The DIAGNOSIS behind Why patients say NO!

We usually talk about technical issues dealing with big cases but the first BIG problem is to make the patient accepts the treatment plan.
It’s not a mystery that in order to master these cases clinically speaking we need to master another art before …the art of communicating with patients.
If we don’t focus ourselves on mastering this skill, we will forever damned to listen a long serie of NO …
No I don’t want!
No I ve not the money!
No I am scared!
No, I don’t really need this!

and the maybe longer list of:

Thank you i will think about it
Thank you I will let you know.
Thank you I will discuss at home

The point is: what is your main thought when you listen to these answers? Cause here lies the genesis of your path to improvement in communication with patients.
Like in dentistry the first thing we have to understand is: DIAGNOSIS
Why they say no? what are their real motivations behind and are all the “NO “ equal or not ?
Here I will start discussing the several nuances of NO.
You have to become good in understanding these differences cause each one of these needs a different answer.
A first kind of NO is the fear of the customer of feeling “stupid “ accepting the treatment plan cause most patients know they have not sufficient data in order to evaluate and so, they re scared to be manipulated and to realize this just after.
A second kind of NO is the fear of other’s opinion. When people has to do an expensive work they also think they re going to spend a sum most of the people they know, friends or relatives, never spent. The fear to listen a friend asking: How much did you spend?!? all this money! are you insane?, or maybe the friend saying: my dentist would have done the same for half! Imagine also if the same may happen with your spouse or similar …
A third kind of NO is connected to fear of physical damage. This is quite understandable and poses many questions about finding a good balance between state of the art dentistry and dentistry patients can withstand.
A fourth kind of NO is the fear the proposed plan won’t work.
A fifth kind of NO is the economical fear of losing money.

Most of the people say they have no money because is an easy answer to close the discussion.
The reality behind instead is another one: or they are not patients interested in that treatment plan (useless to speak about esthetics to a patient not interested in esthetics for example) or they ve not been placed in the right scenario in order to understand the real value of our work.

People spend money when they feel the value, when they are not afraid to feel stupid (or at the opposite they think to raise their status like buying a rolex’s watch or a gucci’s bag) , when they feel it’s safe.

To make patient accepts is Not easy but, with the right answers, we can make this process much easier.

You have to find the right answer for each NO, you have to learn to diagnose which kind of NO you ‘re fighting with.

Being focused on technical issues in dentistry is not enough in order to thrive in the modern world and to learn these extra clinical skills will become always more important.

Cause dentistry nowadays is not only about teeth.

It’s much more.

The Journey and its lessons

It was 2001… freshly graduated with my excellent 110 cum laude I entered my  “family” office in my city of birth: Syracuse.

My father ran the studio in the “old way”, we didn’t work by appointment but by order of arrival, the rubber dam was that “thing” seen at conferences but which, in my father’s words, was “only used for courses”.

Endodontics involved multiple appointments and was completed by using a bit of cement with a gutta cone embedded in the middle and “decapitated” with a red-hot instrument heated with a lighter.

Appointment management was simple, 30 minutes per appointment including tidying up, the instruments were reduced to a minimum, the price list was truly simplified: a flat rate of 50,000 per session for each 30-minute appointment. If 3 appointments were needed for a molar, the fee was therefore 150,000 lire.

Only one assistant  from picking up  telephone (which rang continuously) to help doctors  (to the extent possible) to tidying up and sterilization (even more to the extent possible).

Lots of mobile prosthetics… lots of extractions and lots of “crowns”.

Not even 25 years ago…but it seems like a lifetime ago.

Needless to say, I arrived with the arrogance of a fresh  graduate who, thanks to the courses always paid  by his father, passed out opinions on how good dentistry should be done.

The first year of my profession I took a course in conservative dentistry, endodontics and prosthetics and, without even an assistant  to help me, I tried to put into practice what I had learned, certain that that knowledge and those protocols were the main road to personal success and of study .

Doing that dentistry was not easy and it took years to develop the skill that allowed me to document beautiful cases.

To do this I “forced” the patients to the protocol. However, managing the studio was very tiring. Carefully following all the “prescribed times” literally took me a long time and messed up the management of the treatment plans a lot… especially considering that at the time there wasn’t even a secretary or someone who coordinated the treatments, and, needless to say, not even a management software but a nice leather diary from the Italian commercial bank with everything written on it.

Retreating a tooth with a lesion and before doing  a crown,  doing  x-rays at 3-6-12 months to check the success of the treatment meant in the real world losing sight of the vast majority of patients, only to then see them again perhaps with a fractured tooth to extract it.

Doing a posterior crown lengthening and waiting those canonical 3-4 months to finalize the treatment was madness… considering, moreover, that I saw at least 5-6 subgingival cavities a day.

I tried to force the patients by giving rigid directives: “here we work well: either crown lengthening, endo and then prosthetic finalization after maturation of the tissues or extraction” …..with the result that the extractions increased (and also the implants ) which was absolutely not my aim .

I therefore began in certain cases to “skip” steps such as doing simple papillectomies (one minute of operating time) instead of crown lengthenings, discovering that these patients not only did not develop pockets and bleeding (as feared by invading the famous biological width of the famous 3 mm) but they were also better than the “elongated” ones, I began to oversimplify the occlusal modeling and remove the stains discovering that no patient complained, on the contrary…

I began to develop the idea that, often, we dentists have a point of view distorted by courses and conferences where every detail is magnified on a 10 by five meter screen. Details of exquisite beauty but which could only be appreciated by an expert, and which often did not even lead to better clinical results

After years of horizontal shoulders and preparation under magnification (already in 2006 I bought my first microscope) I started doing vertical preparations, at the time the “supreme” evil, illegal preparation, only to discover that they worked better than horizontals.

I could go on for hours describing all those changes from the “high road” that I did , but it would become boring; but the main point is that each change has led to a shortening and simplification of the procedures in the studio.

Each of us has different priorities within our studies… over the years I have tried to find a way to combine good clinical results with an optimization of time and simplification of procedures. Sustainable dentistry that I can do every day on every patient, even if I have a fever and argued with the assistant.

And with that priority in mind, I’ll gladly sacrifice some enamel in order  to make a crown if cementing that overlay is going to be akin to a battle of waterloo.

I don’t think my approach is valid for everyone, but there is certainly a portion of the dental world that would benefit from it.

And I claim the right to share certain clinical approaches that , in my hands, have given success over the years without having to wage a “war” just because they are different from the “official truth”, a truth which, over time, is also subject to changes. Do we want to talk about the dogma of the buried implant of “modern” implantology when our Tramonte were already carrying out immediate loading?

Because, as Nassim Nicholas Taleb says: “For real people, if something works in theory, but not in practice, then it doesn’t work.

For academics, if something works in practice, but not in theory, then it doesn’t exist.”

The Dental “Vocabulary”

This is not the vocabulary you may think at first glance , this is the vocabulary of your dental experience.
I will explain it better ; when studying how top people were playing chess they don’t work like “mathematical minds” . Their reasoning is very different .
At first , researchers noticed that chess masters (top players) had a superior ability to remember without any effort the position of all the pieces on the game , other players ,like A players (the rank below masters) weren’t so effective doing so .
We may argue that it was an innate ability and a superior short term memory but it wasn’t.
Cause when both groups were tested with pieces put randomly in the game, without a logical pattern , their ability was dropping down to zero .
Something else was at work .
Chess masters had much more highly developed long term chess memories , built playing thousands and thousands of games; and these memories take the form of subconsciously remembered pattern .
Researchers call these patterns with a term : vocabularies.
On average a class A player has a vocabulary of around 2000 patterns , while a master player has up to 50.000.
What the mind of a master players does is : Have I seen this one before?In what context ?what worked before?
I got struck by the application of this concept in our field .
We overemphasize in our medical education the “ rationality “ ,the “protocol” and the “education” and where we study…thinking that getting your degree at the Harvard University may be the straight road for clinical excellence.

We build new dentists that with their “protocols” and “education” think they have the key to manage properly complex dental treatments.
It’s not a mystery that the famous Dunning Krueger effect is exactly on this …the famous cognitive bias according to which people with limited competence in a domain overestimate their abilities .
Coming out from the “polished world of academia “ world seems clear , with clear rules .
It isn’t…..and your “vocabulary “ is too poor to manage the complexity you have to face .

Education is not enough .
In these days I saw a small complication on a case made by a very talented colleague who also attended twice my vertical course . During the course I spent some time talking about how to avoid that complication …yet he did the mistake.Why? Cause he never faced that complication before so , during my teaching , his mind was not really focused.
For him, I was speaking about a black swan , a so rare event , never seen before . Now , after facing the complication , his mind is completely open to learn .
I realized that vocabulary is something we have to build on our skin .
I also realized that learning itself is related to our experience…people with different experience can go back home after a course with different things.
In the past I was thinking that a good teacher was able to make people avoid mistakes. I tried hard to get that . I could not.
The aim of a good teacher is to accelerate the learning when the student faces the situation .
A student alone has to recognize the pattern …this needs time ; a student alone has to recognize the features of the pattern ..this needs time ; a student alone has to understand why that pattern arose and what was the solution ..this needs time and multiple attempts.
A student with a good teacher will move across the pattern faster , with less wrong attempts ,gaining a bigger “ vocabulary “ in a shorter amount of time.

The expert is not coming from a podium . The true mark of a professional is the rich “vocabulary “ of patterns developed through years of practical experience.
To recognize that to add every single word to your vocabulary you have to face a new situation with an unseen problem.This is part of the game you have to play and accept if you wanna build your competence .
Through years Vocabulary will become a sort of instinct ….that gut feeling that will drive your hands in tough moments.

Beyond education and your teachers the biggest skill you have to acquire is to accept new challenges and failures as the greatest teachers and chances for improving yourself.

Today , too often , nobody want to fail cause is scared by the shame ; is scared by others blaming him , is scared of losing his credibility ; is scared cause he feels to be the only one failing in a world where everybody are always successful and show their best.

Yet this is the perfect recipe for mediocrity.

Like the chinese Yin and Yang , like the day and the night , failures and expertise are two faces of the same medal .

If you want the latter , you have to go through the former one. Next Journey to increase your vocabulary on Vertical preaprations is in Italy, 3 days LIVE course with strict focus on hands on and real world dentistry!

The Imperfect Dentist

Recently I read about a very famous architect : Tadao Ando and its opinion on its work. Being an exceptional, awarded and very famous architect I thought immediately that his first quality was Perfectionism.

Yet Ando’s opinion on perfectionism was very different than I thought. He got famous for his ability to make compromises.
He is esteeemd for its ability to make the most of limited spaces with limited budgets. He is able to do this cause he fully understood that in order to get the best on something you have to settle for good enough on others.
Ando’s style is famous for prioritizing durability and design while compromising on comfort .
Ando has be able to become a top notch architect cause he put a very practical and realistic approach to his work .
He realized that ,in the real world ,predictable and ideal things rarely exist, they are easily found in academic world.
Yet the real world is another story.

When I read his interview many things started to resonate in my mind.
Soon in my career I dove in an ocean of dental courses, where everything showed was nothing less than perfect.
Perfect endodontic treatment, perfect restorative cases, all the patients treated were compliant. with the treatment plan. All of them had esthetic requests, no financial concerns.
Going back to my reality I faced instead a very different scenario. Most of the ideal protocols I learnt in the courses were useful in a bunch of cases. many cases were literally outside of the protocol.

I tried hardly to force my patients to adapt to these protocols. My aim was nothing less than doing perfect dentistry. After a depressing day in the office I was scrolling my laptop every night looking websites of scientific societies or swiping on social media looking stunning cases. I was comparing my photos to that photos….and the comparison was awful.
My scenario was not the ideal one, that was clear …but at that time my self esteem was highly related with the growth of my professional skill so i I didn’t give up and went on pushing my dentistry as hard as possible.
After few years my skill got better and i started having nice cases, yet these cases were just a small part of my everyday work. I was cherry picking cases for courses and social media, yet my unsatisfaction for my daily routine remained. I spent several years in this state of unsatisfaction, trying to push perfectionism in my imperfect reality.
Paradoxically I also got more angry over time ; it was like that collecting a lot of nice cases made more painful to cope with my daily routine, something like i was saying to myself : I have the potential for great dentistry but i am not allowed to do this every time.

With time I also started to collect failures …and some of them happened also on nice cases. This, at the beginning, was a shock for me … even good cases well executed could fail.
My perfectly executed shoulder under a microscope and the perfect seal made by my technician had a decay …my abutment restored under strict isolation and rubber dam and magnification with a fiber post debonded ….with the patient bringing the crown with the post hanging below.
I was forced to rethink what was working in the real world and, slowly, i started changing my vision. Not focusing on impossible ideals but trying to focus on achievable standards.
The real goal in a real dental office is not doing 1 perfect cases over 10, it’s to get let’s say 10 good /even if not perfect ) cases. This is less fancy ,yet this is what is going to change your life. Achievable standards is the key in our work, and after we can adjust these over time. Feeling satisfied doing good cases require a different mindset. I have to admit that for me this has been a long and tough journey. You have, like Tadao Ando, to prioritize.
That’s why for example my restorative work is nowadays focused on sound biomechanical and mechanical concepts and less on estethics. I purposely decided to give priority to long term outcome and function and to get something “good enough “on esthetics.

That’s why also in prosthetic work I ‘ve a similar approach, prioritizing some areas and getting good enough on others.
Understanding this now I am really satisfied after the majority of my working days. I am proud nowadays not to be able to show “nice cases “but to be able to produce consistent dentistry with a good yet achievable standard I can apply on a daily basis.

This has been a 20 years journey for me..a journey to recognize that traveling great distances depends on recognizing that perfection is a mirage -and a journey learning to tolerate the right imperfections ….till I realized that these weren’t real imperfections at all but the reality we really live, outside of the fake world others pretend to live in.
Tadao Ando got famous in the world acknowledging this, where are you on your personal journey away from impossible things?

Next vertical course is on learning real prosthetic dentistry for every day working, next will be 8-9-10 March 2024, limited places, contact me with a private message for further informations!


The basic armamentarium for great Dentistry

Surrounded by a pletora of devices, techniques and toys we easily get confused by the multitude of things that we apparently need for performing a good dentistry. Being a sports-lover it resembles the pressure for supplements you find in each sport. Nutrition is for sure a great part of every sportsman but the emphasis on supplementation is overwhelming. I recently read a book where the importance of every detail of nutrition was classified in a sort of pyramid. hence I had the idea to to something similar in dentistry. What are the most important things in order to work with a good outcome in dentistry,
What is really important and what is instead just marketing or mainly so?
I had several chitchat on this topic with some younger colleagues who were thinking they were in need of many things. My opinion instead is different. We really need few things in dentistry to perform well.

So let’s start with my “List”:
On the top of the list I place the rubber dam, I am not a fanatic and I find there are some situations where to put a rubber dam is not worthwile but, in general, in +90% of cases rubber dam is a game changer. You work more relaxed, a better view, a better access and it allows a unparalleled management of deep margins when you need to cut some soft tissues and some bleeding occurs, in these cases the rubber dam will do its job allowing you to work dry .

Immediately after I would place a good magnification system with light, teeth are small objects and the ability to manage details with naked eye is not the ideal. You don’t need microscopes or very expensive things, a simple 3,5-4 x loupes with light will do their job for a long time. Being completely honest if you re very young and your sight is stunning (like I was in my twenties ) you can think you don’t really need, but approaching some more years of work (especially after forties ) this is no more a chance.
Endodontic revolution has been brought by Ni Ti files …doing endo with rotating instruments is way more easier and faster than in the past ….it’s still very unclear in my experience the role of irrigants on the final outcome and warm gutta-percha…I started working with single cone and cement and without irrigants (just physiologic water) at all .My father worked like this for all his life (roughly 35 years ) and I have to admit that, as long as you are close to the apex during instrumentation and obturation, the rate of failures is a little bit more, but many times less than you would expect. In the same way I don’t use any kind of activator or special device for activating irrigants. In the same way I also shortened my irrigation time without any clinical difference to just the time needed for shaping, after which I immediately move to dry the canals .

In Prosthetic field I found in 2009 my “path “ in vertical preparation, I performed from 2001 to 2010 mostly horizontal ones but after my +13 years experience with vertical and its follow up I think that the never ending topic of what is better is completely closed in my mind. For doing vertical preps you just need burs and even normal flame burs available all over the world with a little more dexterity may do the job .
I was in Colonia at IDS this year and it seems all the world is moving digital, digital impression, digital modeling ,cad cam machine and so on …yet what I ve seen is just a faster workflow /especially for lab), probably most comfortable for patients…but I didn’t see a better quality of the product, if anything quite the opposite. If I had to choose I would choose a good technician working in analogically way and pay him more than spending money for some digital toys. A old fashioned PVS impression will do his job more than anything else. The same trend is on orthodontics, all the world is moving towards aligners but, again, I saw zero clinical advantages if not again the reduced time on chair for each appointment and the esthetic of the treatment. A good Niti wire and braces will do a great job, the only advancement I saw in ortho was the MEAW technique by sato but this is beyond our topic (you can easily check it on the web).

Really we need few things to work with a good outcome … maybe the only thing that makes the biggest difference is the one we never talk about …TIME.
The time you spend on a procedure is chief…you can have all the toys of the world but If you run through two or three chairs behind your schedule, everything is useless.
If you don’t spend a little time documenting your cases so that you can see your follow ups and understand what is working what is not …everything is useless .

Getting older, I also realized that a good time is also beneficial for our health, for our wellbeing, to avoid burn out, to get a peaceful environment in the office. Time is the same for everybody, we all share 24 hours a day, yet many complain about not to have time…you have all the time you need as long as you set correctly your priorities in your life. That is maybe very old wisdom, even Hemingway in his famous “ the old man and the sea “ wrote : “Now is no time to think of what you do not have. Think of what you can do with what there is “.
and time is yours.


In my 20 years Journey I realized the big challenge of giving an high value to a dental practice ? What do I mean with “value “ ? Value is a subjective topic but for sure value is NOT determined by dentists or the owner of the practice ….value is assessed by our final customers , our patients .
Our patients , of course , are not doctors so the perception of value is biased by personal “interpretations” and cognitive bias .
For the success of a dental office is chief a good “perceived “ quality of the practice by patients .
Under this point of view , we realize that giving value is something complex in our field for many reasons I am going to highlight in this article .
The funny thing is , year by year , despite my increasing skill in delivering “360° value “ to my patients and bringing forward my office , I realize that this task is always more complex than I was thinking in the past .
It’s really the famous Dunning Krueger effect : if you don’ t know this effect , it’s a cognitive bias where people with scarce experience and expertise feel more confident than more experienced ones. In my case , this worked at its best ! I was much more confident in my quality and dentistry when I was younger than now …now , despite my higher reliability in my procedures and the smoother workflow , I feel myself to say nothing more than doing dentistry at 360° is “complicated” . I will introduce several reasons because dentistry is complicated in the attempt to give an order to our daily struggle .
1)Patients are not doctors ..stupid maybe but probably the most important ..patients are not able to understand technical details and “quality “ , their perception of quality is based on different things we often take care of . People look at other “indicators “ of quality , like how the office is clean , how the office is in time , how people like ,your secretaries and assistants ,behave . A smile and a nice talk and the perception of being understood in his/her own needs is much more important than the use of rubber dam or other “quality clinical indicators “ in a talk with a patient .
2) People is not able to choose between different options …often we propose different options with the idea of giving some freedom ..instead the final result is the opposite ..patient has no means to decide and the final result is “stress” . A STRESSED patient often will decide to wait , doing nothing , or , sometimes , to look for another opinion .
3) Based on the first 2 the problem of dentistry is that we need to learn a lot about psychology , sales’s psychology and cognitive bias that affect patients and dentists themselves.
4) Courses and congresses push dentists toward an idealized version of dentistry , something that doesn’t exist in the real world, Frustration and feeling of being unlucky is the typical reaction , till you are able to realize that there is a gap between theory and practice few courses are able to fill , and these are usually not the most famous one (in my experience more famous the speaker , more idealized his dentistry )
5) Time : in other works where we sell a product , the time spent working on the “product “ is a value .Doing an extreme example when we read about pyramids and how many decades of work and number of workers were needed , that translated in our mind as a enormous value for the future owner . In dentistry , instead , time is a problem cause it’s paid by the patient with tiring sessions in the dental chair . Also the number of appointments required is an issue in the real world . The ability to develop reliable , efficient , and fast protocols in dentistry is chief in the success of an office .
6) Delivery of the service : in other fields the “product “ is made far by the eyes of the future owner , if the work is done underpaying people , in third world countries , or in dirty places this is not perceived by the customer . Just think to how easy is to buy some chicken in the market without any regret and going to a farm and asking to kill , under your eyes , a chicken . In dentistry we do our “product “ while the patient is there with us . In this way even the production and the delivery of the service become and experience that has an enormous value in the perception of the customer . An anxious dentist , despite his good technical level , will perform for a patient in a worse way than a colleague with better communicational features and a lower technical level.
7) We live in a strange era where we have often the chance to go back . You write a comment on facebook and you can delete . You edit a video , you cut it , you adjust colors , you add scenes since the result is satisfactory . You say something wrong to somebody , and , after , you are going to say “sorry” . We do things by approximation with that inner feeling we are able to go back . But dentistry is not like that . Many things in dentistry are made “one shot “ …when you perforate a pulp chamber , a damage is done, when you drill to much interaxial dentin , the same , when you clean too much dentine looking to the “yellow “ dentin of congresses you harm the tooth and so on ..Dentistry is like writing on a paper , once you wrote something , everything is there , is not like writing on your laptop and just push “delete”.
😎 Human interactions are not just between the doctor and patients but the majority are between patients and staff…so you need to develop a culture in your dental office about employees must behave with patients . You need to develop strong ideas and you must become the “ example “ of behavior for your staff..if you are rude with patients , they will feel the freedom to do the same (probably when you’re not present ), you have to become the better version of yourself . You have to become an example of behavior .
9) Communication : Words you say things is very important . I dove in several books and courses about communication , human interactions , I also read a little about NPL , there is a he world in these fields .
10) Leader ship : you need not to command staff but to do push them to do what you want , this is a complete different strategy but much more effective . If you “command “people, they will usually not perform at their best , when you are not present they will behave even worse and they will always complain with somebody else lowering the mood of the office . You will also be the first “slave “ in your practice unable to go away , cause things won’t work . Even this point should become a “course “ itself . I spent the last 5 years improving and studying on this topic.
This list may go on endlessly but I cited the main ones my mind is thinking about . Dentistry is complex …no way..if you think differently you’re new to this game or not really working 🙂.

TOXIC PEOPLE all around you

A topic we have never discussed is : TOXIC PEOPLE , in our work as dentists we usually have  a great number of interactions with other people .In our clinic we deal every day with our employees and with our patients…on average in a month I see something like 200-250 patients  and i deal everyday with my staff (10 people plus 2-3 more like technicians , financial consultants and so on ) .

Finished the work and , apart personal life like family , relatives , friends and so on ,  I have other several opportunities on social media to meet/discuss with other people and , in our case , even colleagues.

The reality is that , in every field of your life , you will have to deal with some people we can define TOXIC.

I’ve met several of these in my life (just statistic and big numbers at work !) and I realized that there are some traits in common that are helpful to identify these people . I will also highlight some strategies to deal with them .

TOXIC  people are a wide category of people but they all share a feature : their behavior is designed in order to exploit , belittle , harm friends , colleagues , relatives.

They usually have a fragile ego , well hidden below a facade of aggressiveness , extreme certainty of their suppositions.

Their aim is to feed their ego BUT in order to do this , they need to push down other people . The game is easy : he wins , you lose and you or the whole world is blamed for everything .

They are often good doing conversations and doing complex reasonings to bring people to their position . They usually tend to indulge in long monologue and they are always strong and sure of their point of view. They are usually very good at exploiting sentences or actions of other people and use them at their unique advantage , their aim is just to show your ideas and opinions are absurd and stupid .

I read a book on this topic recently and I discovered that most of the toxic people share similar strategies in their life I am going to talk about .

-they look for small defects making them bigger in order to carry on personal attacks , the main point is that they criticize in order to destroy and NEVER to make people grow or improve  ( a completely different thing and what we should  do if we are NOT toxic people)

-they easily blame others and are prey of anger

-if they can , they try to threaten  people, blackmail them  or use other similar means ; they are able to use force of fear to make people follow them .

-Love -bombing : toxic people easily follow this pattern..they  start developing  relation with people with  a high level of appreciation . Only after this stage they start their typical behavior attacking them . This is very typical in Love relation where he/she always belittle and denigrate  the previous wife/husband .

-he/she often uses a paternalistic tone treating you like a small child or stupid person.

-One of the sentences very typical of these toxic people is : “You must be ashamed” , so when you listen at this ….beware of those!

-They look as much as possible for control and they will try to put other people in the middle in order to make their strategy more effective (look for triangulation for more informations)

-They are very good in circular reasonings, they easily try to move the discussion from the subject to the person with the attempt to destroy the person and not the topic ( this is very common in politics , like in the last US presidential ; the typical politician attacking the other one not for his ideas but the person himself).

During your life you will be often exposed to these people.Of course closer they are , worse is the situation . The worst option is when you have , of course ,a toxic wife/husband . This a very challenging one …but ,apart this hellish scenario , you will find yourself dealing with them often …may be an assistant in your office , maybe a collaborator ,  a patient , maybe a colleague or friend in your personal life . Nowadays with social network it will be very easy to deal with them even online….the best way to deal with them is to drive them away . Sometimes they will try to bother you and the best solution is just : IGNORE  them . Don’t let them bring you back at their game , their diseased game .

If , for any reasons , (let’ s say you have a toxic brother …)you are not  able to drive them away you have to minimize your contact with them and to recognize , in your interactions  , that they have power on you just if you give credit to what they say .

Nobody has power on you , unless you give them that freedom .

If a very old man with advanced dementia would scream that you’re a horrible person  , you would’t take their words as real but just think  : Poor old mad man…..

In the same way , when you deal with toxic people and they attack you , you have to think almost the same. They are the problem , they have their problem , you re not the problem .

What is your personal experience and way to deal with them ?

Is talking with your technician tougher than talking to your wife?

I started dentistry thinking it was a very technical work …everything was about doing perfect details like drawing perfect shoulders, sealing cervical margins with perfectly adapted matrices, doing endodontic treatments with the precision of a sniper.

During my journey, instead, I realized that there was a fundamental skill i was lacking.
And during my courses going everywhere in the world I realized that this is a general problem.
In the last years I dedicated myself a lot to this topic and, honestly, this improvement has paid me in several ways.
We have, on average, trouble communicating properly with our patients, with out employees, with our technicians.
We shouldn’t amaze ourselves too much, cause we experience this problem also in our houses.
How often we have troubles communicating with our spouses and we have different opinion on several topics?
Useless to say, in western countries like in Europe the number of divorces skyrocketed in the recent years because of these.
There is a strict analogy I found in dentistry, and this is the relation between a dentist and his technician.
Most of the times this is a really tricky relation.
All the doctors complain about their technicians.
All the technicians, more politely, complain about doctors.
The problem is that both of these two parties are focused on their different needs and problems.

When I started with minimal vertical preparations my technician was complaining about the lack of space. This will be a very frequent complain if you start working with vertical preparations.
You ‘re just making their work tougher and they don’t understand why.
When doctors receive a faulty work, they are much more prone to complain than think about which kind of work has been sent, most of the mistakes coming back from the lab are doctor-generated in my experience.
We work in a harsh environment and we usually over estimate our work,
We easily overestimate also occlusal reduction.
We easily overestimate lack of parallelism between different abutments…and so on.
Our technicians often just go on with the work cumulating mistakes over mistakes.
What i am talking about is a recurring topic I see all over the world.
The solution is just one. Both of two parties have to learn each other’s work.
Of course not in detail but the minimum required to understand the problems each part experiences during the work.
Just understanding lab problems we can really communicate with our technicians and realize good dental work.
Only understanding lab problems we can improve many mistakes we do in our office.
Have you ever put two models in articulator? Have you ever checked with exocad your prep? Have you ever done the preparation of the die? have you ever seen the deformation of the wax after the removal on a preparation with some undercuts?
Is your technician aware of the biological and biomechanics problems our patients have when we give them “more space”?
Are they aware of what happens to their work in the mouth after few years?
Prosthetic is a really team work and it’s not possible to work in this branch of dentistry thinking : this is not my job, this is the technician’s job!
In the same way in a football team, the player has to know exactly where to pass the ball in order to make other players do the goal, we have to know exactly how to pass the “ball” in order to make the goal.
If you wanna really thrive in prosthodontics, this is my advice : stop thinking, this is not my job! when talking about lab part.

Your job is even that!

The perfect patient

There is  a common canvas in the patients presented by the dental speaker , up there in the podium .

The patients are always well educated , able to understand all the possible alternatives beautifully exposed from the doctor , they have always high esthetic requests , they have ( or they develop during the first plan of the treatment )   a good oral hygiene and they have no financial constraints.They also , it seems , understand the high value of the dental treatment they have to go trough..

Simply the perfect patients we all would like to have in our offices .

This description was someway ubiquitous in most of dental courses and conferences .

You go to an endodontic course and you see patients willing to stay 3 hours with their mouth wide open in order to save  a tooth with broken instruments , ledges , apical lucency . …cause they understand the value of  a tooth .

You go  to an implant course and you see patients going under the third  graft from the palate in order to rebuild the lost thickness of soft tissues and improve their esthetics .

The list of perfect patients in each specialty is endless.

The problem arises when you go back in your office and your patients are anything but not perfect .

You discuss with your patient about saving a tooth because of  a deep decay ;the treatment , a normal root canal treatment , is highly predictable yet the patient decides for a simple extraction .

You talk each day with your patients and your feeling is exactly the opposite : your patients are not good ,definitely  .

The good ones are those going to the famous ’s speaker , yours are the worst ever .

And because your patients are not “good”  enough is almost impossible to perform a good every day dentistry .

The quality of your patients become one of your strongest reasons to justify your dentistry .

How many times I ve heard the sentence : I wish I could do that , but in my office I simply can’t”.

The problem is at the foundation of our education . We develop protocols and techniques for ideal scenarios . But everything falling apart this ideal scenario is not covered . This is something peculiar to dentistry .

If you go in other fields like , let’s say , engineering , the techniques , materials and protocols are tested in the worst environment before being applied in the real world .

For example aircraft’s wings are tested with a 50% increase according to expected maximum load during their life cycle .

If you study about skyscrapers and the effects of wind on their safety you will learn incredible tests and this was the incredible  ability of the skyscraper Taipei101 to withstand a wind of 233 km /h  in 2014 during a typhoon .

Back to dentistry …quite the opposite . We develop protocols for ideal situations and when conditions are just less than ideals we are alone .

And real dentistry is anything but not ideal , especially nowadays .

We have financial limitations both from our patients and the competition we have to deal with everyday from our competitors .

We have time constraints , we have to deal with multiple health problems and assumption of drugs .

I get crazy when I read the nth article on implant dentistry with a 95% success where they selected young people , without parafunctions, non smokers , good health , no periodontal problems , good oral hygiene ….cause the simple problem is that most of the patient where I place implants are people with some periodontal problems , often with  a less than optimal oral hygiene and , maybe, also smokers.

I think we can do  a “quality “ dentistry everyday in our office , but to do so we have to redesign our mindset . we have to stop , as speakers , to show just our best and share our daily struggle .

We have to redesign our goals treating our patients, They are the ones paying for our bills and our employees .

Too many times we have different values in deciding goal of treatment .

The perfect patient is  a chimera .

Looking for the perfect patient in order to do great dentistry is  useless.

We have to rebuild a “perfect “ dentistry around imperfect dentists and imperfect patients.

But the first step is to stop self deceiving ourselves : perfection is not a goal , it’s a chimera.

The value of “screaming “

I am not talking exactly about screaming or talking with a loud voice, neither doing doing something taking the lead like at Speaker’s corner in Hyde park!
It’s about our attitude towards goals, any kind of goals we do in our life.
It may be improving our technique, it maybe losing weight, or start doing some different activities.
The main problem we do is how do we approach to them.
The first seed of these action is just in our mind, it’s just an idea in the backyard of your brain.
The problem is that too many times we are not fully in that idea, we are just wandering about doing that thing, already acknowledge that the idea is a good one …but we are not really believing we will do it properly …so what we do ?
we start with a shy approach.

We start in an almost invisible way doing this new plan, probably when we have time, probably when we are in the right mood, probably when we are inspired.
Think to writing, how many people love the idea of writing something but they never start waiting for the “ inspiration “.?
The writer Stephen King once said that the most important feature for a writer is: put down their ass on that chair even when their brain is empty and start writing 2000 characters, every single day.
How many people stop their diet during the weekend thinking to start again the following week ?
The same applies to dentistry …how many courses you ve followed about a procedure and, going back to your office, you got a busy day and thought: I will try this procedure tomorrow.

Tomorrow becoming the following week, the following week becoming the following month.
I‘ve managed several courses in restorative and prosthetic procedures and what I realized doing some follow up of these colleagues was that the majority was NOT doing the technique, but not cause they were thinking it was wrong, not because of the learning curve we have also to face, but, very simply, cause they never started trying a first time.
Some, instead, start thanks to the enthusiasm of the course but get lost during the typical mistakes of learning a new work, going back to their usual routine.
We never start something, or we start weakly something in the solitude of our dental offices in most of the cases. We fail in our willings without anybody acknowledging this.
That’s what I mean about the importance of “screaming”…not to scream in the literal term..but to say to the bigger group of people possible that you’re committing yourself to do something.
I find very useful doing this, and writing a plan of how you will make this possible, to develop a detailed plan and, if possible, to take a diary, a journal to all the steps you reading ahead.
We live in the era of TouchScreen and smart devices, Yet I find a huge power in using a pen.
Journaling is sort of writing meditation. Our mind easily goes in the past or in the future losing the clarity of the plan. That small time you dedicate to writing is the best time to meditate and make detailed plan for your goals, to set some milestone, to see the progression, to reach the goal. I will make you a short was a while I had the desire to learn a new language and I was looking at french, I started a couple of times but stopped after few lessons. During the spring of 2022 I received an invitation to lecture in France in Bordeaux. I knew almost zero about French and I also had the possibility to have a translator but, a back voice in my head, said: NOW or NEVER.
Despite my zero knowledge of french language I said no to a translator, I took with the french guys the duty to lecture a full day in their language. I said to my friends and colleagues that I was going to lecture in French. I did my PUBLIC PROMISE. I took back my old french manual, there were 25 chapters, I took a paper and started writing my plan, a detailed one. 9 months available. 36 weeks available. I took my lecture, it was almost 700 slides. I planned to translate all the slides in french and write all the speech. I put the goal of doing this work by 20 weeks in order to be able to train myself several times before lecturing. I divided the 700 slides in 20 weeks, just 35 slides each week, just 5 slides each day. I usually talk around 1 min on a slide so it was a realistic effort. I hired a tutor on an educational platform and I payed immediately all the lessons till January and I immediately booked all the lessons. Each thursday, one a week, from 10 to 11 pm. Doing so I had not to think to book each lesson (easier to skip ) but I had to contact the tutor in advance to move the lesson or I had to pay in case of no show. I followed my plan. Of course I had some impossible days, it’s part of daily life, sometimes I did more on Sunday to get back on the program. I always tracked my advancement. In August I completed the manual, the french grammar and to translate the lecture and I started exercising myself in order to be more relaxed.

Finally January came and I went to Bordeaux. The place was an amazing chateau and had a small group of french doctors under the organization of Dr. Jonathan Murcia. I was quite relaxed ,useless to be anxious and I had also the awareness to have done properly my duty.
I asked them to use english for some questions cause listening spoken french is still my weak area, I put bigger effort in speaking on my lecture. And I did …I did a full day of lecturing on dentistry from 9 to 5 pm. I did my pubic promise, I did my plan, I followed the plan and i got my goal.
And what’s your goal now ? not next week, not next month …right now.
Do you really want it? If yes start mixing all the ingredients you deserve for your goals.

Failure may be a part of the game, it happens. But Inaction is way more worse than trying and fail. Failing is losing a battle, and you learn at least how to improve your planning, your scheduling and your goals ,you gain experience but the real “war” is your whole life and you can just succeed in a way …starting NOW.