headphones and I'm going to steal Rok's idea and get some rocking hot red ones.
The telescope, how many teeth do you like? Do you like two on the lower, two on the upper? Do you prefer four, like a table has four legs, so there's no rocking? What is your ideal number of [inaudible 00:18:41]?
Rok: The perfect is four.
Howard: Like a chair?
Rok: Yeah, it's like the same that you want with a classic removable denture. If you've got a molar, canine, canine, molar, that's the perfect you can get for a removable denture and it's the same for telescopes. I've done cases with one and the maximum I did was six teeth. You could, in theory, do it with 16 teeth, but no body will do it.
Howard: These teeth don't have to have root canals?
Rok: No, actually it's better that they don't.
Howard: Why is better that they don't?
Rok: The patients have a different feeling when removing and inserting on vital teeth than on non-vital. If it's all non-vital, they tend to break them because they lose a bit of that perception for cracking.
Howard: Really.
Rok: Yeah.
Howard: I did not know that. I've always wished I had a root canal just to know what it was like and what it felt like. That's why I think women go to women gynecologists because back in the 50s and 60s they got sick and tired of men telling them it was all in their head. If I was a women, I'd rather go to a women doctor. That's interesting, but you do say they're more expensive. Why are they more expensive? Just the lab bill's more expensive?
Rok: Yeah and I usually use [inaudible 00:20:02] percentage gold for the primary and secondary copings. For reach tooth that adds, let's say, one-hundred-fifty dollars of gold.
Howard: Why do you feel that's worth it as opposed to using a low-cost base metal?
Rok: They last longer. The friction last longer and it's more precise and everything and also my lab really, really prefers working with high [inaudible 00:20:30] for cases like this because it's much easier to fit, to work a high level alloy.
Howard: Do you mostly use the same lab?
Rok: A local lab.
Howard: A local lab.
Rok: I use a local lab for everything, but for telescopes I use one lab specifically.
Howard: Locally?
Rok: Yeah, locally, locally.
Howard: Has that lab owner ever posted any cases on Dental Town?
Rok: No, I don't think so.
Howard: You should tell him to do that. Some of the lab men that I know that have posted on Dental Town say it's their entire marketing budget. Instead of paying money to advertise, they just pay in time and post cases on Dental Town and they say it's just a slot machine for business.
Rok: We don't have advertising here.
Howard: Is it illegal?
Rok: For dentist yes.
Howard: Wow, talk about that. What does the rule say? What can you not do? Can you have a sign in front of your office?
Rok: You can have a sign that says dentist here. You can have advertisements but they need to be educational. They have to tell you why periodontal disease is bad for you and why should you get checked up from you dentist and stuff like that. If it's too straightforward, you'll get reprimanded by the chamber. I don't think anybody has ever lost a license but I also don't see a lot commercials.
The worst thing about that is that Croatian dentists do a lot of advertising in Slovenia and we can't do anything about it and we can't advertise ourselves. People just see that, that, that, that, on Facebook, and internet, and jumble boards and things like that and we can't advertise at all. It's a bit lopsided for us.
Howard: I also heard back during the war in that area that a lot of the nations said that if you are a war refugee you can come here and we'll accept your license whether you're an architect, an engineer, a dentist, whatever, and a lot of people just got degrees on the internet and went to other countries in the region saying I'm an architect or a dentist or an engineer and they weren't really. Is that still an issue in 2015?
Rok: No. I never actually heard about it so. We have a lot foreign trade dentist because we're in the European Union and we don't have any restrictions from moving people other countries in the European Union. We got a lot of dentists from Bulgaria, from Macedonia coming over here.
Howard: Slovenia is part of the EU. How many countries are in the EU?
Rok: I think 27-28, Germany, Sweden, France.
Howard: You could take your license and practice in all 28 countries of the EU?
Rok: Yeah, as far as I know, yes.
Howard: Would you have to take an additional board exam or a license?
Rok: No, usually not.
Howard: Usually not. Then I'm curious, why do dentists move around from one country to another? Is it more lucrative to practice in some countries versus the other?
Rok: Money, money, money.
Howard: Moneys the answer, what's the question. Do you stay in Slovenia because you think it's a better economic situation than if you cross the boarder to, say, Hungary, Italy, Croatia, or Austria?
Rok: No, I think if I going to Austria or Germany, I could have a seller that would be at least twice as high as I have right here now. Maybe I'll move, I don't know. It's hard to move. We're more tied to our roots than people in America who like to move and retire to our houses. It's hard for us to sell a house and move. I think it's just psychologically over here. My brother, for example, is just moving Switzerland, to Zurich, and he got a job there, so he will move.
Me and my wife also think about that, but for now, we are staying here with our daughter.
Howard: Yeah, there's definitely nothing more home sweet home than home. Back to the telescope or extracting the teeth. One red flag I've always have from dentists is when they study the world's major religions, the only sentence or paragraph that's in common in all the major religion is only phrase. There's no name of a person, place, thing, city, nothing, except for the phrase treat other people like you want to be treated. Red flags for me in dentistry are when dentists send their own daughter to have orthodontics and bleaching, but then when it's a patient and they can't do orthodontics, they file down the teeth and do veneers.
Another red flag for me on implants is when the dentist goes and gets a root canal and a [inaudible 00:25:37] and all these heroic procedures to save his tooth, but then doesn't blink on pulling it on a patient and placing an implant. I always think that's the best litmus test on every single patient. Just look at that patient and think, even though we have more money as dentists than most of our patients, I still always want to think, before you just throw that tooth away, if it was in your mouth, would you go to an endodontist and have it retreated or what have you?
What's your next topic you want to talk about? I feel like I could talk to you on any clinical subject. What else has got you excited and passionate?
Rok: I think isolation, especially rubber dam isolation. I use the rubber dam pretty much for every procedure except surgery extractions, but I've used it for prosthodontists and obviously restorative. It's actually really nice when you prep a tooth for a crown the first time when you have a rubber dam on. You'll have tongue that's in your way, a cheek that's in your way. You've got a nice tooth to view. It's a nice contrast, not like the mouth when you've got red and black and stuff like that. You've got a smooth surface behind the tooth and you can really see the depth of the preparation and everything. The first time I prepped a tooth with a rubber dam on, it was on a patient who had half of his tongue removed because of carcinoma and he couldn't put his tongue far back enough to seal in his mouth. Every little drop that sprayed caused him a coughing fit, so I had to prep with the rubber dam on and it was a great experience, so I've done it a lot of times since then.
For restorative reasons, obviously you don't have saliva, you don't blood. You don't have anything. You don't have a tongue. It's really nice to work. It saves me more time than it takes me to put it on.
Howard: What percent of the 1500 dentist in Slovenia do you think put a rubber dam on a tooth before they prep it for a crown?
Rok: Zero.
Howard: Yeah, so since that is so rare, maybe ... You just really love the isolation.
Rok: Yeah.
Howard: I agree with you that the time to put on the rubber dam always saves ... for every one minute of time you're putting on a rubber dam, it usually saves at least five, six, seven, maybe ten minutes of time. That's just the way it is. A lot of dentist don't use a rubber dam, they'll numb up a patient and then they'll leave the room to go seat a crown and do a hygiene check and all they had to do was tell their assistant to place the rubber dam, because you had the assistant sitting in the room the whole time and they don't even take the energy to just turn to the assistant and say put on a rubber dam. Have you tried to isolate?
Rok: No, I've seen it in action, but I didn't try it. I really would like the high speed suction. I'm a bit deaf and, that sound, it really makes my ears hurt, so usually when I put the rubber dam on, I take the saliva ejector out of their mouth, so it's nice and quite.
Howard: When you say you're a bit deaf, is that from dental high speed sounds?
Rok: No, no, no, no. No, no not from high speed sounds, at least not yet. We'll see if it gets worse.
Howard: Yeah, every once in a while it will pop up. Kavo has those electric hand speeds, those electric high speeds and the massive ... they don't go as fast, but the torque is unreal. That's another cultural thing I see when you go around the world. Americans always put in an air compressor and go with air-drive high speeds. Then other countries, they don't do that, they just go electric. Would you say the 1500 dentist in Slovenia, are they mostly high speed or electric?
Rok: Yeah, high speed, high speed.
Howard: High speed.
Rok: Yeah.
Howard: Are there in the EU, do you see any countries that are more likely to be electric hand piece versus air driven?
Rok: No, I don't think. Yeah, but most of the younger dentists stopped using the turbines. We just use the high-speed hand pieces, so red and blue for me. I don't use a turbine at all.
Howard: Okay, I'm confused. You're saying the younger dentists do not use the air-driven turbine and use the electric?
Rok: No, no. We all use air driven, but we stopped using the turbine.
Howard: What does that mean, stopped using the turbine?
Rok: It's a different hand piece.
Howard: Is the turbine the electric? Electric motor?
Rok: No, they're air driven.
Howard: They're all air driven.
Rok: Yeah, turbine, I don't know how you call it in the States. It's really high speed hand piece that has low torque and then you have the red hand piece that's a bit slower, but has high torque and the blue and green hand pieces are much slower for dental removal and caries or endopreps.
Howard: Can you do me a favor? Can you do me a huge favor because I don't even get that. Will you start a thread on that because I haven't heard the blue and the red.
Rok: Yeah, sure.
Howard: I wish you would start a thread and explain that because one of the things that I've noticed ... I've been a dentist ... you're 30, I'm 53. I've seen, back in the day, there were countries that were pretty much electric hand pieces only and then Americans were all air turbine. Now it's just really changing. I'd really be curious to see of the 206 countries, who was all electric and went to air, who was air and went to electric. How do you feel that's progressing in the EU? Do you think there's a shift towards more electric or less electric or do you think the air-driven hand pieces has dominated the market?
Rok: Yeah, they do over here. It's pretty much in every commercial we get, we don't get any electric hand pieces, we just get air driven.
Howard: Are you talking about Slovenia or the whole EU?
Rok: I know for sure for Germany and Austria. I don't know for France and Italy.
Howard: Germany is going all air turbine?
Rok: Yeah, most of them, most of them.
Howard: That's ironic because the electric hand pieces come from Kavo and Kavo's from Germany.
Rok: Yeah, I think pretty much every Kavo chair they have over here has only air driven pieces on it.
Howard: You know back in the day, I did put in the electric hand pieces and I told the ... I think it was when I had come back from lecturing in another country and I said, "Look, we were just born in air driven and we're going to do electric," but the three of us, the feel was so different. It wasn't that high speed fineness with a feather. It was more a slower ... You had total torque. You could not ever stop a bur. It's a totally different feel.
Rok: Yeah, some people on Dental Town say they like electric hand pieces to finish the preparations. They say, I don't know, more precise.
Howard: I just kind of fancifully wanted the electric hand piece to win because you don't have all that plumbing infrastructure that's problematic. It'd just be so much nicer to just to have something that plugs into electricity instead of something that plugs into air. What else do you want to talk about?
Rok: I don't know, microscopes are really something that I'm into right now.
Howard: You're still using the one you've been demoing?
Rok: No, I don't have one now. I'm currently not really working because I'm waiting for my knee surgery that's in three weeks. I'm going for my second ACL reconstruction.
Howard: What did you do that made your wife hit your knee with a baseball bat?
Rok: I play volleyball.
Howard: Oh, volleyball. A volleyball injury, were you diving for the ball?
Rok: No, I was jumping pretty high. I teared it when I was 16 for the first time and I probably tore it again soon, but I lived with it and now I really need to get it fixed. It's a really unstable knee.
Howard: I'm sorry about that.
Rok: No big deal.
Howard: Better a knee though than like a lower back or the neck or something. Tell us your thoughts on microscope. Let me tell you the first flag on my scope. A lot of dentists said, "Man, I can see everything better and the quality goes up so much, but man it slows me down." They say, "it takes me twice as long to do it." Do you see your quality going up and your speed going down or do you not really ... ?
Rok: At first, probably yes because you see so much more, but then also you diagnosis much more because when you look at a crack at 15, 16 magnification, you really what's in there. You see a lot of things you can't see with your bare eye. Maybe if you're using four and a half loops, you already see a lot. I'm 30 and part of the thought process on microscope is that ti's an insurance policy for me, for my neck, for my back for my next 30-40 years without me working bent over. I use loops all the time, but I still sometimes get neck pain and back pain. With the scope, you can't flex your neck when you use the scope. You just have to look forward or you don't see anything.
It is a learning curve, but when I got my first demo machine, I think, I need one or two patients to get used to it and then it maybe took me five minutes longer than it would taken with a telescope.
Howard: It might be only regret in dentistry. I wanted to be a dentist in the sixth grade. How old are you in the sixth grade, 12? Now I'm 53. I mean 41 years I've wanted to be a dentist. If I had to say if there was anything negative about it, yeah it was trashing my neck. It was by the time I was ... because I hung my 10 pound bowling ball head over, even though I looked through a mirror ... Here's a big secret to save neck, not just magnification, but why do dentist always use that little half inch or three-quarter inch mirror. You can buy an inch and a half mirror, a two inch mirror. Get bigger mirrors. It throws in more light. You can see the draw with the whole arch.
If I walked in 10 dentist offices in [inaudible 00:36:47] right now and look on the tray set, they all have the same little size small mirror. You walk into my offset and I might have three or mirrors, anywhere from three-quarters of an inch to two and a half inch. I did a lot of direct vision, but my God. Finally at 50, when I was driving a car, if I even just turned my head to see if could change lanes, there was an electric wince. Finally a dentist friend of mine, his wife talked me in to going to a hot [inaudible 00:37:15] yoga and I did it this morning. I do it at least three days a week and that's just to unjack my neck.
In fact, Ryan, we have an ergonomic lady coming upon one of these podcasts because I really want to preach more ergonomics and more all that because when you're 30 you think you're going to live forever, but when you're 53, you realize the price you paid by not sitting up straight. Also the chairs have changed. There's a lot of chairs that don't have the back and you ...
Rok: Back support.
Howard: Yeah and you kneel into the chair. There's a lot of big, exciting things going on in ergonomics. Cosmetics, anterior bonding. You post some amazing anterior work. Talk about your anterior work.
Rok: I'd say I'm pretty far off in the anterior section. It's something I like to do, but there are other guys on line that you just can't believe that they did it directly, especially on Facebook you'll see some cases. Then again, you have to see if that case took 12 hours to finish.
Howard: I'm old enough to be able to say in 1998, a lot of those legends were posting on dental school and they'd never done any cases. Just because there's some older guy that's a legend doesn't mean that you're the next guy int eh batting cage. A lot of these dentists, I can remember their first questions asking what is this. Now they're actually out there legends teaching it. Life's a journey and if anybody was going to be a legend in any type of clinical, it would have to be you because you got the attitude. You're really going for it. What type of anterior work do you like? What would you like to master? Do you like doing direct composite veneers? Do you like prepping teeth and doing indirect veneers?
Rok: Everything. I think a lot of this has to do with case selection. You have to know what you want to do and what specific case you want to do it. With a microscope you can really finish a margin to point one, point two. My lab works with a scope. If I give them a tooth that is prepped to point one, point two, they can actually make a veneer that fits on that chamfer.
Howard: Let me ask you ... I think the most informative things we can do on podcast is not talk about anything everyone [crosstalk 00:39:54].
Rok: Yeah, yeah, yeah.
Howard: Always go after the uncomfortable question. I have heard a hundred dentists in my lifetime, at least, say that I don't care who you are, I can spot your veneer case across the room. They're just not natural. Some of the biggest legends that do these veneer works, I just always have dentist saying, "Yeah, it's great. It's pretty. It's whatever, but hey come on. We're dentist. You can still tell it's fake from across the table." I still think the most natural work on veneers I ever see is always direct composite. Then you got to ask the dentist themselves. What do you thinks better for a tooth, filing down doing a veneer or doing it direct? I think a lot of veneers are done because a dentist says, "I don't want spend all the time doing this. I'd rather have my lab man doing it."
If I was going to have veneers, I would do direct. What are your mind thinking about prepping off the enamel a millimeter and a half and doing indirect veneers versus doing direct bonding?
Rok: You have, as I said before, it's all about case selection. When you have a case that a patient just wants a new smile, it's always best for me to take an impression, some photos, digital slides of that and then make a wax up and then a mock up. When we do that flash mock up, we see if we need to remove anything or just add. If I just need to add, maybe I could go direct composites. It's less invasive, that's for sure, but it takes a lot of time and a lot of patience and it's really hard to pull off to have it look really, really nice.
If you go on Facebook, on my provision group, there are guys here in Europe that do real minimal prep, maybe even no prep veneers. I don't think anybody can do from direct composite like they do with feldspathic veneers. They're really thin, no prep. Now we have lasers and you can debump the porcelain in practically one piece. You don't have to worry if something goes wrong. You just pop it off, make a new one. I think, indirect, if you really want the best looking, I'd say indirect.
Howard: What porcelain would you like for your feldspathic.
Rok: Feldspathic.
Howard: Feldspathic.
Rok: Yeah or E-Max. If I need to do a crown, then I usually do an E-Max. If I do veneers, then it's feldspathic.
Howard: That's kind of like asking a painter do you like water colors or do you like oils or do you like acrylic. Talk about when would you like E-Max, which is probably the biggest brand. I imaging that probably four out five anterior crowns or veneers are E-Max versus feldspathic, which is the old school. Talk about what you're thinking when you think about should I use feldspathic or E-Max.
Rok: Usually if I go full coverage, it's E-Max and for veneers it's almost always feldspathic.
Howard: Talk about that, why? Exactly why?
Rok: I still think that feldspathic porcelain gives better esthetics, especially if you compare some of the cases from Europe and the United States. I talked to [inaudible 00:43:21] in Prague this year and all of his cases were bleach white. He said it's really easy to make a bridge in Canada when everyone wants bleach white. Over here you see a lot of really, really nice porcelain work. It's almost always it's feldspathic. If I go full coverage, I go E-Max and sometimes even layered E-Max or layered [inaudible 00:43:48].
Howard: You know, again, the most fun thing about being alive half a century is I remember when I lectured in London at the Royal College of Dentist, a lot of dentist would tell me, kind of guarded, they'd say, "Don't you think a lot of these American Cosmetic work is too white? It kind of looks goofy and the American's teeth are too white and they put on too much makeup and their boob jobs are obnoxiously too big." Now when you go to Europe, you're starting to see a lot more of this what they used to not like 25 years. It's like to the bleach white clown faces getting a little more popular. What do you think are major differences between Europe and North America as terms of what the average person sees as beauty or cosmetic?
Rok: Well, if we limit that to teeth, I'd say we are at least two shades darker than you are. If you go bleach white, I don't think we don't have anything lighter than A1 here.
Howard: Agree, agree. Besides teeth, what other things in beauty? I noticed back in the lat 80s, early 90s, shaving legs wasn't very popular.
Rok: No, no, no. That's popular.
Howard: It's far more popular now than it was two decades ago.
Rok: That's true and I think in France there's still some ladies not shaving their armpits maybe a little bit, but I think that's a minority, not a majority.
Howard: Was that the way it was, do you think, 20 years ago? Like Slovenia, 20 years ago, did your mom and grandma, did they shave their legs and armpits?
Rok: I don't even know.
Howard: You never asked them that?
Rok: No. I can if you want me to.
Howard: I wonder if the whole world's moving towards one kind of cosmetic look.
Rok: Yeah, I think it will be because of the globalization. It's [inaudible 00:46:04].
Howard: I think it's very cute whenever you're in Asia, around there, the dominate fashion music culture is Korea. If you're in China and you walk in there ... If we all had black headsets on and you walked in with the red fancy ones, they'd say, "Aw you're looking Korean." Whenever you're looking fanciful, they'd say you look Korean because they're the ones with the most pizzazz or flash music.
Rok: They all want white skin. When I was in Thailand, their beauty concept is white. All the girls with naturally dark put a lot of white makeup on so they would look less tan. Over here pretty much every girl wants to be more tan.
Howard: The most tanning salons I ever saw in my life was in Poland. What do they call them? How do you say ...
Rok: [inaudible 00:47:02].
Howard: The dentists were stomatological. The suntanning, I forgot. They were on every corner. I almost thought Poland was the land of tanning beds. I never saw so many tanning beds in the world. The most ridiculous thing is I live in the desert of Phoenix Arizona and there's a tanning salon on every corner and we're only [9 00:47:29] miles from the sun. You could just pull up to a tanning salon, lay on the hood of your own car and have a melanoma in a hour and pay money. That just shows you that you can sell ... When a dentist is whining to me about how patients won't pay money for their teeth, it's like in the desert they pay money for a tanning salon. You can sell anything to any human. Humans are so funny and incredibly complex.
Do you do direct composites?
Rok: Yes, I do. I do anterior and posterior. I really like posterior. I like to play with posterior composites. It gives you a little more time.
Howard: I want to ask you the most controversial question I can think of and that is, I'm going to ask you. You're a very smart guy and I'm a big fan of your thousand posts, what do you think lasts longer on a first molar, an MOD three surface filling, an amalgam or direct composite?
Rok: I think it depends on how it's made and who's making it. With composite it's really more operator dependent. Let's say, people don't take their time that's need for a direct composite. For an amalgam with can get away with a lot of things, you just stuff it in there and it will usually last as long as it's sealed properly. With composite, if you get some saliva contamination on the margin, it's going to fail catastrophically down the road.
Howard: A direct composite extremely technique sensitive and if you're going fast and you're cutting corners, an amalgam probably would be much better.
Rok: It's better to use the amalgam.
Howard: Of the 1500 dentist in Slovenia, for your standard, the first molar is the first tooth most likely to be missing, decayed, filled, root canal, crowned, replacement implant. Of your average first molar in Slovenia, if 100 fillings were done, what percent would be amalgam versus composite in your country?
Rok: I'd say it's about 50/50 now.
Howard: Fifty-fifty and would that line up perfectly with the public versus the private insurance systems? You said half the dentists were public ...
Rok: No, let's say fee for service, we only have maybe five to ten percent of dentists are fee for service. The rest work privately, but they have a contract with insurance company, like PPO in the United States. They have limitation of how much they can produce each year. They have a contract for, let's say, hundred thousand euros per year and that's all they can make from the insurance company. People now pay extra ... patients pay extra for posterior composites, like for premolars and back. On the front, canine to canine, is fully insurance paid for and the rest is then paid extra by the patient themselves. More patients decide to have white fillings now, especially in Ljubljana.
Howard: Okay and the number one feedback I get from my podcast is they would say on this like, you said you do posterior composites, so the feedback would say, "What kind, what bonding agent?" Dentists are like chiefs. They want a recipe. They don't want to hear you talking about, "Oh yeah, I make lasagna." They're like, "Well, that doesn't tell me anything. What noodles did you make? Was it pork, sausage, beef?" Walk me through your posterior composite and mentioning the name brands.
Rok: I use total edge system. It's [inaudible 00:51:22] from Kerr. It's for generation, so primary adhesive and then adding composite. Mostly G-aenial from GC or Gradia from GC. For composites it's OptiBond [inaudible 00:51:35] for most all fillings or maybe a Excite. I don't know what company makes Excite, but mostly OptiBond [inaudible 00:51:47], I've had great results with that, so I'm just sticking with it.
Howard: Then let me ask the most controversial question that I can think of that, a lot of dentist listen to this and say, "Dude, I tried Total Edge and I had sensitivity and I switched to a self edge, like a clear fill SE." Why do you like Total Edge and why do you think you don't have problems with sensitivity? Why are you not using a self edge? Do you think again it's just technique, isolation, sensitivity?
Rok: Yeah.
Howard: I'm sorry to be putting words in your mouth. Why do you use total edge and why do you never go to a self edge?
Rok: Because I never really had any problem and it doesn't take me any more time to do it than with a self edge. I think if you just stick to the instructions, you won't have any problems with any bonding agent. It doesn't matter what you use as long as you read the manual and follow the instructions, it's as simple as that. I see a lot of posts on Dental Town about sensitivity issues, just follow the instructions. It's as simple as that. Isolation, follow the instructions. I don't do anything special.
Howard: You went with Kerr's bonding agent. How come you didn't go with Kerr's composite? Why did you switch over and use Kerr's bonding agent, but then switch over GC to use their composite Gradia? Was it cosmetics?
Rok: No, no. I don't have specific reasons. I switched to G-aenial, that's the better composite from GC, for esthetics, so that's what I use for anterior and I'll probably even switch to GC Kalore, that's the top end composite from GC over here. We don't have the same brands as you do. We have GC, but we don't have ... I see a lot of posts on Dental Town using composites that we don't have like Apex Dental and stuff like that.
Howard: I still have the ... I'm still shocked. We started Dental Town in 98 and now it's 2015, 17 years later and you still have these companies that make the same product and put it in a different name in Australia than they do the United States and I'm like, "Dude, the internet killed nationalism. People's identity is no longer ... They're identity is more of I'm a dentist than well I'm a dentist from Australia, New Zealand." I think the internet has killed nationalism. Some people their identity might be their country, some it might be their religion. A lot of dentists is their profession and with the internet and Facebook and Twitter, you can't call a product different in different countries because you're confusing the market. There's a lot of folks on Dental Town where they're actually trying to figure out if this product is the same as another product.
I shouldn't say this, but do you think GC is more notorious for that than other companies of calling products different in different countries?
Rok: I don't know. I really don't know.
Howard: I'm just going to leave that right there, but anybody who's listening from the dental manufacturing world, when you're on the internet, it's a flat earth. We all live in one little town and it's called Dental Town, it's called the internet, it's called your smartphone and it's extremely confusing to the dentists when the exact same thing is called, literally, 15 different things in 15 different countries. We were classically trained ... When I went to MDA school in the 90s, they said, think global but act local and that's what they're still playing on. That was a pre-internet concept. After the internet, you just can't think like that. What do you finish your composite with? Do you like diamonds? Do you like carbids? Do you use sandpaper disks like 3M, their disk series? What do you for finishing up anteriors?
Rok: For anteriors, I go with soft like disk disk. I go with coarse, and then with fine, and then I polish with diamond paste and that's goat skin bur, that's my polishing processes for the anteriors. For the posteriors I just use the fine rubber soft flex disk. It's rubber, so it's not sandpaper.
Howard: Everything you just said there was pretty agreed upon, I'm sure, by the listeners, but I think the rarest thing you said is the diamond paste. I think that's a very, very rare thing used anymore. Talk about the diamond paste. What brand? Why do you use a diamond base? I'm assume it's in [inaudible 00:56:39].
Rok: Yeah or you use some special [inaudible 00:56:43]. I don't know the company right now. We have a whole set from ... I can't remember the name but it comes in three densities, diamond paste, and you use this special process to finish it.
Howard: Is it actually a paste or are you talking about ...
Rok: Yeah, it's a paste. It's in a tube but you don't use it as much as you would use like tooth paste, just a bit and polish it. It gives you a nice finish.
Howard: How often on anterior work ... is it common in your practice to have people coming back every three to six months for a cleaning?
Rok: In our practice they do, every six months, but our hygienist does that.
Howard: You have a hygienist?
Rok: Yes, the office that I work in we have a hygienist.
Howard: What percent of the offices would you say have a hygienist now, since it's kind of new?
Rok: I'd say maybe five percent.
Howard: Five percent and I'm not surprised that you're in the five percent. I've only got you for three minutes. What do you want to close on in three minutes?
Rok: I don't know. Go on.
Howard: How could we get more ... I want to do a podcast interview with a dentist from every country. I just that would be cool. If you have any friends in Austria, Italy, Hungary, or whatever, I would love to fix me up. I think that's so interesting because I think ...
Rok: I'd say you wouldn't having a problem finding somebody from Italy, I think. There are at least five or six guys on Dental Town from Italy and they post some really good work. I think for Italy it won't be a problem.
Howard: I've done some podcast with Italian doctors. Do you got any friends in Hungary and Austria?
Rok: No, not really. Maybe someone in Croatia.
Howard: Croatia. I love Croatia. Croatia, the beach. The beaches in Croatia are just as gorgeous as the ones in Italy, but it's just a fraction of the price and the cost of the resort. For what ever costs a dollar in Italy, what would say it would cost on the resort on the beach in Croatia?
Rok: I think it's not that much cheaper anymore.
Howard: Oh really?
Rok: Yeah, because when you look at Croatia they have a lot of German and Dutch patients, tourists and that drives the price up.
Howard: You know what the most undeveloped beaches on the Mediterranean that are the most beautiful, in my opinion, is Albania.
Rok: Yeah, I'd say that too.
Howard: You can go find beautiful beaches in Albania and there's zero development for as far as the eye can see. I just sand there looking at this saying, "Wow, this could all be resorts and condos and ... It's just gorgeous." Hey, that is our time and I just want to say to you, seriously, I think ... Your name is Rok and you are a rock star, Dr. Stern. You only graduated in 2012.
Rok: Yeah, I'm working for two years.
Howard: You've only worked two years, you've got a thousand posts of some the most amazing cases on dentistry. I'm trying to think back when I was two years out of school. I look at where I was two years out of schools and I wonder if I had feet sewed to my wrists instead of hands. I can't think of one kid who's done more the first two years out of school than you, so buddy you're a rock star. It's 10 a.m. right now in Phoenix. What time is it in Slovenia?
Rok: Seven p.m.
Howard: Seven p.m. All right, sounds like it's time for dinner. Good luck with your knee surgery and thank you for all you've done for dentistry and for Dental Town.
Rok: Thank you, Howard, bye.
Howard: Bye bye.