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VIDEO - DUwHF #886 - Rob Waters
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AUDIO - DUwHF #886 - Rob Waters
Rob founded Watersedge Dental Laboratory in order to offer more than high quality products: its “raison d’être” was to give doctors the calm confidence they need to deliver perfection to their own patients. With over twenty five years of experience in dental technology, Robert knows that the best way for any doctor to navigate new and unfamiliar waters is with an experienced guide. His focus on implant restoration has provided a knowledge base that many dental professionals have come to trust - often calling him in for chair-side assistance during delicate restoration procedures.
Most of Watersedge’s clients have followed Robert throughout his career at many different laboratories in the Ottawa-Gatineau region where he has held both management and production roles. At the age of eighteen, Robert acquired his first laboratory job, polishing crowns, pouring models, and delivering cases. His natural ability to absorb and implement the scientific principles and engineering skills required to be successful in the industry is attributed to his engineer father, while his strong work ethic and individual care for the patient, colleague, and client, are accredited to his mother.
As a dedicated father and stepfather to five grown children, some of whom follow in his footsteps and work alongside him, Robert is living the “Canadian Dream” with his wife Suzanne and the family dog Harrison in their home in Carleton Place, Ontario.
www.watersedgedentallab.com
Howard: It is just a huge honor to be sitting in the capital of Canada. I'm in Ottawa, Ontario, Canada with the founding father of Watersedge Dental Laboratories. Thank you so much. So, let me read your bio. Rob founded Watersedge Dental Laboratory in order to offer more than high quality products. It's raison d'etre was to give doctors the calm confidence they need to deliver perfection to their own patients. With over twenty-five years of experience in dental technology, Robert knows that the best way for any doctor to navigate new and unfamiliar waters is with an experienced guide. His focus on implant restoration has provided a knowledge base that many dental professionals have come to trust, often calling him in for chairside assistance during delicate restoration procedures.
Most of Watersedge clients have followed Robert throughout his career at many different laboratories in the Ottawa region, where he has held both management and production roles. At the age of 18, Robert acquired his first laboratory job pulsing crowns, pouring models and delivering cases. His natural ability to absorb and implement the scientific principles and engineering skills required to be successful in the industry is attributed to his engineer father, while his strong work ethic and individual care for the patient, colleague and client are credited to his mother.
As a dedicated father and stepfather to five grown children, some of whom follow in his footsteps and work alongside him, Robert is living the Canadian dream with his wife Suzanne and the family dog Harrison, in their home in Carlton Place, Ontario. My gosh.
How long have you had a dental laboratory? How long have you been in the business?
Robert: Thirty years.
Howard: Thirty years.
Robert: Started when I was 18.
Howard: So you're 48.
Robert: 48 years old.
Howard: My gosh. You're a young one. I turn 55 next Tuesday.
Robert: Well thank you for that. That's a great way to start off.
Howard: Man, dental labs; that's seen a lot of changes in 30 years.
Robert: Sure has.
Howard: And you're in the sector. The two fastest growing areas of dentistry are orthodontics, like Invisalign, Clear Choice. Is it Clear Choice or -- no, Clear Connect. Clear Connect is the clear aligners and Clear Choice is the implants, right?
Robert: Clear Correct.
Howard: Clear Correct is the ortho. And it's because ortho and implants: nobody sets the fee, from United States PPOS, they set the fee for fillings, crowns, cleanings but not implants, not Invisalign. Same with Japan, Paris, London.
So, you've seen the implant revolution, haven't you?
Robert: Yeah. I did my first implant case in 1989 and that was a lattice work framework that I waxed up directly on an impression of a mandible with three blades sticking up from that framework.
Howard: Was that a subperiosteal?
Rob: It was. It was my first dental implant. The first case that I worked on.
Howard: And what year did you start in then?
Robert: I started in 1988.
Howard: And this was ‘89.
Robert: This was 1989, yeah.
Howard: And it was a subperiosteal?
Robert: It was, yeah. So I've seen it go from that, which was really kind of barbaric compared to what we're doing today. I saw the development and integration of the root form implant.
Howard: And what year was that?
Robert: It was the early ‘90s when I saw my first case: 91, 92. And that was a Branemark external hex implant with a CeraOne abutment attached to it. There aren't many guys these days who I can use that word CeraOne with and get instant recognition, because that goes way back. It was really limited in what we could actually do in as far as restoration was concerned. And it was back in the day when the philosophy was to place an implant where there was bone to accommodate the implant, rather than where we are today with a lot of reverse engineering; where we start off by thinking about what the patient actually came to you for, which is a tooth. Let's start with where that tooth should be and what that tooth should look like and let's reverse engineer everything to the implant placement from that point, so that we can be sure that at endgame, when the bill is being paid, your patient's really happy with the final outcome. Back then, we were seeing implants coming in at a 45-degree angle with a solid abutment already attached to it, and we were supposed to be able to try and generate something that looked similar to a tooth. Generally, I could make most things function, but whether or not I could make it an aesthetic restoration was really hit and miss back in the early 90s. That's come a long way from there, where treatment planning and virtual reality, we're making absolutely certain that the structure is there to receive the implant. So I've seen some huge changes, yeah. I've seen it go from zero to hero.
Howard: I like that, zero to hero.
Robert: Yeah, yeah. Most of the cases back in the early days, unfortunately, were disasters for the patient. Completely successful for the surgeon, right? The implant's in, it's integrated. That's successful surgery.
Howard: But, you know, I want to remind the millennials that, gosh, when I started -- I graduated dental school 30 years ago in ‘87, and in my dental school -- while I was in dental school they would openly trash talk the oral surgeons for placing subperiosteals. They'd call them butchers. Those early pioneers -- a case would fail and go before the board, and they'd look at this -- they didn't understand it and they thought it was: ramus bars are so crazy, and they take away the dentist's license. They take away their way to provide for their family. And those guys now, got us up from zero to hero.
Robert: Yeah.
Howard: But some of those early pioneers, the price they paid was too high.
Robert: Yeah, and it was profound. But, I mean, pushing the limits of what it was that we were all doing is what got us to where we are today. And you're right, we should we should be recognizing that. There were a lot of risks taken by a lot of very daring people: clinicians, patients, technicians, even the implant companies themselves and some of the things that they were developing back in the day. A lot of people took a lot of risk to get us where we are now.
Robert: Oh my god, you know the scariest thing for me was, with a sub, is taking an impression, not wanting to pick up the metal framings. And you know there was something like an Impregum, if you got around that metal frame and you're like, "Oh my god.”
Robert: You've got a disaster on your hands.
Howard: Oh my god, those were crazy days.
Robert: You know, back then I was a bench hack and my vision was limited. It stopped at the end of my bench. Patients, to me, when I started off my career, they weren't humans. They were stone models that arrived on my bench in plastic pans. It took a long time before I really started to appreciate the human being on the other end of the spectrum. And it's unfortunate that most technicians will spend their entire career thinking of patients as stone models arriving on their bench in plastic pans, instead of people; human beings who need good quality care. That connection is missed in a lot of large commercial laboratories, where technicians work behind the scenes and never ever see the patient.
I was really fortunate that I met a few wonderful clinicians in the early stages of my career who understood that for me to become what I wanted to be, which is an expert, I needed to have the full picture. I needed the perspective from the chairside as well as the perspective that I was developing quite well on the bench. But I needed to know exactly what the clinicians were dealing with. So I spent countless hours chairside at implant surgeries and during the restoration process with my clients as well, just to see what is it that we're all dealing with.
And then I had the implant surgery myself. I had two deciduous canines extracted, a couple of implants placed, unfortunately one of those implants went south and I dealt with a massive infection. Horrible thing to go through but an invaluable experience for me as a professional. I don't just sympathize, I can empathize when it comes to some of the things that patients go through with implant therapy. And it's a wonderful thing for me to be able to touch on with them when we're talking about it.
Howard: And that's why when we were little, all the OB-GYNs were men and now they're all women. Because since those men never had periods and delivered babies and they'd say, "Well, you know, it's all in your head, you're being hysterical.” From the Greek word ‘historicist’ meaning uterus, you're basically saying, “You've got a uterus brain, quit being hysterical." And so they couldn't have empathy.
Robert: Yeah.
Howard: They could fake sympathy but they didn't have empathy, and now women all go to women OB-GYN. They want to go to a woman who's had a baby and had a period.
Robert: Yeah absolutely.
Howard: And how many dentists -- how many millennials are doing root canals they've never had a root canal themselves?
Robert: Never had a root canal. Or trying to describe to a patient the benefit of having implant treatment and they've never had one themselves. Trying to minimize what it is that the patient's going to go through, when really, they don't have any practical experience with that. A lot of my clients have come to know that they can tap into my experience. If they've got a patient who's kind of waffling between a three-unit bridge or a single implant, they'll just send them over to have a chit chat with me in my exam room. Patients see me a little bit differently than they see their clinicians. It's unfortunate, but when a doctor very often describes a treatment, the patient is concerned that maybe there's an agenda that's playing out as well as the care that they need to receive. But when they come over and they have a conversation with me, I present them with facts. It's not going to matter to my bottom line whether you choose to get a three-unit bridge or you choose to get a single implant. At the end of the explanation, I have yet to meet the human being who opts for something that doesn't give them the best level of care.
So, depending on the situation and how the discussion plays out, very often they're shaking my hand and running back to their clinician to say, "Okay I'm ready, let's go with that higher end treatment because I now understand it's not about you, the clinician, it's about me the patient." That makes a big difference.
Howard: Well, what do you tell a patient -- because the dentists, they all drink from the same purple Kool-Aid, and they all say, "Well I'm not going to file down two adjacent teeth, two virgin teeth." It's like, what do you mean virgin? Do they not have sex? But then they have no problem filing down a sinus. And then when I go to my friends who are ENTs, they say, "God dang dude." The the rhinologist and the ENTs in Phoenix are showing me videos where a person thinks they've had allergies for 20 years. They see a failing root canal into a sinus and there's white fungus all over the sinus cavity. They see people who did a sinus lift and there's a titanium implant sticking into the sinus and it's horrible. And they're telling me, they're like, "Well, damn dude. You had a tooth in front of it, behind it, why didn't you do a bridge?" And you're like, "Well I didn't want to file down two adjacent teeth." "Oh, but you wanted to file down the whole sinus?"
So all of your clients, they drink the odontology purple juice. So my question to you is this: in your 30 years, what percent of just the missing first molar; maxillary first molar, that was a three-unit bridge all throughout the 80s and 90s. Now from 2010 to 2017, what percent of those three unit bridges replaced in just exactly a match for your first molar have now gone to an implant and a crown? And do you still do any three unit bridges to replace some?
Robert: Of course. I think we're always going to be doing three unit bridges. I don't think that's something that's ever going to go away. That's like saying removables are going to go away.
Howard: But people get shamed for doing bridges on Dental Town and Facebook.
Rob: I know.
Howard: They’re like, "Dude, why did you rape two adjacent teeth? Why didn't you do"-- they're shaming them for doing bridges. But you're saying -- so give them a relative for you, what percent are still three unit bridges?
Robert: First of all, I'd be guessing at numbers, based on just my view, and I never like doing that, but I'm happy to give it a shot. I'd say the three unit bridges that replaced a missing first maxillary molar have probably been replaced 80 percent of the time now, with implants.
Howard: 80 percent. So the 80/20 rule still applies.
Robert: Yeah. And maybe it's a slightly different philosophy up here north of the border than it is down in the U.S. I'm not sure what the driver is behind it, but ultimately, I'd like to believe that clinicians are delivering the care that is best suited for that particular patient. So if you've got a situation where you've got minimal bone left around an expanded sinus and you know you're looking at a fairly invasive procedure to get the bone in there that's required to get an implant placed, well in that clinical situation, a three-unit bridge seems to me to be the appropriate direction to go. But I'm not a clinician. I'm a dental technician and I don't direct treatment plans. I advise and suggest based on my past experience, but ultimately the clinician is the one who decides which direction this case is going to go. And I'd like to think the vast majority of people that I work with really are making decisions that are based on the best interest of the patient, as opposed to the sexiest thing to be able to post on Dental Town.
Why did I do a three-unit bridge on this particular patient? Because it was the right thing for this particular patient, who you don't know. I do. I'm the clinician with the relationship there. So I would never question any of my clients. If I've got a client who sends me a dozen implant based cases a month and next month he sends me a three-unit bridge, I'm not giving him a call and asking, "Hey, why is this a three-unit bridge instead of a single implant the way the other 12 cases were last month?" I have to believe that the clinician has decided that this is the best treatment for this particular human being. Whatever the drivers are for that decision: whether it's a physiological reason, a psychological reason, or just a financial reason. Those are big drivers into deciding what that final treatment plan should be. And I trust that clinicians are doing what's best for that given human being. Maybe not the gold standard of care, but not everybody can afford that and it's not indicated for everyone. So yeah, I think maybe before some of those other clinicians jump on the thread saying, "Hey. Why did you butcher those virgin teeth instead of doing a single implant?" They should take a step back and realize that's a clinician who probably did the best possible treatment that could be done for that particular patient. And that's something they should be commended for.
Howard: You know, dental laboratory technicians and lab owners tell me that a lot of them are afraid of communicating with the dentists, because they're afraid they're going to lose the account. They're afraid to say, “Your preps are bad, you don't have enough reduction.”
Robert: Oh yeah, I've heard that.
Howard: And then when they do the crown, then it comes back and the doctor is mad. "It didn't fit." Or "You should pay for the remake." And they're sitting there like, "Well that was the shittiest impression I've ever had." And some of the dentists are very arrogant like that and you say anything bad, they don't work. But I always tell them, "If you want to be a great dentist --" Like when they want to learn endo, they feel like they've got to fly all the way to Santa Barbara, California and go listen to Cliff Ruddle and all these expensive guys, when they could walk across the street for free to an endodontist and sit by there for free. And then when you have an endo problem, you have a buddy. If you want to learn how to place implants, these periodontal surgeons, half of them think in fear and scarcity, and they say, "Well if you wanted an implant you should send them to me." The other half are like, "I get it, you can watch it and I want you to watch me because you'll do the easy ones and give me the hard ones." But I always think the greatest way we can do is use a lab up the street from you. Why are you mailing your crown and bridge across the country? Because when I was little -- I remember it was ‘87, I called up my lab guy, and this was an old German lab man -- I shouldn't say old -- and his name was Wolfgang, from Germany. Big accent. And I said to him "Hey, how was my impression, I mean, how was my prep, did you like it?" And there was just like this pause. I'm like, "Hello, hello did you like it?" You could tell he didn't know what to say. And then when he realized that I wanted him to feedback, I realized that that wasn't the average dentist. And he said, "You know what? You need to come down here." And when I went down there, this old German guy showing me all these pans coming in and showed me the prep and he took me under his wing, because I was hungry, humble, hustling. And I tell people that if you put your Impregum impression and mail it across the country, you couldn't do that when you're 50. You can't do that when you're 25.
Robert: And you shouldn't be.
Howard: You need to go to somebody. I'm not calling you old, but you have done it 25 -- how many years have you done it?
Robert: This is 30.
Howard: You're 30, and there's kids opening up in Ottawa that ain't 25. And then you need to be humble, but you have to tell your lab man that you're that rare dentist who is humble. If a young kid from Ottawa came up to you and said, "Will you take me under your wing and help me?" what would you say to him?
Robert: I'm happy to try as long as you and I can maintain a very healthy, open line of communication between each other. Because I haven't seen what they can do yet. And you and I both know, what did they call the dentists that graduated at the very bottom of their class?
Howard: Doctor.
Robert: Exactly. So when they show up at my door I have no idea what their capability is. Now, I'm about to step into a business partnership with someone. Anytime I have a client approach me and say, "Can I start working with you?" This is a business partnership that we're about to dive into, and I'm about to dive into that without having any idea whether you graduated at the bottom of your class or at the top of your class. Without knowing whether or not you're a Michelangelo with your hands or if you've got feet attached at your wrists. I don't have any idea. But I'm always open to beginning the relationship as long as we can communicate, because I know what I know and I've seen what I've seen and I can tell you, looking at the impression, whether or not this case is going to be a success.
And it doesn't come down to what you're willing to compromise on as the clinician. I'm not a make it work kind of guy. If you send me an impression and I look at it and I know there's just no way that I can possibly identify the margin on this case, and it's going to be compromised if we make a restoration, and the response I get from you is, "Just make it work." It's the last case I do with you. And I'm sorry to say that. It sounds arrogant, I know it does.
But I'm really fortunate that after 30 years in the industry I don't have to work with everybody who shows up at my door. I want to work with everybody who shows up at my door but I don't want to compromise what I produce. Up here there's never a question when it comes to a crown failure as to how I'm going to handle it. If we installed a crown on a patient within five years and that crown fails, I'm covering that remake 100 percent. So it just doesn't make any sense for me to look at a case that's come in the door that I know is doomed to failure and just proceed with the production. And a lot of laboratories, they will. You asked for the wrong material, you sent us a terrible impression, but you're the clinician, you're responsible. I don't see it that way. I'm responsible for what I make. And if the records I've been provided are not conducive to me being able to produce something that I know is good for a human being, I don't want to do it, and I'll get on the phone and explain exactly why. And that explanation is not based on some book that I read somewhere. It's not based on me guessing what could happen. That feedback is based on 30 years of experience and you can accept it or not. Every person is free to make that kind of choice. And if you're the kind of person who just doesn't want to listen: you're 25 years old, you've graduated dental school, they call you doctor, you know what's right, there are lots of laboratories out there for you. But the kind of quality operation that we're running, that's not the place for you to go.
Howard: What percent of dentists do you think -- because they only know themselves, and they look in the mirror and they think, "Man, that's a great guy.”
Robert: "I got a great degree. I'm amazing.”
Howard: What percent of dentists do you think are humble and that you can talk to and say, "Come on doc, let me --"
Robert: You know, that's like asking me: what's the percentage of mechanics that are humble? What's the percentage of plumbers that are humble? I don't think there's any difference in the cross-section of humanity that makes up dentistry as there is in any other facet of our society. Unfortunately, nor is there any difference in the performance of that individual. People are people and getting a degree doesn't change who you are as a person. If you were crazy before you became a dentist, you're crazy after you've become a dentist. If you're calm, humble and kind before you became a dentist, you're calm, humble and kind after you became a dentist. Same applies with all aspects of our society, in my opinion.
I'm really fortunate. The vast majority of young dentists that I meet are very humble. Maybe that has something to do with the fact that they know I've been doing my craft since before they were in high school. Maybe to some extent that affects how they interact with me and their willingness to be a little bit more open to my opinion. That may play a big factor in it. The vast majority of new clients that come to Watersedge are very open to the idea that we're here to help them.
The last thing that any dental lab owner or manager wants to do is call up a client and say, "This case you've just sent me, this business interaction that we're about to have that I rely on to keep the lights on and pay my bills and get my kids through college, I don't want to do that for this particular case." A clinician needs to appreciate that that's the last call that a technician ever wants to make. That's not how we get paid and that's not how we survive. We get paid for production. We don't get paid for calling you up and expressing our concern about the quality of an impression. In fact, we know there's a certain amount of risk with making that call. And if we're doing it, we're doing it because we really believe it's the right thing to do, not because it's what we feel like doing.
Howard: I can't remember the name of it, but on the way to a lecture in Sydney, there was a movie -- there was two movies -- one was the comedian with Robert De Niro, but there was another movie about comedians, and the question was -- they interviewed like the 20, 30 of the most famous comedians and asked them: does comedy come from pain and are comedians more messed up than the general public? It was funny listening to these guys and a lot of them were saying "Yes, all the comedians, all the famous comedians say all their famous comedian friends have the most messed up lives." But they agree that people were just messed up in general. So you were saying that: what percent of dentists, it was no different than plumbers, welders whatever. Back to holding your feet to the fire. What percentage of dentists call you up and say, "I'm humble. I want you to feel safe to call me, and if you don't like the amount of reduction, if you don't like my preps, if you don't like what I'm doing, I want you to help me. Because that's the fastest, easiest, cheapest way to raise my quality." The most expensive way is flying to Key Biscayne or Hoyts or Spear.
Robert: Vegas.
Howard: And Vegas. And dropping $3000 dollars a weekend. When you can go over to -- how much would you charge a little kid that's 25 years old to walk in your deal and you show them 100 incoming cases of what you need to do quality dentistry? What would you charge them?
Robert: I'd charge him nothing.
Howard: I know.
Robert: And I charge him nothing to go over and stand next to him chairside while he takes an impression, so that I can validate the impression then and there before the patient ever gets out of the chair. I charge nothing for that.
Howard: That's what your problem is. Smart people are street smart: dentists, lawyers, physicians are book smart, they're never street smart. And I'd rather have a street -- you look at the greatest business built, like Steve Jobs: went to one college class and dropped out. Bill Gates dropped out first year Harvard. Marty Zuckerberg of Facebook dropped out. And by the time you got eight years of college, you’re book smart but you're not street smart.
I mean, if the endodontist -- if you go across the street and the endodontist says, "No, I'm not going to have you. I'm not going to show you how to do molar and dental. I want you to send me the molar and dental." Well, he thinks in fear and scarcity. Thank God you met him, you can cross his name off and never meet him again. Go to the next endodontist. Half the endodontists, they can hold growth and abundance and say, "Any time you want to sit on my chair and watch me do endo." Periodontists teach you how to do implants. Orthodontists teach you Invisalign. And I don't think any dentist is smart enough to be sending their lab work across the country if you've got a lab man in your backyard that can help you.
Robert: I agree. But I don't think that every clinician has had the experience with that type of laboratory or that type of technician, that opens up their mind to that particular point. My people are taught in the laboratory to follow instructions: read the prescription, read the prescription, read the prescription, right? I want to get it tattooed on the inside of everybody's eyelids so every time they blink they see 'read the prescription.' However, they are taught to follow those instructions but not follow them blindly. We're the material experts. We know what's going to survive on any given situation: whether it's prep design, antagonist interference, whatever it is that we're looking at on a given case, we are the material experts in the laboratory. So if one of our clients has asked for material that we know isn't conducive to long term success for this restoration, we're picking up the phone and we're calling. And we're explaining why. We're not just going to tell you, "This is the wrong material to choose." But we're going to explain to you why and we're going to give you another option.
So, we find the problems but we also offer the solutions and we do it immediately. Now, not everybody is like that. If you're packing your case up and shipping it across the country and it's hitting a laboratory where you are nothing more than a number and a plastic pan and some stone models making their way through the laboratory, nobody really cares enough to pick up the phone and make that connection with you. And if you've been through your whole career: 20, 30 years of having had that experience, well you don't know what you don't know. And you don't know that you can tap into your most valuable resource right down the road at your laboratory. Your laboratory can keep you out of more trouble than anybody else on your team.
Howard: So we are talking about how dentists were 30 years ago, was all three unit bridges to replace a missing first molar. And now it's only 20 percent. When you started 30 years ago did you ever think you'd see the PFM go to the way of the dinosaur? What percent of your PFMs in 1980 have gone to all porcelain?
Robert: 90 percent.
Howard: So only 10 percent PFMs.
Robert: Only 10 percent.
Howard: So who's still doing PFMs?
Robert: A lot of the old-school guys.
Howard: It's older guys?
Robert: Yeah.
Howard: And what do you think of the PFM, is there still a place for it?
Rob: Absolutely.
Howard: What's the place where you still like a PFM?
Robert: Where I've got limited occlusal clearance and you've got a patient who has aesthetic concerns, even on a first molar or on a second molar. I'd like to maybe use some nice gold occlusion on that case on a nice porcelain buckle facing, so that we know functionally it's going to work beautifully, it's going to wear exactly the way that it should wear over time and aesthetically the patient's getting exactly what they're after. These days we're doing a lot more zirconia work, where we've got full zirconia occlusion and maybe we'll cut back the facial or some ceramic [00:29:41] on tip [0.3] to have it be as aesthetic as it possibly can.
Howard: I want to ask you a question only for -- first of all, I know you don't have the same numbering system in America as in Canada.
Robert: No, we don't. We use the international notation system.
Howard: The international notation.
Robert: We're in quadrants and then individual teeth within that quadrant.
Howard: And you use international and Americans use the universal.
Robert: Americans use American.
Howard: But don't they call it the universal?
Robert: I don't know.
Howard: Yeah, they call it the universal.
Robert: But I know you're the only ones that use that system.
Howard: Because if you would have named it the universal system, we would have named it the parallel, dimensional, parallel universe --
Robert: Intergalactic system.
Howard: Right. I'm sorry I don't know the notation for yours, but when you look at, like, a hundred million claims for dental insurance, you go around and you've had four spikes for that six-year molar. I mean, the front ten teeth hardly ever get cavities, root canals. The difference between a six-year molar and a 12-year molar on a homosapien is just huge. The tooth most likely to be root canalled, crowned, extracted, replaced, everything. So you just have these four huge spikes on the six-year molar.
So, I want to focus just on the six year molars. And a lot of people, people listening to podcast shows and the Dental Town app are usually born after 1980. And the people on the desktop are usually old like me. And she hears things like -- well if your pretty wife Suzanne came in, she'd want to empress on the six year molars. But if it was an old, fat bald guy like me, zirconium, because zirconium is stronger. Is empress strong enough for a six-year molar in most cases or do you need to go zirconia? I personally --
Robert: That's a good question.
Howard: I personally -- all mine are gold. Every crown and inline in my mouth is gold [00:31:39] losing fossa [0.7] because I think that is the gold standard, literally. But back to six year molars, because she's wondering, when she sees debates on Dental Town, so six year molars. Zirconium, e.max. What are your thoughts?
Robert: Either one. Either one, provided the crown's been designed properly, occlusion has been managed properly, everything has been validated correctly at insertion. I don't think you're going to see any difference in failure rate. It's just going to be a difference in what actually fails. I mean, a zirconia crown is a beautiful product. It's bulletproof and they rarely fail, but the underlying structure occasionally does. In particular, if occlusion hasn't been managed properly.
An Emax crown: incredibly strong material, easy to adjust chairside, where zirconia it's a little bit more complicated and you need to be a little bit more careful. But in my opinion it's six of one and half a dozen of the other. Even gold crowns will fail if they're not delivered effectively; if occlusion is not managed properly. If marginal integrity is not there a gold crown is going to fail more rapidly than an e.max crown that has a nice marginal integrity and a really good seal.
In my opinion it comes down to using the right material for the right situation for the right prep design. Things as important as the vertical height of a preparation can have a lot to do with whether or not we go with an e.max crown or we go with a zirconia. Now it's unfortunate: there's a big price point difference between full zirconia and e.max crowns here in Canada. A full zirconia crown, you're maybe looking at $180 to $200 for the laboratory, where an e.max crown could be anywhere from $250 to $350. So very often if the patient expresses to the clinician --
Howard: That's Canadian dollars, that'll only be ten dollars in the U.S.
Robert: That's like 57 cents I think, yes. The clinician, if they've got a patient in the chair who expresses to them, "Okay, you're putting a crown on my first molar but I want it to look like a tooth. I don't want it to be metal, I don't want it to be silver, I want it to look like a tooth." The clinician may knee jerk prescribe zirconia for that particular case. But when it comes into the laboratory -- and again, we get the models poured up and articulated and we have a look at it, and we see a limited vertical height to the preparation, two and a half millimeters high, a minimal amount of surface area, we're going to pick up the phone and call that clinician. Not trying to make an attempt to upsell the restoration, but simply explaining to them, "If you want to cement this restoration in place, it's very likely going to debone within the first year or two years. You might want to look at a bondable material, something we can etch in the laboratory, like e.max for this particular situation." So it's not about upselling the product, it's about making sure that what the clinician delivers is the best possible solution for that particular case. And I think the responsibility should fall more on the laboratory than it does on the clinician. And I know that's an unusual position to take, but we have a lot of clients who will prep a single tooth, let us know what shade they're after and then completely defer to us for the material at the laboratory: "Whatever you think is best, apply it here. Just make sure it's the right color, margins are sealed, contacts are there and occlusion's perfect.” We'll take care of all of that.
Howard: Yeah that is amazing. In Arizona there's just a partials framework lab that does partials and most all their clients are lab owners who don't do partials.
Robert: Yeah, we've got quite a few of those up here too.
Howard: Yeah and they ship into Nogales, Arizona and then they drive across the border into Nogales, Mexico. It just surprised me how only 10 percent of the incoming -- for removal of partial cast frames -- did anyone even prep a seat or designed a partial on the deal? Nine out of ten was just an impression and sent it down. And these guys are like, "Oh my god, you're a doctor, you're doing a partial, you couldn't even pick up a football and just cut a russ seat? You couldn't do anything?"
Robert: Well, you know, I think --
Howard: And that's what these dentists need to know, they need to go to that lab and see the difference --
Robert: Absolutely.
Howard: -- between that top 10 percent and the 90 percent. You go spend one day in a partial framework lab that's doing eleven to twelve hundred partials a day --
Robert: You're going to learn a lot.
Howard: You're going to learn a lot! I just don't know why dentists aren't street smart. Like, the last two textbooks I got were each like $200. One was, "Pathways to the Pulp." Like, tenth, eleventh edition. One of them was Carl Misch's last book, "Implant Complications.
Robert: Love that book. It's a great book
Howard: You can learn almost everything there is to know about endo in two books. Half the endodontists in your city will help you. Half the periodontists and oral surgeons will help you. Half the orthodontists will help you. You need to get street smart and get friends in your town that will help you, take you under their wing, bail you out when you have a problem. These guys can make you look pretty after there's been a disaster.
Robert: It's in all of our best interests to make that happen, isn't it? If you're working with a local lab that you've never been in, I can't quite wrap my head around that. I mean, that's a huge component to your overall success, is your dental laboratory. But you've never visited it?
Howard: Yeah and you young kids, you got to remember -- I got to tell you a story, because see, when you get out of school -- I mean, you do -- you really, really think you know it all and I've been there. I remember when I was out of school I thought I was so unbelievably smart because these patients would come in and say, "Well those older dentists across the street, they want to pull this tooth. They said it can't be fixed, is that really true?" And it was like a front tooth snapped to the gum line. I'm like, "Oh my God, I must be better than them because I can fix that. I can do a root canal and this big old post buildup and crown and I fix it." And I thought of myself, "Man I am all that and a bag of chips." Yeah, it takes a couple of years for the patient to walk in with that in their hand saying, "What the hell happened here?"
So what I'm telling you is that when you get out of school, it takes you five years just to find out what you don't know. Everything works from your chair to the curb. It takes a year or two to find out that that's a really bad idea. A ferrule. You know, they think if something snaps off the gum line they can put in three posts, a bunch of pins, build it up, but the ferrule, which is -- you know where that technology actually came from?
Robert: No.
Howard: It actually came from barrel making.
Robert: Right, the bands that they'll --
Howard: The band is called a ferrule, so they would make these wooden barrels and they realized that if they just put like a two-inch strip of metal around that barrel, and then eventually it went to like a four incher down the middle, and to two inches and those are called ferrules. And when you're doing a buildup, if you don't have a two millimeter, two structure ferrule, all your build up is up. And then in the front where the forces are not only up and down but forward, I think you need three millimeters.
But I guess the question I'm going to ask is: she's driving into work right now, she's 25 years old, she's just graduated. What do you think she doesn't know now that she'll know in five years? Which is another reason she should be working with the lab man who's done it 30 years up the street, so she doesn't have to learn every lesson the hard way. Because you're going to learn every -- trust me, you're going to learn every dental lesson, and you're going to learn it the hard way or the easy way. And the easiest way is from a guy who's done it 30 years.
Robert: You and I talked about this last night. I was very, very fortunate that while he was still around, I learned from Carl Misch. I went through his surgical program for doctors, sat in the same room as all of the clinicians, wrote the same tests that they all did. Not that I was about to go back to the lab and start placing implants, but again, I wanted to understand what they were dealing with. I went through his prosthetic program as well and graduated it along with 110 dentists at the time.
Howard: You were his first lab tech to graduate.
Robert: Yeah, from what I understand, yes, I was the first lab tech to go through. And I didn't know that until the time he put the diploma in my hand and made a big fuss about the fact that I'd taken the time to go through this to get a doctor's perspective. Carl Misch taught me that if you want to be an expert in anything -- and I mean, this conversation was over some drinks and maybe I'd had a couple more than I should have --
Howard: Carl drinking? No! Are you sure it was Carl?
Robert: He asked me why I was investing the kind of time that I was, when he knew I couldn't take this certificate from Temple University back to the laboratory and start popping in implants. I told him I wanted to be an expert. And he told me. "My course isn't going to get you there, Robert. The only way that you'll ever be an expert is if you have a really narrow field of practice and you've made every possible mistake within that narrow field." Thirty years later I can confidently look at any new doctor that I'm dealing with and tell them I'm an expert. Because I've screwed up everything that can be screwed up and I've seen other people do it around me. And I can anticipate those problems now before they are even here.
So what's the biggest thing that a 25-year-old dentist should really tap into? That experience: find a relationship that you can forge with somebody who's already been there. A dental tech with 20 plus year’s experience is going to be able to let you know whether something will be successful long before you begin. Talk to them, develop that relationship.
And if whatever laboratory it is that you're working with right now doesn't have someone who can sit down and have that kind of conversation with you, it's time to find a new lab. You need to have them support you if you're going to be as successful as you possibly can.
You were asking me before: how many dentists are humble? How many are open to the notion that I might actually have something to show them, even though it doesn't say DDS behind my name? It's a hundred percent. It's a hundred percent of the clients that I work with. And I think the biggest driver behind that is anytime somebody reaches out to my laboratory and expresses an interest in working with us, I get out there and beat them. I will drive out to their practice, I will sit down in their office and let them know exactly what they can expect from me. I'll let them know where I've been. I'll tell them what I learned from Carl Misch. I'll tell them I'm an expert and that if something's going to go wrong I'm going to be able to see it before it's a problem. I tell them that the only silly question is the one that they didn't take the time to pick up the phone and ask me that got us both in trouble. Because we're in it together and we'll get out of it together, but only if we communicate.
So when I get out with a new client, whether it's they've already sent their first case to the laboratory or they've just called up and expressed an interest in dealing with us, any time I’m getting out there and letting them know: this is who we want to be for you. This is the resource that we want to be for you. Not just for you, but for me. The only way we'll be successful is if we deliver restorations that your patients are happy with, but take great care of them, and the best way for us to accomplish that is working together. So I can't just be some big box store on the other side of the country that you send an impression to with a prescription. And if that's all I am, well, you'll move ahead: you'll move ahead based on your own experiences and your own failures, and 30 years after you start practicing, you'll be 55 and you'll be able to look at a technician in the eyes and say to them, "I'm a restorative expert too." You will be by that time. But why go through all that pain and suffering? Why don't just establish a relationship with somebody who can help you now and prevent those problems from ever occurring? Just make sure it's somebody who can actually explain to you what it is they've seen in the past and what they're anticipating may happen in the future. That's how you'll learn. Not from somebody who simply says, "This won't work." They need to be able to explain that. Dentists are highly educated people and they're not just going to accept an opinion. That has to be backed up with some meat on the bone and that meat on the bone is 30 years of experience.
The number of failures that I've seen, the number of complications that I've seen, enable me to prevent future complications and failures. It's as simple as that. It's not a complicated equation. Surround yourself with great quality people who support you and you will be successful. That's your assistant, that's your hygienist, your office manager, your treatment coordinator, and it better be your laboratory. If it's not, you're missing a huge element to your overall success.
There are lots of clinicians who don't need that, mind you. They're very experienced, they're very knowledgeable, very aware, and they're quite happy shipping their cases wherever to get a restoration at the minimal amount of cost. I understand the driving reasons behind that particular decision. But for somebody who's looking to advance themselves, there's just no replacement for experience and it doesn't have to be your own. It can be somebody else's. Why not? Why not benefit from all those other dentists who had things go way off track working with me 25 years ago? Why go through it yourself now to learn those things?
Howard: I want to ask specifics again, for the millennial born after 1980. She's under 30, she has specific questions like, "When can a triple tray be adequate? When does it need to go to full arch?
Robert: Oh boy. That's a question I've been dealing with for over ten years, really since triple trays started to really penetrate the marketplace. When should I work with a triple tray, when should I work with the full arch? When you want me to deliver you a perfect restoration, you send me a full arch impression. When you want me to deliver you a restoration that may require some chairside adjustment but it will be a good restoration, send me a triple tray. Why do I make that kind of harsh statement? I like to check function. A human being is a complicated animal. And the systems that we have are incredibly complicated. The fact that I'm not able to check lateral function in both directions when I make a restoration, because you haven't provided me with the other side of the human being, it just means that I'm going to ask you to check that movement chairside instead. Are you doing it? If you are, great! Save the time and the material cost and take a triple tray impression. It's a wonderful device. But it puts some of the responsibility for checking that restoration in all aspects back on the clinician rather than relying on the technicians who have done it properly on the bench. And I think maybe that's part of the reason why triple trays took off like they did.
There were a lot of technicians and laboratories who are thinking human beings and their jaws are a door hinge or a mouse trap, and it's a much more dynamic movement than a hinge. Why take full arch impressions when the laboratory was only checking things on the door hinge in the first place? Move to triple tray and you get the same quality. I'm a little bit different in how I approach those kinds of situations. I want to treat the whole human, which means I need the whole arch.
Howard: I had a patient who lost his left side and he's alright now.
Robert: He lost his left side entirely?
Howard: So now he's all right.
Robert: He's all right. Haha.
Howard: Another question, yes. Some of the old men only use polyether like Impregum, some use polyvinyl siloxane. Does it matter to you?
Robert: I want you to use what you're comfortable using that delivers me the perfect record. Whether that's polyether, polyvinyl, you want to use rubber base impression material and copper bend dyes. Yeah that's how far back I go.
Howard: Yeah, I remember doing those.
Robert: All right.
Howard: What was the green stuff in the tube? Do you remember that?
Rob: Compound something. Horrible, the smell of that stuff was -- just thinking about it now I can still go back to what that rubber base --
Howard: Okay she's wrestling with this decision. Help her get her arms around it.
Rob: And she's also considering digital, which is something we need to talk about today.
Howard: And so she's using, right now she's using 3M's, polyether Impregum. And her reps telling her to upgrade to a 3M, $17,000 true definition scanner.
Robert: Alright.
Howard: So how should she be thinking about a $17 Impregum impression versus a $17,000 true definition scanner impression?
Robert: The first thing she needs to do is take a look at her past history. Is she successful with standard impressions? First question anybody who's contemplating moving into intraoral scanning should be asking themselves. Am I successful and consistent with the conventional impression technique? If you're not, don't go into digital, because it's not a magic bullet, and nor is any new impression material a magic bullet for somebody who can't manage the impression site in the first place. If you can't control the saliva, if you can't control the blood flow, if you can't displace the soft tissue from the margins so that we get a nice clean record with the conventional technique, moving into a new impression material or a new impression modality like digital scanning is not going to solve your problems. Absolutely make sure that you understand the basics and that you're successful with them consistently, and then you can contemplate making a move to something different like digital scanning, if it makes fiscal sense for your business, if it makes sense for your patient base to be going in that direction. There are a lot of benefits to working with digital impressions.
Howard: But ten years ago what percent of your incoming impressions were digital and what percent are they today?
Robert: Ten years ago maybe two percent were digital. Maybe a single percent really. These days I'm looking at about seven and a half percent coming into the laboratory digital.
Howard: To me, if you told me seven and a half of Canadians like some movie -- when you tell me market share of B to C, it doesn't mean anything. At least a quarter of Americans are bat shit insane. But in dentistry --
Robert: Only a quarter?
Howard: Only a quarter, yeah. Except for a {00:52:08 fram frown reunion} then it's the whole damn thing. But when you look at market share among dentists, they all have eight, ten, twelve years of college, so when I look at market share penetration means a lot to me, like 80 percent plus -- 90 percent plus of dentists have computerized their business. So you know that's a gimme. 80 percent have got digital x-rays. You know it's a gimme. But if less than 10 percent of your dentists are sending you digital impressions, it almost makes me think it's still bleeding edge as opposed to leading it. I still think about chairside milling, because all these people talk about: you got to go to chairside milling. It's like, "Well if it was all that and a bag of chips. Why --
Robert: Wouldn't everybody be doing it?
Howard: Why is only 15 percent of my homies doing it? I mean, dentists are smart. They know the difference between trig, geometry, calculus. They were always the smartest kid in the room. They got straight A's. So when only seven percent of your clients, which I met a lot of them today, if only seven and a half percent have adopted it, what is the deal with that? To me that's a red flag.
Robert: I think the biggest problem right now is that we're still -- everybody's waiting for the dust to settle. There are a lot of competitors in the marketplace spinning a lot of different messages when it comes to intra oral scanning. The price points are astronomical to get in, and if you're already successful taking impressions, why?
Howard: Yeah. One thing --
Robert: The drive isn't there.
Howard: One thing that's how -- I'm going to switch from a $17 Impregum to a $17,000 GF scanner, it's like, "Dude it's not like that." But now you have to sign up for the $200 support, times 12 months, that's $2400 --
Robert: Sometimes a click fee on top of that too.
Howard: A click fee on top of that and you weren't even buying $2400 worth of Impregum before. "Yeah, but I just want to be a good dentist." So my question is: to be the best dentist, does she need an intraoral scanner or can she still use polyvinyl siloxane.
Robert: Absolutely not. And you can still use polyvinyl siloxane. and be an incredible dentist. My best clients are not digital guys. These are guys who have perfected conventional impression technique to the point that everything they do drops into place. No impression leaves the chairside that isn't perfect, because they've been able to develop their technique to the point that they can look at any impression and know whether or not it needs to be retaken. They do not lie to themselves. They don't look at that impression and think, "Oh wow, Rob will make this work." They know what they know and they don't kid themselves about it. There's an imperfection here, I'm going to go back in and I'm going to focus on just that one area and I'm going to send Rob two impressions and I'm going to explain to them this area. There's a bit of a void. I need you to verify that on impression number two. I'm quite happy to do that for them and it ensures that we deliver a quality product. You can be very successful using conventional techniques if you use them properly.
Howard: So I want to answer this question, but my homies are going to think, "Oh, well he says that because he owns a lab." What do you think of: she's considering chairside milling versus going to a lab, knowing the fact that the chairside milling machine will be in competition to a dental lab.
Robert: A chairside milling machine is not in competition with a dental laboratory, I'm sorry.
Howard: Okay. How do you explain that Rob? Does that mean you've been drinking?
Robert: No.
Howard: Have you been drinking today?
Robert: No, I've just been around for 30 years.
Howard: Because she'd say, “If I buy a chairside milling machine I'm not sending you the crown and you make crowns.”
Robert: No. You buy a chairside milling machine, there is a small segment of what you're doing that that machine is going to be able to address. But there's a big difference between the clinical acceptability of the restorations that are produced by some of these chairside mills, and what we call laboratory standard. And clinical acceptability is not acceptable for everyone. I'm not talking about just the clinicians here, it's the patients. There are patients who are not going to accept any compromise in the restoration that you give them. And those are patients where you may think twice before you use your chairside mill. You'll take a conventional impression and send that to the laboratory. I told you I get about seven and a half percent of my cases coming in digitally. The vast majority of those are CEREC files that are coming out, that we convert to a standard SDL file and then we're free to use any of our systems, not just a CEREC system to restore that case. Well, if it's a CEREC file coming into the laboratory, I know that doctor has a chairside mill, why aren't they producing the restoration? Well, for most of the patients, maybe, or some of the patients, maybe, but not this particular patient, Rob. This particular patient, I know if I do it with the chairside mill and that color’s not a 100 percent perfect match, I'm going to be redoing it and redoing it and eventually sending you the impression so that you can do it at the laboratory standard which this particular patient is going to demand. I don't think at this stage the technology is there. It's coming. There's no doubt it's coming, but I don't think it'll ever completely replace what we bring to the game. It's more care than what your chairside mill can do for you.
Howard: I can't believe we are already past an hour. Our brand is an hour because that's your average commute to work, but I want to ask you one overtime question. Another difficulty is taking a shade. When people send a crown back to the lab, is it more likely because it didn't fit or that shade didn't match?
Robert: I can answer that. Absolutely 100 percent of the time it's coming back for color rather than for fit. The primary reason for that is the controls that we have in place in the laboratory to make sure that what we've produced in as far as a record from your record. The model from your impression. We make sure it's an accurate representation of what you sent into the laboratory. Every impression that comes into the lab is poured three times. Why do laboratories make multiple models from a single impression? Well, to make sure we haven't done anything wrong with the model production. The restoration has to fit perfectly on all three of the casts that we've produced from your impression before we send it out of the lab. So if there's no distortion to the impression, and we've poured three models from that impression and checked the fit of the restoration on all three models, chances that that crown is coming back because it simply doesn't fit are very, very small.
The issues that we deal with primarily on remake returns are shade related. But that said, a lot of my guys who have been through that experience can identify difficult shades before they begin the case. And they send the patient to the laboratory.
Howard: She sees technologies advertised --
Robert: Oh, scanning technologies for shades? Oh yeah. I've been around to see a few of those too.
Howard: And is it worth the money?
Robert: Not yet. No. Again, it's in its infancy and it's not the right time for it to be something you can rely on.
Howard: What I do when it's a beautiful woman, highlight blonde, I try in the shade. My trick is I reach back and turn off the operatory lights and then I hand her the mirror in the dark.
Robert: Yeah, it looks perfect. Everything looks perfect in the dark. We say if you close one eye and you run by really fast, the shade is perfect.
Howard: When she says it doesn't match I always say, "Well here, let me turn out the lights and put the sunglasses on." And then look at it.
Robert: It's beautiful.
Howard: So any advice, final question, any advice on shade taking?
Robert: Again, defer to the tech. How often is a clinician taking a shade? You're doing crown preps three, four, maybe five times a week. How often does a professional ceramist take a shade? How often does a professional ceramist deal with the materials related to creating an aesthetic restoration, and just looking at teeth? Go with the experience. Like you said before, why take on a responsibility for something that you have a resource you can tap into for? Deal with your local laboratory.
Howard: And never take a shade on an old grandpa with a liver spot. If he has a liver spot, at 35. No one's looking at his tooth when he has a liver spot on his head. He ain't even looking at his tooth. With a liver spot, A35 speeds up everything.I just want to tell you that you're an amazing man. You have an amazing lab. Thank you for all that you have done for dentistry for the last 30 years.
Robert: Howard, thank you very much. I really appreciated this time with you. It was great having you here in Ottawa.