Dr. Howard Farran and Dr. Paresh Shah discuss the evolution of a comprehensive care dentists: trials, tribulations and successes.
Howard Speaks Audio Podcast #15 with Dr. Paresh Shah
Howard Speaks Video Podcast #15 with Dr. Paresh Shah
About Dr. Paresh Shah:
Dr. Paresh Shah maintains a private practice in Winnipeg, Canada with a focus on implant, cosmetic and interdisciplinary complex restorative care. He graduated from the University of Manitoba in 1991. Dr. Shah has a proficiency certificate in esthetic dentistry from the University of Buffalo (SUNY) in 2007 and a masters in physiology from the University of Manitoba in 1987. He is also a graduate of the Misch Implant Institute Prosthetic Program and the Kois Center in Seattle. He serves as a consultant for numerous dental manufacturers in product development and evaluations. Dr. Shah is also a founder and co-director of a Seattle Study Club in Winnipeg. Dr. Shah may be reached at: Drpareshshah.com or firstname.lastname@example.org, or by phone at 204-295-2233 or 204-837-4517.
Podcast Transcription (Download Here):
Howard Farran: Hey, we are going to have fun today with what us Americans call the Canadians who live upstairs in the loft. You are basically from Winnipeg, Manitoba. Dr. Paresh Shah, which is right above North Dakota. So I assume being born and raised in Kansas, it is a lot of small greens farming. A lot of wheat, milo?
Paresh Shah: Absolutely.
Howard Farran: Do they grow corn that far north?
Paresh Shah: Canola, corn, sunflowers, potato farms. They are all outside.
Howard Farran: Is it true the sunflowers in the morning are facing the rising sun and their head turns all day long?
Paresh Shah: They do. They do turn.
Howard Farran: That is truly amazing. It is a real honor to have you on here today. You have done so much in your career. Tell us what you are going to talk to us about today for an hour.
Paresh Shah: I appreciate very much, Howard. I have always wanted to be involved with you in Dental Town. Essentially my topic that I wanted to talk about is interdisciplinary and how an average restorative dentist can kind of evolve from going from a tooth by tooth dentist who just does reparative work to actually doing comprehensive care in your practice. It is not something we generally are taught well in school. There is just not enough time as you know. And so there is an evolution of that. I thought I would just maybe have some discussions with you about that topic and how people can kind of change the way they practice.
Howard Farran: I am sorry for my poor ____ there are nine specialties according to the American Dental Association and the only acronym I can think of for them taking the first letter for each one is POPE POO DO. So what you are talking about is how you work with POPE POO DO, nine different specialists. I have – and the latest one was the maxillo and oral facial radiology, which I believe only became a specialty because of CBCT 3D X-Rays. I cannot believe when I am reading a CBCT. I mean I dissected a dozen people and heads in dental school and I am looking at those CBCTs and oh my gosh I don’t know half of what I am looking at and I had to get a guy, Dale Miles who is a board certified maxillo-facial radiology and upload them to him and I want him just to read him because I mean half the time I don’t even know what I’m looking at.
Paresh Shah: I’m exactly the same way. So the first thing the guys are going to call you on on this is going to be the economy has been horrible since 2008. Nobody can afford this quadrant dentistry or full mouth dentistry. I am in Salina, Kansas, sorry Paresh, but I can only fix the tooth that is hurting them today.
Paresh Shah: For sure. It is the same situation here. Winnipeg is a place about 750,000 people. It is a wonderful place, but it is very hard to have a boutique practice here. It is not like living in Toronto or Chicago or LA where you can. And what I am trying to get at is in spite of – I’m not saying that all I am doing is full mouth rehabilitation. What I am saying is as I am looking at a patient I am looking at them globally. I am not just focusing on one tooth. Just asking the right questions. Well, why did that tooth break? Why are there carries? Why are there periodontal breakdown? From there making sure that we have covered all of the bases. Don’t get me wrong, a lot of my work is still – the majority of my income still comes from doing single crowns and lots of restorative. But I want to be able to not paint patients into a corner just by doing a little bit and fixing up that cusp and finding out it has been creating wear because the tooth is out of position. I want to at least have that discussion with them and inform the patients that look you have some bigger issues and we can help you with that. Let’s get you stable. Let’s get you comfortable and then over time we can make it fit in your life kind of like how Paul Homily[ph] talks. Just figuring out a way to fit things into a person’s life.
Howard Farran: So walk us through the logistics of your thinking and how you do it. I call you up. A friend of mine referred me to you. You have an amazing reputation what is my first visit? Is it a new patient cleaning or it is a new patient – do I get to meet you? Is it X-rays?
Paresh Shah: Typically I like to – I ideally like to have what is called a comprehensive exam. We would ideally book a patient for about an hour and a half. There they will meet pretty well our entire team. Quite often a little counter intuitive, but they will probably meet our hygienist first after our treatment coordinator, go through their health history any relevant history that they will have that they want to share with us. Dental and personal and health related. We will start with a basic set of radiographs, but not a full mouth series just yet. And we will go through – the hygienists I have worked with them very diligently and all three of my hygienists they will do a complete periodontal exam. So not just periodontal measurements, but bleeding scores, plaque scores, mobility, furcations, everything. They will also take a series of photographs as well intraoral and extra oral photographs. When I come in there they will have that information there. They will already be talking to the patients a little bit about it. If there is time you know how most patients come in and go look. I need to have my teeth cleaned. That is why we book enough time. Because for the majority of them we can at least get something started in terms of scaling and root planning. But we want to be sure that we give them at least a diagnosis for whatever dental condition they have and their periodontal condition. And once we have created that diagnosis I find that we have engaged them now. They have seen some of the records that we have shown them. They have seen the periodontal chart. They have seen the bleeding score. It is very visual. Just like our periodontists will do. That is why it helps me communicate with them better because I have already got records that are very similar to what they take. That is kind of how that first appointment goes.
If it is a really complex case like yourself then what we are going to do is look, Howard, we need a little bit more time because of these complexities. I would like to bring you back and spend more time. I also need a full mouth series and here is why. And that is kind of how we start things.
Howard Farran: I can’t get the smile makeover until I lose all the fat in my face so you can see my teeth. I got to lose 50 pounds first.
Paresh Shah: I got a trainer that can help. No.
Howard Farran: So you talk about the interdisciplinary account. Do you work with all nine specialties? Do you share your records? Tell me about why interdisciplinary approach you are so passionate about?
Paresh Shah: Here is the thing.
Howard Farran: Another way to look at it – let me reverse the question – out of 150,000 dentists in the United States how many of them do you think use the interdisciplinary approach?
Paresh Shah: I don’ t think as many as we would like to think.
Howard Farran: Okay. So what is the inter disciplinary and how would you say you are doing the – what is the inter disciplinary approach and how are you doing it differently than some people you see that you would describe as not using the interdisciplinary approach?
Paresh Shah: One of my – I have numerous mentors and one of them that is a guy named Rick Roble. He is an orthodontist .I am not sure if you are familiar with hi from Arkansas. He actually wrote a book called interdisciplinary dental facial therapy. And my orthodontist buddy who is part of my study – our study club we run together –
Howard Farran: The Seattle Study Club.
Paresh Shah: Yea. I run a Seattle Study Club with my orthodontist friends. There is a difference – he distinguishes – Roble distinguishes between unidisciplinary, multidisciplinary and interdisciplinary. Uni being just basically looking at things in just one dimension. Not really taking into account that there are or even not even acknowledging that there are any specialties involved in the treatment. So you might look at a tooth. There is a fracture there. It is out of alignment. Put a veneer on and not even consider ortho and perio that might be required. Then there is multi-disciplinary where you have the different disciplines. You are aware of them, but you don’t communicate with one another. You just say okay send it off to the orthodontist and the periodontist. Do the grafting. Do the ortho. Bring the patient back and I will continue on. Then all of a sudden you still have recession. The teeth aren’t lined up properly, but you are going to correct it by placing veneers on it and be more invasive. Then there is interdisciplinary where you are actually – the specialists are actually on the same page as you. They understand the challenges you have and what you are trying to accomplish in terms of restorative. You understand what their strengths are in terms of ortho, perio, oral surgery, endo. And we are all communicating with one another. It has been very hard to try to get that together. I have a team of specialists I work with now. We talk regularly. We meet together. We will email certain images. My orthodontist will do a call like this on his secure website and he will have all of the images there and we can actually communicate with one another about it. It is taking it to another level.
The other issue is – okay, well as a young dentist when you get out you want to pay your bills. You want to just do dentistry. You almost feel invincible. Hey, I took that weekend course on veneers now let’s just do it. Or a weekend endo course and let’s just do it. But it is also understanding what your strengths and weaknesses are as you start to evolve as a dentist and your standard of care starts to improve. After a while I started realizing I know most things, but I can’t do everything perfectly. So why don’t I feed off the strengths that I have and get some people in who can provide their strengths better than me. I place dental implants, but I have a periodontist that works with me sometimes in my office actually. Her talent for some of these cases are so much better than mine in certain cases, why would I not use her.
Howard Farran: Is she using CBCT 3D radiograph and – does she make a surgical guided or not?
Paresh Shah: Yes. I will make it, but it won’t be milled guide. It will be a guide that I get my lab to make off of the mounted diagnostic wax up. Then we will sit together and I will discuss what I want to do restoratively. She will tell me what we can do surgically and then we pair the two together.
Howard Farran: Another thing I think about – you mentioned Paul Homole a few minutes ago.
Paresh Shah: I’ve read some of his book. I have listened to him as well.
Howard Farran: For those of you who don’t know Paul Homole, Paul Homole what was he from South Carolina?
Paresh Shah: Yes.
Howard Farran: And this guy was selling $50,000 full mouth implant reconstructions back before anybody knew what they were. He was so far early in implants using blades. The one thing that really hurts the consumers the most is we talk about Paul Homole presenting cases. If you don’t understand perio like a periodontist you don’t have the passion to even sell the case. You only know what you know. You know some of your unknowns. Maybe you don’t know calculus or trigonometry, but you will never know your unknown unknowns. The case in point is this in my 27 years in practice I have seen a couple of really bad orthodontic surgery cases gone wrong and the thing that bothers me the most is this person was getting their teeth cleaned every six months from age five, six, seven, eight, nine, 10 at a dentist and he just watched his whole face to where – it all could have been so easily intercepted. If he had an interdisciplinary approach or if he realized I don’t do ortho. Well, if you don’t do ortho there should be some time frames where this kid should have an orthodontic consult. And the other thing is the lowest cost education in the world. I mean besides this free podcast and the Dental Town message boards and everything on Dental Town is pretty much free, what I don’t understand about dentist free education is don’t fly clear across Canada or the United States, fly in a jet, stay in a hotel and drop $3 or $4,000 when all they had to do was walk across the street and spend the day with their periodontist or their endodontist or their oral surgeon. It is like why did you have to go to the Mish Institute of Implantology in Pittsburgh, when you live in Nevada when if you just want to ask your oral surgeon or periodontist can I watch you place implants and can we be interdisciplinary. I think they think in fear and scarcity oh the oral surgeon isn’t going to be nice to me because he thinks I am going to pull out my wisdom tooth. And the orthodontist isn’t going to teach me anything because he thinks – successful specialists don’t think in fear and scarcity. They think in hope, growth and abundancy and want to share everything with you.
Paresh Shah: It’s interesting, one of the keys in something like this and changing the style of your practice is finding mentors. Not just from books and not just necessarily dentistry, but also from the business side as well. When I first – I am going to digress just a little if you don’t mind – when I first – 10 to 12 years ago I wanted to change the way I practiced and do a little more cosmetics and just to have more fun with dentistry rather than just patching up fillings. And there was a dentist in the city that had a reputation for doing nice aesthetic work. I didn’t know him from a hole in the ground. I just called him up one day, introduced myself and said hey, can I take you out for lunch. And he is like sure. We met and I said look, I know you have done a lot of things with your practice in terms of marketing and courses and I want to do the same. He was just – he opened up. He was so good. The same thing with some of the courses I have taken over the years. You probably know Paul Belvedere from Minnesota. I mean he is one of my mentors. Now he is retired, but we still meet once a year and fish. John Cois and like I said David Sarber and Vince Colcich before he passed away. All of these people they are great people.
What I –
Howard Farran: And to throw you under a bridge if you are the same age as me what would you say to a young dentist who just opened his practice in Manitoba and wanted to call you? How would you take that call?
Paresh Shah: I always mentor kids. I run two study clubs in the city. One with a group of our colleagues like yourself and my orthodontist buddy and I just started a branch of our Seattle Study Club where they are young dentists between one and three years out of school and we are starting it in September. We have already introduced and we got 18 people. We are just charging for the meals and nothing else. We are just putting five meetings a week for the next two years and we want to teach them about diagnosis and treatment planning. So we do that. Having said that I 100% agree with you. You need to find specialists that are open to mentoring. Not putting their hand on your hand and saying look you shouldn’t do this. You need to send this to me. Instead say look come on in. Let me teach you how to diagnose and do this stuff and look for red flags. You do what you feel is comfortable and you know through that if you develop a rapport they are going to get the big stuff. You know, if you want to do a class one crowding case that is fine. But my orthodontist friend knows that he is going to get some of the fun cases out of it.
Howard Farran: I got to tell you a story of one of my best friends. I don’t want to say his name because it might get back to Craig Stiken and he might get mad at me. He decided he wanted to do ortho. And he went through some ortho programs and he started doing all of these orthos. He got about two years into it and realized that every time he is doing ortho which is he was doing crown and bridge and fillings and restorations and he is not an orthodontist and all that kind of stuff. When he was asking for help all of the orthodontists pretty much shut him down. You are doing ortho that is your problem. One of them was like if you have a problem call me. One day Stiken went over there and said can I give you all of my ortho cases and transfer the whole damn thing? And I swear to god if you take these I will give you all of my ortho for the rest of my life and everything. The orthodontist made bank on this for being open.
I want to say one more thing about the interdisciplinary approach. In my own personal life a lot of them became actually life coaches. You know, like a couple of these guys convinced me you need to get on a bicycle. You need to start running. You need to go to Lifetime and swim. They would meet me there. So you start off in dentistry and the next thing you know you are biking, swimming and running and they cut my blood pressure from 145/95 to 90/60 and my cholesterol – they doubled my HDL. They can become life coaches.
Paresh Shah: Listen, I have that part-time endodontist that comes to my office. His name is Rodrigo Kunya. He teaches at the school full-time. About six weeks ago he came in and he looked at me and he goes you look really stressed out. What is going on? I go well what about you. Even in the morning. He said I just went for a swim. I got up at 5:30 went for a swim. You are going to come with me next week. Now we go swimming. I feel a lot better. I get up early in the morning. I meet him two or three times a week. And we go swimming.
Howard Farran: Then you don’t have to take a bath for three days. That is what I love about swimming.
Paresh Shah: You don’t have to worry about the chlorine count.
Howard Farran: Chlorine has a post biostatic property. Yea, so what else do you want to say about interdisciplinary dentistry?
Paresh Shah: I think it is very scary for young kids, young dentists and even experienced dentists to give up what they are doing. You are always looking at the bottom line. You are looking at production. I don’t think you realize that if you set your practice up in such a way to be successful just by being able to provide the best quality care and working with the right specialists to help you in the areas that you know they are going to be better at, but you just don’t want to give it up. You can spend more time focusing on the things you are good at. It is a matter of just realizing that. It is not a complicated formula, but you get so caught up. Oh yea, I got to have my schedule full so I got to do that endo. And you spend three hours doing it. Sure. You bill $800 for it, but if you really look at the bottom line you could have done a lot more. You could have done a quadrant of fillings in that time in half the time.
Howard Farran: You got to ask yourself if the orthodontist is doing an ortho check in 10 minutes and you are scheduling yours for an hour or 30 minutes how is this working?
Paresh Shah: Same thing with wisdom teeth. You can get the four wisdom teeth out and they are impacted, but if it takes an hour and a half and you know a surgeon is going to do it in 20 minutes once they are sedated are you being fair to the patient after? Part of it is an altruistic thing.
Howard Farran: Extremism a lot of people are buying a yes, no, right, left, black, white. If you don’t know any of your discipline then you see a kid every six months that you didn’t recognize his face is going to fall apart. Then when they are 25 they are going to need orthognathic surgery and big surgeries things go wrong. The truth of the matter is I own a publication, Dental Town. According to the filed reports there are 40,000 publications that go to doctors in healthcare every month. So you are not going to know – you can’t learn it all. You can’t learn nine specialties. In fact, every single specialist will tell you they can’t even learn everything in their specialty. If you are telling me you are doctor centered instead of patient centered would you have to be into interdisciplinary if you are patient centered? If it is about the patient you can only be interdisciplinary.
Paresh Shah: Absolutely. One of the ways that I have been able to learn more about it – part of it just comes from internally just being motivated to want to be patient centered. But it is the types of courses and the types of programs and the people that I tend to gravitate towards. Being introduced to the Seattle Study Club network was one of the life changing things as well about eight years ago.
Howard Farran: Explain that to our peers the Seattle Study Club. I bet you half of them have never heard of it.
Paresh Shah: Well, the person who founded the Seattle Study Club is a periodontist by the name of Michael Cohen from Seattle. The concept of the Seattle Study Club is about comprehensive diagnose treatment planning and treatment in an interdisciplinary fashion. One of their slogans is a university without laws. There are two main things – there is about 250, 260 study clubs around the world. The majority of them in the United States. Probably eight or 10 in Canada and some in Australia and Europe and Asia. They run typically all but about 10 of us are actual specialists. And then we will have an advisory board. I am one of the rare general practitioners that is a co-director with my orthodontist buddy. We have a group of specialists that are a part of it. Endo, oral surgery, perio, restorative. I serve as a restorative advisor. And then we have other dentists with us. Anywhere from about three years out to 35, 40 years out. We meet – we have a curriculum starting in September going to May and we usually meet one evening a month – once a month. There is three times a year where our study club has a full day speaker. Our evening sessions are typically treatment planning sessions. But in our treatment planning sessions we ask everyone to bring full documented records; X-rays, conebeams, models that are mounted like everything. So when we are sitting at a round table we try our best – the first couple of years it was more threatening. Now we finally diffused that to the point where we are colleagues. We have to be non-threatening. Let’s discuss treatment. Sometimes it is just a localized area. That is fine. Everyone looks at things a little different. We can get a perio consult, we can get an endo consult. We can get a restorative consult. And we discuss treatments like that.
Howard Farran: So how do you make it less threatening for them? Because most dentists they don’t want to show their models because they think there is a bubble on it. They don’t want to show their diagnosis because they think they missed something. So how did you make it less threatening? And how big is this group?
Paresh Shah: Our study club has about 30. Some of the study clubs out there they will arrange anywhere from probably 17 to 20 up to like 40. We have been running ours for 10 years and six years as a Seattle Study Club.
Howard Farran: How did you build the love, trust and respect to make it non-threatening where I am not going to be the dumb guy in the room?
Paresh Shah: After a while you got to just lay the law down and go look guys. I’m sorry, if you can’t work this way this isn’t the place for you. We are here to work with one another. We are here to learn from one another. Share with one another and to help our patients. If you are just coming in to just chastise people this isn’t the fit for you. I am pretty blunt when it comes to that.
Howard Farran: Have you had a few of those – on Dental Town we call them cyber bullies and we ban them. Have you had a couple of those over the years where you have had to say you know what this isn’t really the place for you?
Paresh Shah: They realized the value and they got rid of that attitude. It has been far more approachable. That is great because everyone benefits from that. Because when we are talking also when we are discussing treatment or discussing a new procedure we also bring in some new literature with it. Like it is not just oh I tried this how many times it works for me. The group is set up in such a way that a lot of them are specialists that you have to be able to talk about some science behind why you are choosing something. We learn that we elevate each other’s knowledge base.
Howard Farran: I am going to throw you a question that I get all the time. I am in a half dozen dental schools a year and these kids come out of school and they go okay there are nine specialties. And a SERAX[ph] 100 grand, a CBCT is 100 grand it would take me a lot of time – I can’t get good at endo, placing implants, perio, I can’t be a cosmetic spa dentist, master veneers. Five thousand graduates a year I am at a school five years or less. What should I learn first?
Paresh Shah: You know what I tell them and for some people they look at me and roll their eyes, but I think you should learn a good way to diagnose and treatment plan and learn occlusion as well. I don’t think people understand that. I think if you can learn that you can do almost anything. It is very easy to go and learn. If you want to do almost a commodity type thing you can go take some endo courses or take a continuum from someone and learn how to do that and do that well. But a lot of young dentists will go well, I want to place implants because I know I can bill a lot. I go well, that’s fine. If you just take a one day course or sit in a surgeon’s office and learn how to place them do you know how to diagnose and treatment plan? When to put it in, when not to put it and pick the right spot. And I think if you learn the other way you are going to be better.
So I recommend taking more comprehensive courses. I did a poll continuum through the University of Minnesota and University of Buffalo. It was a three to five year journey where you take a series of modules and you learn occlusion, you learn different disciplines. And then you also get to treat patients. It is a phenomenal program. I did an aesthetic certificate from there, but it is a misnomer because you learn about all different types of dentistry. Then I have also – I did the continuum at Mish’s. I finished John Coise’s entire continuum and I have a new associate that is going to start with me in October. I told her before you start with me in that first year you have to go and take John’s first treatment planning and occlusion course. You have to. I am going to contribute to that the cost of that because I want you to start learning how to look at things globally.
Howard Farran: Now you are making me feel old because when I saw Cois he was still with Frank Spear, just like when I saw Cliff Reynold he was still with Buchanan. I am going to tell everyone why Carl Mish probably became one of the greatest implantologists of all time. It is exactly what you said he started as a prosthodontist. He was noticing these other people that were putting lower dentures, snapping onto implants. But the implants were snapping at the gum line. And Carl though that titanium implant doesn’t snap at the gum line if you – if we have balanced forces here. You just can’t force forces. It is funny how the guy who learned how to make removable first and established occlusion could build a great denture has learned how to make the greatest amount of implant supported dentures known. And wrote a book that has been updated six times on it. You need more than one tool in your tackle box to be a great dentist. And you are saying start with comprehensive treatment planning with all nine specialties and pick up occlusion in first two.
Paresh Shah: Absolutely. There are some great programs. As you know you have the Clois program. You got Panke. You got Spear. You got Dawson. It is like doing a little specialty or mini residency in everything over a period of time. Through that, as you were eluding to power is all of a sudden you start meeting other specialists. And you start creating – finding mentors and also being mentors. And it is just a wonderful –
Howard Farran: And the best way to learn a relationship with your mentor is you should always have mentors but always be protégés. This goes back to when you were a little kid and you were always following your big sister’s advice of next year I start kindergarten and what is it going to be like in first grade and what is it going to be like in high school. Then you turn around to your lower sibling and you were coaching them on what to expect in kindergarten and first grade and grammar school and high school.
Paresh Shah: You were suggesting about approaching specialists in your city. Well, as I said I have a part-time perio and a part-time endo that is out of my office so this new associate she actually came in yesterday and spent the entire morning with the endodontist. Because she is going to be doing some endo. I said look, why don’t you come and spend a few hours with him and he will teach you a few things about access and how to use the equipment that I have. And none of the people that I have developed a rapport with in my area that are specialists refuse any of that. Even the oral surgeon will go look come on down. I will bring your associate in and she can spend a day or two and I will just show them how to take teeth out properly. Because they know they are going to get referrals.
Howard Farran: Another question that people get confused when they go to Panke or they hear about Cois and Spear and all that other stuff – specifics. I mean do you take full mouth study models on every new patient? I mean what if it was a two year old? Ten year old? Nine year old? So go through that.
Paresh Shah: After a while you learn where you need that and where you don’t. Say 80% of my practice is still single tooth dentistry. It is not that I don’t talk about the other things or make people aware of it. I think it is an obligation. Like John Cois talks about his risk assessment. And it is basically explaining the risk of the situation and the condition that they have and trying to give them a prognosis for the work. If the tooth is broken off at the gum line a bicuspid and they will ask you questions. They will say what can I do. I would like to keep the tooth. Okay, well you need crown lengthening, you need a root canal electively even though it hasn’t broken into a pulp. We need to put a post and a core here is the cost. What are my other options? Well, we can take it out. The other teeth are perfectly fine. We could put a dental implant. Here is the cost. Well what is the long-term prognosis of that tooth after you have done the root canal and the crown gum surgery that you are talking about? Well it is not going to be very high. We know that. As long as we explain that to them it creates a perspective for them. Well look if you are saying it has only got like a 50/50 chance but if I take it out and I put the implant I got a much better chance. I might have to redo a crown, but the implant is going to be there because I am a non-smoker. Yea, I am going to go for the implant.
Howard Farran: If I was your patient. I am 52 next week. I busted off my upper right canine number two and number six what would the odds of a crown lengthening, elective endo, post core and a BFM on six versus extracting it and doing an implant?
Paresh Shah: If you still have a favorable crown to rubrate[ph] there is no reason why you can’t have that five plus years. You have an unfavorable one normally I just recommend taking it out. I mean if you are going to have less than a one to one crown to root ratio and you have gone through all of that work generally what I do in my practice is I would like to look the patient in the eyes and say look, I can get you at least five years on something do you see value in that? On a complex situation like that. And if I can’t get you five or 10 years out of it then is it really worth it for you?
Howard Farran: I am having a soul searching problem in my practice right now. I am in Phoenix so lots of people they say last year 10% of all the homes bought in Phoenix were Canadians. Did you know that?
Paresh Shah: I didn’t know it was last high.
Howard Farran: Ten percent. In my neighborhood the Americans only put up their flag on labor day or 4th of July the Canadians have them all the time for social benefits. Hey, one of us is over here. So there is a lot of retirement people. Especially from the northern Midwest. North and South Dakota, Iowa, Kansas and gosh, I have been doing this 27 years. I have a lot of patients in nursing homes. It seems like when they get to nursing homes root surface decay is just a plague. And I go look at my patients and where I place an implant and a crown or an implant and a removable they are perfect and we already did some of the most exquisite dentistry; root canals, build up the crowns, whatever it is all just bombed with root surface decay. Is that something to play with your mind and by the way in a nursing home this doesn’t apply to men because they average man in America lives to be 74. The average woman is almost 80. If you go into a nursing home I swear there is 100 women and only one man named Lucky.
If your mom was 70 years old. Your mom had number three she had a big MOD amalgam or PFM or whatever and it was – and it needed a complete root canal build up of crown and she was 70. Would you give your mother a root canal, build up and crown or would you extract it and do an implant and crown? Because you are thinking I bet when she is 85 she might be in a nursing home with rheumatism, not being able to hold the brush, not enough dexterity to floss. And the nursing home you go into the cafeteria all the food is macaroni and cheese and cottage cheese it is a carb fest.
Paresh Shah: Absolutely. Let me answer that about my father. My dad is 80. At 76 he fractured his K9 tooth number 11 – in ours it is 23. He needed exactly that. He had that happen in the Dominican. He came back and I actually sent him to my oral surgeon and I said Mark, you are going to take this out and you are going to put an implant in and he did. It was for that reason.
Howard Farran: Our entire profession is still built on the fact that your dad was born without streptococcus mutans, without ____ without Herpes Simplex 1, without HPV and then somebody kissed that baby on the mouth, gave them streptococcus mutans and as he gets older and his mouth dries up and the medication dries him up his defense goes down and streptococcus mutans goes crazy on senior citizens. I am almost wondering when – and now I am starting to see in Phoenix the endodontists are all now starting to get CBCTs. And now they are starting to look at a ____ and say either A. that tooth is cracked so it just needs to come out and I am going to extract it and put in an implant. I am really struggling with doing endo and crowns on women over 65.
Paresh Shah: People still want to keep their teeth and that is one of –
Howard Farran: That was the perfect call. If I was your dad since I am messed up in the head because I am a dentist I would emotionally say no, that’s my tooth. You are not pulling my tooth. It would be an emotional bad decision.
Paresh Shah: Part of the reason that I have trained my hygienists in what we do in our practice is I have a pretty comprehensive periodontal program. When I say that I am not talking about a soft tissue thing. I do that – all our new patients and all of our existing patients at least once a year all adults will have a full periodontal assessment. Okay? Once we do that we re-check even if they are coming in annually and give a periodontal diagnosis. You know, case type one, two, three, four based on AP classification, American Academy of Perio. And if their bleeding score goes up over 20% we actually show them that. They can see it on Dentrix. All of the bleeding spots and obviously, you are not looking after things well. What is the risk? The risk is cavities. So now we are going to bring you back in six weeks. You got to clean this up otherwise you are going to go see our periodontist and get more treatment done.
Whether the patient is 70 years old or 27 years old we do that on every patient. It allows us one extra measurement of evaluating whether a tooth is going to survive well or not. We tie that in along with carries like looking at the risk of carries as you said and root decay. I give them the whole picture. I give them a restorative diagnosis and I give them periodontal diagnosis. It is a game. Look at all the structure and look at function, look at perio, look at aesthetics all of those four things. When you do that it at least gives the patient a full picture and not just a partial picture. The tooth broke. Can you fix it? Well, yea. I can fix it but you got a 9mm pocket there. It is not worth fixing. I can put an implant in there, maybe graft that area and you will have something that will last. We can do a bridge it will look nicer.
Howard Farran: You have been around the block several times so we talked about the pitfalls of a root canal built up crown on a 75 year old versus an implant and a crown. I want to carry those thoughts into periodontal surgery. What are you thinking when tooth number 3 a maxillary first molar have furcation involvement and trifurcation and the options are 25 years ago the only option was flat perio surgery now there is extraction implant how does Paresh’s mind wrap around this?
Paresh Shah: If it is a – I know now, maybe I am a little more of a geek if you will because I spend time reading going to some specialty meetings as well with my specialists, but they come to restorative meetings with me. That is how we learn to be on the same page not just through the study club. I know if we got a class 2 or class 3 furcation that the long-term prognosis is going to be fair to guarded. If you have something like that I will tell a patient look you will see my periodontist –
Howard Farran: Explain to the listeners the difference between class 2 and class 3. Some might not understand what you just said.
Paresh Shah: Well, when you got a furcation in between the roots and you got bone loss in there a class 2 furcation you can get – it is called a neighbor’s probe that is a periodontal probe. It has got a hook on it and has different measurements. A class 3 you can basically get that probe – the bone loss is through and through basically from the buckle to lingual.
Howard Farran: So three would be all the way across. All the way through.
Paresh Shah: Yea. And then a 2 would be halfway through. The 1 would be you can just get your probe or the measurement just getting into the furcation. I will tell patients look it is like you have the roots here and you got bone loss here. If you get a cavity in that spot you can’t treat it. So you really have – I need to see you every four months rather than every six months because the literature shows that we can at least help you try to maintain that a little better seeing you at shorter intervals because you are going to build up plaque and bacteria around there. The longer you wait the higher the chance it can get worse or you can get decay. So we will bring you in a little bit sooner to keep that area clean. The other thing is if you are seeing constant inflammation we have a measurement of that and we can see the bleeding score. I will get my periodontist to look at it and they may consider doing a flap in that area and cleaning it up. Then they will say look the prognosis is poor. Let’s take it out while you still have bone. Let’s put an implant in here.
Howard Farran: And are they usually doing the extraction in place of the implant at the same time or not?
Paresh Shah: It depends on the clinical skill of the specialist. Some of it – for me I am not as confident doing an immediate extraction in a molar area. I am in other areas, but I have one surgeon that he has done 10s of thousands of them not a problem for him. He will be able to take it out. Get it in there. I got a periodontist that can do that as well.
Howard Farran: What should the dentist be thinking about immediately if they had gum disease and a cavity? Maybe they had an endodontic abscess or a perio ____ how do those three things affect your comprehensive treatment planning n the placement of an implant?
Paresh Shah: A lot of times I will tell them what we are probably going to want to do is just get the tooth out, clean up that infection. Now if there is not active puss coming out of there some of the literature shows you can clean it up and actually graft that site right away. I wouldn’t be placing an implant personally in that area just yet.
Howard Farran: And what are your thoughts about immediate loading or waiting to load?
Paresh Shah: If we can get the right amount of stability then I will do that. In fact, we just did a full arch case this week and the periodontist took out a bunch of teeth that the bridgework on the lady was breaking down. But good, solid bone. So she took out the 11 teeth and put in eight implants because she wants a fixed prosthesis crown and bridge. I ended up taking the four most stable implants cross art stabilization and gave her a fixed denture right now for the next four months until everything stabilizes. Now the literature does show that you can do things like that as long as you got good primary stability, good bone and health.
Howard Farran: We are three fourths done – we are 45 minutes. We only have 15 minutes left of your outstanding podcast. What do you want to talk about this last 15 minutes?
Paresh Shah: There is a young dentist that had just graduated from our dental school and just moved to another province and she was emailing me a couple of weeks ago just talking about I want to do cosmetics. I want to go to AACD and I want to do this and that. I said well, why do you want to do some of these things that’s great. It is a wonderful conference and you are going to learn some things. She goes I just want to be a better dentist. I said you know what? I think one of the things that you should consider doing is joining a study club that has a variety of disciplines in there and start learning from them. Use them as mentors and they will teach you. Yes, part of it is going to be maybe learning how to refer and there is a business component to all of that stuff. Not in our study club because I am a general practitioner. I am not looking for referrals. It kind of is disarming to some extent. I actually connected her with perio and prosthodontist out there. Just about an hour before I got on the podcast with you.
I think it is important for these young dentists to make these connections that you suggested. Go and meet an orthodontist. Go and meet a periodontist. Go and meet an endodontist. Start learning from them saying I want to work together. I want to do some of the stuff, but I want to send stuff to you. Find a study club. A good interdisciplinary study club. There is probably Spear study clubs and Cois study clubs. Of course I am very partial to the Seattle study clubs. And they are around all over the place.
Howard Farran: I call that the difference between being street smart and book smart. Book smart person will drop five grand to go learn three things 1,000 miles away from home. The street smart person can go do that at McDonalds over lunch or picking up a foot long Subway sandwich and splitting it. I want to tell you in Phoenix, Arizona, the most successful endodontist hands down is Brad Geddleman. He has an open door policy any dentist in town can just walk over to his office. It is like watching Mozart play the piano. And the whole time he is doing these amazing root canals he is just talking to you like you are both just sitting there at Arby’s having a roast beef sandwich. He is talking and you are learning all that over the shoulder program and all it will cost you is $3.00 in gas to drive over to Glendale.
Paresh Shah: That is because he loves what he does. Right? That is the same with me. I have no problems with people coming in. I mean – it is interesting now that over the last five or seven years as I am lecturing more I will get people that will email me. I am not about to start giving them a diagnosis for their problem. I will continue to ask them questions to stimulate their thinking. But I’m more than welcome if they want to come to this office and sit with me and spend a day or two with me and follow me and my staff and learn things. Because I know that I am going to learn something from them as well. It is a two way street.
Howard Farran: Dr. Shah, I want to throw a problem at you. I hear this all day every day all day long. As you know, the United States economy tanked in 2008 and here it is 2014 and it is still flat, anemic. Half of America lives in 117 towns where 2/3 of the dentists. And the other half of America lives in 19,022 towns where only 1/3 of the dentists are. There are thousands of dentists who will say to me, Paresh, my town the big factories left. Five years ago we had 6,000 people. Now we have 5,000 people. My city is flat. My country is flat. I am not going anywhere. I’m starting to get burned out. I am starting to not like my job. My brother – I’m burned out. My town is going nowhere. My economy is going nowhere. My practice is going nowhere. What would you tell that dentist?
Paresh Shah: Here is one thing – I hope I haven’t portrayed this the whole thing is about doing full mouth rehab. What I am talking about is looking at things in a comprehensive manner. If you are in a small town and you are isolated by yourself you have got Dental Town chat lines. You have got study clubs that are online like Spear and now Cois will be doing that. Things like that where you don’t necessarily have to be isolated and there will be people that you can communicate with.
When I am looking at building relationships with your patients and understanding all of the disciplines it allows you to be able to set the patient up for treatment at their own pace. If they need a lot of work and if you understand occlusion and you can manage it wither it is by doing orthodontics or by taking certain teeth out that are tipped just to manage and get the spaces right and the eocclusion right what happens after that? You got tooth to tooth dentistry. Right? You got everything all nice and stable and now you can break it down into quadrants or even to sextons or even tooth by tooth. And it is understanding those concepts and understanding what you can bring in to get that person to that point and explaining it to them properly. Now all of a sudden I got a patient – I have lots of patients that I am doing full mouth rehab. But you know what? I’m doing it over six or seven years because they don’t have – they don’t even have 10 grand a year to drop down. They might have three or four.
Howard Farran: More specifically, you got a glimmer in your eye. You are tall dark and handsome. You are passionate. You just love this stuff. What do you say to that burned out guy in Salina, Kansas who is sick of the Republicans and the Democrats. He is sick of the economy. He is sick of everything. His town has dropped 15% in population. He is just burned out. He is not smiling and talking with passion, with a sparkle in his eye like you. What would you tell that guy?
Paresh Shah: I think they got to look inside of their practice, look inside of themselves and say look, first of all one simple thing is what do I not like doing? What just gives me anxiety when I walk in? And get rid of that. You got to start enjoying it. If you don’t have the passion and you don’t enjoy it patients know that as well.
Howard Farran: I assume you are talking about all pediatric dentistry.
Paresh Shah: Yea.
Howard Farran: When I have a three year old kid crying I would rather be a newspaper delivery man for a $1.00 an hour.
Paresh Shah: I am the same way. That is why I don’t do endo anymore because I kept doing it was like you know what it gives me anxiety. I don’t mind placing a dental implant but I don’t want to do an endo and I don’t want a screaming kid. I just had a three year old the other day he was a gem. If I had a thousand of them that just sat there and laughed with me it would be fine. But 900 of them are squirmish. I don’t want to do that. You have to get that passion back and I went through that. Eight years out of school I didn’t like what I was doing. That was where I met Belvedere and a few of these others. And they put that sparkle in my eye.
Howard Farran: Talk about that metamorphis. So eight years ago you didn’t have this sparkle and passion in your eye?
Paresh Shah: Eight years out of school and I am starting on 24 now and I just didn’t like it. And all of a sudden someone introduced me like I am trying to introduce people to all of these different courses. To the University of Minnesota there was a post grad aesthetic program. I went there. It was four weekends. It was about 30 hours each weekend. I met some amazing people. Probably some of your friends as well who were there. They are teaching all sorts of different things about dentistry. But the interaction that you would have one on one it is like meeting Howard Frann and having a beer afterwards or a wine and just talking about your trials and tribulations. Say Paresh, I have gone through it. Don’t worry about it. It is good. And get rid of that crap because if it is not making you happy get rid of it. And just learning how to do dentistry well. And learning the stuff that you enjoy learning how to do it really, really well and having someone that you can email or pick up the phone and go look, I’m having trouble with this. You showed me how to do that. Can you go through that again? That is the value of that type of learning. You need that in your city and you need that outside as well to keep things in balance. And that is what happened to me. I had this epiphany because I met these people and all of a sudden I am in a room with 35 other people that are like-minded from Kansas and from New York and from Fargo and Winnipeg. All of a sudden we are like jesus. You have the same problem I do. I’m not a lone. And sometimes you got to –
Howard Farran: You are just lucky the dentists from Fargo didn’t stick you in a meat grinder.
Paresh Shah: Absolutely. Sometimes – some of the people that drag you down even in your own town you just got to cut loose.
Howard Farran: For our viewers around the world who didn’t understand that inside joke one of the all-time cult movies of America one of my top 10 favorites called Fargo and the last scene they stick a person in a – it was a woodchipper. God, I love that movie. What I love most about that movie is the accents. I can’t believe you have been on here for 52 minutes and you haven’t said eh one time. What’s with that? Are you really not a Canadian?
Paresh Shah: I am. I am. All my friends keep bugging me about saying eh all the time, but I guess I –
Howard Farran: You haven’t said it one time. I have been waiting for it for 53 minutes. I haven’t heard it once. Just say it for the viewers so they know what it sounds like.
Paresh Shah: Hey, take off eh. Take off you hoser.
Howard Farran: There you go. And why do you do dentistry in Canada when all the teeth will be lost from hockey pucks anyways?
Paresh Shah: You know what I just love – that’s a good one. Because at some point in time I will be able to replace more implants or restore more implants.
Howard Farran: We got a professional hockey team in Phoenix called The Coyotes.
Paresh Shah: That’s our team you took.
Howard Farran: Yea. Sorry about that. It was good for us, but my gosh it is so funny – if you stay home and watch it on TV when they are panning the hockey players before the game they take out their partials and they are all sitting there and they are all missing at least half of their front teeth. Is that a fact?
Paresh Shah: It’s true. It’s true. That’s why a lot of them will avoid – now with dental implants you can maybe put the implant in but don’t restore it right away just to preserve bone and everything.
Howard Farran: I want to ask you another thing I just keep throwing questions at you. Feel free to take it any direction you want. You don’t have to sit here and answer my questions. What do you say to a dentist who wants to start placing implants and he sees there is a closed system where Serona has a CVCT integrated with Galileos?
Paresh Shah: I have an E4D.
Howard Farran: Okay. And then the open system E4D which can work with 3M and all different kinds. So you are E4D. Why did you go with the E4D open platform as opposed – which is more like Microsoft or Google as opposed to the Serona CAD Galileos which is more like an Apple deal that only plays with Apple?
Paresh Shah: My initial thing I will tell you the truth my initial purchase which was four and a half years ago, which was based on who I wanted to get support from locally. I had a really good relationship with the Shine people and that was my main thing. Which is not always a sound business decision. Now when someone is coming in and asking well what should I do now I honestly feel that you should look in an open system. Whether it is – I am partial obviously to now it is called PlanScan or Nevo, but Three Shape has a fantastic scanner. 3M just launched their new scanner just a month ago. They are all really good open scanners. And so it allows you the freedom to do your dentistry in house if you want to, but you also have the freedom of using any lab in the world. And I know Serona is a wonderful product. I have nothing bad to say about it, but it is a little more closed. You still have to use the Serik and Serona network while the other way I can send a case right now to any lab in the world. And I have done it to different labs.
Howard Farran: If you placed 100 implants how many of them would have a surgical guide?
Paresh Shah: I have probably done over 200. Pretty well I would say about 95% of them have, but I am a little fussy with that. Even if it is a single tooth I still do a little guide even if it is just a –
Howard Farran: What would you say to my best friend who has never used one and said yea, I’ve never used one. What would you say to a dentist who has never used a surgical guide and has done like 200 implants and you have?
Paresh Shah: You know what – part of it is obviously experienced in clinical skill. But I just want to take as much of the unknown out and try and have as predictable, restorative experience for the patient as possible. And using a surgical guide allows you to do that. A single tooth I am not necessarily doing a full on an articulator. I am getting my lab to wax up a tooth. I want to know the parameters of where I want that implant placed where the screw is going to come out or where the long ____ is going to be. And if it can’t work in that are I want either myself or the surgeon to graft and it gives us an indication of if we need to graft or not.
Howard Farran: Don’t you think it actually makes it easier to place the implant when you have a surgical guide?
Paresh Shah: Absolutely. Because all of a sudden you put a whole there and you go and this is it. And if you don’t like it and my surgeon always says can you give me a little leeway. I say yea, I can give you this much leeway, but if I give you more I don’t want the implant put in. That is the rule.
Howard Farran: I can sometimes understand why a general dentist might not want to use a surgical guide because he has to eat his own mistakes. But for a specialist. It is what? It is cost?
Paresh Shah: It is a cost issue too. It might cost $100 to make. There are simple ways to make it where it doesn’t cost a lot.
Howard Farran: Yea, but a specialist not using a surgical guide if he messed up just 5% of his implants, which would be a 95% success rate. That means 1 out of every 20 going out the door of the referring dentist that is paying his bills is not happy.
Paresh Shah: That is why I started placing implants and learning how to place implants because I had a few from specialists I didn’t get my guide back and I can’t use the implants. They are buried because they weren’t put in the right spot.
Howard Farran: I’ve only got two minutes left with you. I want you to go for a close and my question is going to be what if I am listening to you and I want to contact you? Are you available? Can I email you? Are you –
Paresh Shah: Yes. I am available. DrPareshShah.com. My email I think you are going to put it up I’m not sure. Yea, I got an email Shahp@mymts.net. And my phone number is 204-837-4517. If you google Dr. Paresh Shah dentist you can find me now.
Howard Farran: And will we see you on Dental Town?
Paresh Shah: Yea. I have been always a little – I follow and I watch blogs and stuff. This is kind of weird. Here I am not shy talking to you and yet I have been shy to postings. I got to start doing that.
Howard Farran: Yea. I think you should do an online CE course for us.
Paresh Shah: I would love to do that. You just got to tell me what you would like and I would be happy to.
Howard Farran: The kids would love it, especially the ones that – 5,000 come out a year. So just 10 years out of school that is 50,000 dentists. They would love –
Paresh Shah: My daughter just started dental school.
Howard Farran: Good for you.
Paresh Shah: Six weeks ago at the University of the Pacific in San Francisco.
Howard Farran: I think you should start with a course on the principals of interdisciplinary dentistry.
Paresh Shah: Set it up and I will get it going.
Howard Farran: Alright. Show you an email and we’ll do it. Thank you so much for taking an hour out of your valuable time to talk to me. If you ever want to do this again, please let me know. It was an honor. Thank you so much Dr. Paresh Shah.
Paresh Shah: Howard, it was an absolute pleasure. I really look forward to meeting you in person and thank you so much.
Howard Farran: I am sure since you are a Canadian you will be retiring down in my neighborhood in 10 or 15 years anyways. We will eventually be neighbors.
Paresh Shah: If you got a lead on a place let me know.
Howard Farran: Thank you very much. Bye-bye.