“ I am a doctor and my aim is health” , focusing on other things like “commercial things “ , “marketing” is unethical . This is something I hear on a constant basis and that , honestly , in the first part of my career I also thought .
Focusing on practice ,focusing on the final “product “ . the clinical work .
Charged with this idea it seems obvious that the “product “ is the main key to get success in your working life. Sadly it isn’t.
Coming back from my holidays in Greece I needed a stop for the night and I selected a small hotel . I just needed to sleep few hours for the night so to complete my travel back home so , honestly , I took the cheapest available (august is high season and here there are crazy prices across this month ). Well aware that a cheap price was probably a “so and so “ place but fine with that , I arrived to that place around midnight .
My expectations were low or very low .
I arrived in a small square with an ancient church in the middle . The place was on the top of a hill with a stunning view over the coast . A breath taking view despite it was night . The hotel was next to the church . It was the old monastery of the church . It was developing in a sort of vertical way across the hill with an uncommon architecture .
Everything inside the place was rebuilt in an exquisite way . New furnitures , comfortable bed and pillows . Big Flat screen TV , brand new air-conditioning.
Clean and shiny everywhere , really a place worth much more the price I paied .
After a good night of sleep I had my last surprise enjoying a very good and abundant breakfast for my whole family included in that cheap price and had the chance to talk for a while with the owners of the place.
His story was an example of a typical bias of “too much focus on the product “.
The owner was a quite wealthy retired person in his 60’s . He was literally in love with his small village and the historical attractions . Indeed this place , the exact name is Rossano in Calabria , was one of the most important and strategic cities of the Byzantine empire in the period around 500-1000 a.c and around 900 a.c it became also the capital in Italy of this empire . Still very important during the following dominations it started to lose prestige just in the last centuries .
A place with more than a thousand of year of history , a small hotel of the highest quality in a stunning position and location …the perfect “product” ….so thought the owner during the long work of rebuilding …..sure of the success of his idea.
Sadly it wasn’t.
Rossano is slightly not enough recognized in the typical travels people do for historical attractions , Rossano is not close to the sea and in calabria the majority of people moves there looking for sun sea and beaches . The demand for this place is low…so low that he had to lower the price in order to become attractive….at least a little .
Being in love with the product being blind to other factors is not a winning strategy in his field , nor it is in dentistry .
Beside the product (in this case the dental treatment ) you have to look carefully to where you live , the economy of your area , the cultural level of your patients , and to fine tune your service in order to fit their needs .
I know that most of the colleagues , especially young , maybe would love to do esthetic cases with veneers and work on beautiful people . Simply in most of the places (included mine ) this is not the dentistry you will be able to practice . And trying to push that kind of dentistry would backfire your office .
In this era of social media and “perfection “ if we wanna be successful in the real life we have always to ask ourselves how much “ show “ like at the cinema we daily see on these cases and not to be too much in love with the “product “ but look at 360 degrees what we do .
At how many things are you blind every day if you are completely honest with yourself?
[03/10/24, 21:19:22] Andry: educational
[03/10/24, 21:19:23] Andry: ok

It’s funny how in this crazy running world full of technological gadgets I find very often so trivial mistakes in the workflow of vertical prep affecting the clinical outcome . Mistakes that most of the people doesn’t care enough .
On this short article i wanna focus just on one detail : cement and its drawbacks.
During a prosthetic workflow we usually use cement in two phases : 1) after the finishing of a provisional crown with , generally , a provisional cement like temp bond 2) in the final cementation with the final crown.
About the first point it’s a quite common experience to remove the provisional crown and find some temp bond stuck in the sulcus. The problem we have to face is that the excess of temp bond in the sulcus is one of the biggest factors affecting the correct healing of the soft tissues. During a vertical preparation we easily work in the space of the junctional epithelium and we need this to heal properly in order to give to our technician the correct biologic space where to decide the area of closure of the final crown .
The temp bond stuck in the sulcus stops a correct healing and keeps the tissue inflamed . This mix is the perfect recipe for bleeding , troubles in putting cords or other devices of retraction , more discomfort for the patient in the handling of the procedure and , eventually , an overextended impression recording a part that should be covered by the junctional epithelium. The average technician in these cases will tend to put the margin of the crown in the most apical part of the impression manifacturing a crown that’s too deep in the soft tissue with an high risk of inflammation and bleeding over time .
Point 2 : similarly to what happens with temp bond it’s very easy to leave excess of cement after delivery of the final crown …the main problem is that you don’t recognize this properly cause you don’t remove the final crown like you do with the provisional one . Definitive cement is also harder than the provisional one so the risk of leaving excesses is even higher . Even in this case this excess may lead , over time , to some bleeding and inflammation . When using some self adhesive cement the removal may be even more problematic if not impossible especially inter proximally.
It’s interesting to read papers about our ability to remove excess cement in the subgingival area showing two interesting things : the first is that we easily leave excesses already 1 mm subgingivally, and we do a disaster when going already at 2 mm , the second interesting is that xrays are not reliable enough . When we see excesses of cement on xray this means we have left “huge excesses” , but when we don’t see excesses in xray this doesn’t mean 100% that the cementation has been clean but that , probably , we have left small excesses somewhere .
It seems a paradox how a so overlooked detail may affect a prosthetic workflow but this is the reality , how many of these small details are still hidden in your work ?

If you wanna learn more on vertiprep there is the last seat available , due to a cancellation , on November 2024

Running courses in the recent years , and being also passionate about attending courses my self , I recognized a common attitude coming back to our offices .
After spending 2 or more days with the speaker looking at beautiful or successful cases made with that approach we ignite our enthusiasm in that technique and we tend also to identify the speaker with that particular approach .

Speaking about my personal experience , I’ve been running a course recently with a nice group of doctors from UK, a vertical course .
Of course all this course is centered about the vertical approach and almost all cases are some nuanced variations of the vertical technique in the most different clinical situations. in order to show all the pro and cons of each detail.
People comes back home with the perception that in my office I just do vertical preparations and crowns.
After that , I run a Restorative course with a group of italian doctors with many extreme cases of recovering subgingival margins with direct restorations and during the break one of them asked me : Do you still do crowns ?
The same bias working differently coming out from a different course and experience .
The cherry on the cake has been posting also a ceramic adhesive overlay and both the groups got puzzled with my choice .
For some of them I was the” Michelin star “ Verti-Chef (thanks April Whitlock for this nickname) , for the others I was the Resto Guy.
Being honest I ‘ve to say I experienced myself this problem …coming out from a soft tissue course I remember I was seeing recession and soft tissue deficiency everywhere and I was doing much more soft tissue surgery than ever.

Coming back from the GBR course i was seeing bone defects everywhere and membranes were my way to go in most of the clinical situations.
I realizes that we go through a cycle in all the things we do .It goes like this : we are excited about the technique in a unrealistic way and we also think it’s easier than expected , after we get some problems and failures or complications and we start losing some enthusiasm , also the novelty is no more a novelty , routine kicks back and that enthusiasm fades …
Sometimes we move back to other old techniques that in our hands perform better sometimes we stick to the new one but…after a while ….we do another course and the cycle starts back.

Nowadays we live a strange period about knowledge ..in the past there was NO knowledge ….nowadays we move between two extremes …no Knowledge sometimes but , more easily , too much knowledge leading to confusion so the biggest work that the “expert “ has to do is “filtering informations”.
Doing all these cycles over and over filtering informations and selecting what is working more in the clinical scenarios.

After 20+ years of working , failing , and changing of course I ve some bigger “workhorses” like the vertical prep but there is room in selected cases for other things .
I still nowadays do some adhesive onlays , veneers , adhesive rehabilitations . Sometimes is the clinical case matching perfectly , sometimes is the patient.

The patient and his expectations are one of the biggest variables we don’t speak about enough !
The intersection between the single tooth , the whole mouth , and the patient’s mindset is one of the most important skill a dentist has to acquire to thrive in the real world .
We focus too much on the technical skill but the reality is that this is just a small part of what we need to thrive .
We got our degree thinking to use burs , blades and scissors to get our job .
Yet we have to learn the suble art of communicating properly , the art of persuasion .
With our degree in our hands we think that we have the truth and , because of that , patients have to listen to us ….sadly truth is more nuanced and even if you should have that truth remember that truth explained poorly goes nowhere while old or wrong ideas told compellingly can ignite a revolution.
In our cycle of learning, trying , giving up , relearning we , as doctors , show how busy and emotional we are . Why our patients should be better ?!’
After a course it’s easy to see the world through the lens of that technique , to see black or white but , after 20+years of dentistry if I can share a lesson is that the world is coming in a different color …..and that color is grey .The best technique is maybe a” white” with some shadows , the worst a “black” with some lights.

All the life is like that …not just a lesson in dentistry but a lesson for your life .

It’s not a secret that the offer of courses and educational material is nowadays overwhelming. We are literally surrounded by video courses , webinars , residential courses and much more . Indeed many are good quality ones but there is a question you have to put yourself before spending time and money on a course . After 20 years of dentistry I realize this is the most important question on this topic and the question is : who is the speaker?

With this question I am not going to ask his Curriculum Vitae or where he got his degree but , very simply , what is his attitude , his approach to dentistry ? which kind of patients? office ?and how he is managing cases ?
These are the questions you have to answer if you want to spend your money in order to improve your real work.
I realized that , today , there are different styles and attitudes towards dentistry and there is a great chance you can attend a course from a great and famous speaker just to realize that his “style “ doesn’t fit with yours .
Of course it’s really interesting looking people in different scenarios but , in my opinion , these are the last courses you have to attend . These are the courses you attend when you already do a mature dentistry and you’re looking for getting some new fresh ideas to change something in your practice . These are the courses where the ration between what you spend and what you bring back home is the worst . Usually you spend money to live a nice experience and bring very few things back .
So the ability to choose a dental course that fits your needs and allows to bring back home a huge number of tip and tricks is of paramount importance , especially when you’r still struggling on many things in your office .

Who is the speaker?!?
There are speakers you will recognize cause they post only perfect cases . Their aim is excellence without compromises . Time is not an issue , money is not an issue . Number of appointments are not an issue . These are those able to spend 3 hours just for layering 2 central incisors and even a second appointment for further details.
There are speakers living in fancy places and working just on cosmetic cases with celebrities . Of course the idea of attending a course with them is attractive but , often , you will go back home dealing with a very different scenario .
There are dogmatic doctors with their own truth and ideas . Would you be comfortable attending a course with them with zero room for doubts ?
Or…If you live in a small village with low income , for example , you will find few solutions to your problems going to a famous doctor working in a capital like Milan on wealthy patients.
I went to such places , it was inspiring . Yet I went back home doing things exactly like I was already doing and struggling with the same problems .
And there is more about who is the speaker..is this speaker one who manages work in team or is he working alone ? this simple difference may give you more hints about the outcome of your choice.
Is the speaker one who loves indulging on complex procedures focusing on his own work or is the speaker one focused on simplifying procedures in order to delegate work to other associates in order to improve his time management and the productivity of his clinic.

You have to be honest with yourself asking who you are ? what is your approach , your needs , your patients, your struggles and at that point check if the speaker is a good fit .
Recently i was reading a discussion about the “Wim Hof method “. Wim Hof is a man famous for doing “ice “records like swimming in ice water , walking almost naked on the snow and so on . He is famous for a breathing technique that includes hyperventilation . I read several comments on this technique and his pro and cons till i did read the comment that enlightened my mind : “ Wim Hoo is an extreme athlete so he designed a technique focused on similar athletes , extreme ones . If you are not simply this kind or at least very fit, this method doesn’t apply very well to you “.

Who is the speaker ? What do you really need ?
I know perfectly that the idea of learning from the best is appealing but ,too many times , it doesn’t really bring you closer to your goal of managing better your office .
So before choosing your next course just ask yourself this question : Who is the speaker ?

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.

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.”

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!

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!

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 matter..how 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 🙂.