Dentistry Uncensored with Howard Farran
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245 Biomimetic Dentistry with Saul Pressner : Dentistry Uncensored with Howard Farran

245 Biomimetic Dentistry with Saul Pressner : Dentistry Uncensored with Howard Farran

12/2/2015 2:00:00 AM   |   Comments: 0   |   Views: 759




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AUDIO - HSP #245 - Saul Pressner
            


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VIDEO - HSP #245 - Saul Pressner
            

• What is Biomimetic Dentistry?

• What are the advantages of Biomimetic Dentistry? 

• How and where does one learn more about Biomimetic Dentistry? 

• History of Biomimetic Dentistry and how I became involved. 

• How does Biomimetic Dentistry relate to the growth of one's dental practice and how does it benefit ine's patients?

 

 

 

I am President-Elect of the Academy of Biomimetic Dentistry. 

I am on the Board of American Friends of DVI as well as on the Dean's Council of Penn Dental Medicine. 

I received my DMD from Penn Sental Medicine and my Certificate in Family Dentistry from UConn School of Dental Medicine.

 

 

 

http://www.newyork-cosmeticdentist.com


Howard: It is a huge honor today on a lovely Saturday afternoon, to be podcasting Saul Pressner, DMD. Did I say that right, "Pressner?"

Saul: Yes.

Howard: And you're in Washington, DC, but you're not at the ADA convention, you're at a family party. The reason I contacted you and you didn't contact me, is everybody keeps asking me what is biomimetic dentistry. You're the president-elect of the Academic of Biomimetic Dentistry and you're on the board of American Friends of DVI as well as on the Dean's Council of Penn Dental Medicine. 

Saul: Yes.

Howard: The reason I contacted you and you didn't contact me was what is this biomimetic dentistry that everybody keeps hearing about?

Saul: It's basically tooth-preserving dentistry, "bio" meaning life, "mimetic" meaning mimicking. We try to recreate what nature made for us in the first place when we restore teeth. Now if a tooth cracks, for example, if you break off a cusp of a lower molar for example, we were taught in dental school to prepare that tooth for a crown to protect the rest of the tooth from fracturing. But with new adhesive techniques and materials, we can build teeth back up instead of filing them down. We just do it in a more predictable way now.

Howard: Some of the things that us humans believe are just crazy. Like the craziest I believe is a lower mandible incisor and we're taught that every tooth that has a root canal needs to be crowned. Well by the time a lower incisor has had the root canal, by the time you file it all the way down for the crown, it's not even a grain of rice.

Saul: Exactly.

Howard: So we've destroyed 95% of the forest to save it. Do you know the old saying, "I will burn down this forest in order to save it." Isn't that what a lower crown on an endodontically treated incisor, isn't that what it is? When you crown an incisor tooth just because it had a root canal isn't that kind of burning down the forest in order to save it?

Saul: Yes, absolutely. With moderate adhesive you make a very small access opening for the root canal therapy, you have all this enamel left that you can use to reinforce the tooth against biting forces and when you put in a biomimetic composite restoration, which bonds really well to the dentin and to the enamel, you're reinforcing the remaining tooth structure so it's a much stronger tooth than it would be if you filed down all the enamel for a crown.

Howard: So you guys have an association or a meeting or talk about ... you're the president-elect of the American Academy of Biomimetic Dentistry. Tell us about the Academy. What's the website?

Saul: I'm actually president now. The website is www.AcademyofBiomimeticDent.org. And we're an international academy. We have one large meeting once a year, we just had it in Philadelphia about two weeks ago. It was the first time we had our meeting on the east coast because we really felt that it has been a west coast phenomenon so far and we really felt that dentists on the east coast should be exposed to this information and try to preserve more tooth structure.

We have several other smaller meetings during the year. We have videos of our lecturers, we have literature reviews. The website is an educational resource to guide our members in terms of how to learn about the latest material being presented.

Howard: So tell us more about it. Why should people join this society? I just found it, AcademyofBiomemticDent.org.

Saul: Correct.

Howard: Why should people join that and what is some take-away lessons for the thousands of dentists listening to you right now that are not members? How could they be more biomimetic, more bio meaning life, so "biology," "ology" is study of, so "biology" is the study of life. And Biomimetic, "mimetic" is "bio" would be life and "mimetic" is what'd you say?

Saul: Mimicking.

Howard: Mimicking, that's the word I was looking for. With adhesive dentistry, basically your goal, it's kind of like minimally invasive, would you say it's more the marriage of minimally-invasive dentistry and adhesive dentistry, of trying to just save more tooth structure. Is that?

Saul: Yes, it's all those things in a very well sealed environment. Sealing out the bacteria so that the things we teach in biomimetic dentistry allow restorations to last longer and we follow specific protocols. We use ribbon fiber within our composite restorations to reduce stresses within the composite and to reinforce the remaining walls of enamel and dentin. We learn about these techniques based upon the latest literature.

Everything that is taught at our meetings and in courses that we give is based upon peer-review science. Dentists who come to our meetings and become members become very well educated in the literature so that they can feel confident that the treatment that they're rendering is based upon the latest science. That's a real big plus for patients. They're also learning how to restore teeth more conservatively and thus these teeth are going to hang around for a much longer period of time. Patients are living longer and they want to hang onto their teeth.

You know about the cycle of tooth death? I'm not sure if you know about that. Basically you start out with a simple amalgam filing and a cusp breaks off and you then end up doing a crown. You do a crown and a lot of dentists believe in doing, as you said Howard before, prophylactic endodontics. Teeth that have had endodontics and have had caps, posts or prefabricated metal posts made in addition to the crowns, the literature now shows that those teeth are much more likely to be lost sooner than teeth that are restored more conservatively. Like the example you gave about the lower interior incisor. 

By becoming members of our organization, members are networking with like-minded dentists and learning about the latest literature, materials and methods to restore teeth more conservatively, more economically for their patients, and it's a practice builder as well. Patients like not having their teeth filed down as much and holding onto their teeth longer. 

Howard: You're in New York, New York. I'm a Kansas boy. Whenever I see New York, New York, that just means Manhattan and not Brooklyn, Bronx, Queens.

Saul: I'm in Manhattan yes. I am in Manhattan.

Howard: But is that true though? Does New York, New York, mean Manhattan?

Saul: It does because there are five boroughs of New York, and if you live in Brooklyn, it's Brooklyn, New York, or Staten Island, New York, Bronx, New York, Queens. Manhattan is signified by New York, New York, yes.

Howard: But all those boroughs call themselves New York City?

Saul: Yeah, the five boroughs are all part of New York City, that is correct.

Howard: That is a confusing culture.

Saul: It is, it's a very confusing culture. Yes.

Howard: Yeah, where each borough calls itself by name. Your website is NewYork-CosmeticDentist.com. Do you feel that biomimetic dentistry gives you a competitive advantage in what I think is probably the most saturated city in America. I mean how many dental schools does New York have in just the city?

Saul: Two. NYU and Columbia.

Howard: What is the class size of NYU and Columbia?

Saul: I think NYU has a very large class size. I think they have probably close to 200 in each class and then they also have an evening program for foreign students.

Howard: How big is that?

Saul: I think that's probably another 200 students per class as well. Yes. 

Howard: So for each school has the foreign too?

Saul: Columbia has, I believe, a foreign program as well; but Columbia's class size is I think about 120. It's smaller than NYU.

Howard: So you guys are dumping out half a thousand dentist a year.

Saul: That's true, yes.

Howard: 500 a year and Manhattan is only what? What is Manhattan, 20 miles by 4 miles, what is it about?

Saul: I think it's about 20 square miles. Yeah, I mean not all of them stay in Manhattan. [inaudible 00:09:12] and dentists retire.

Howard: I think the most interesting statistic about Manhattan is that if all 7 billion people on earth lived at the density of Manhattan, we would all fit on the island of New Zealand.

Saul: Really?

Howard: Isn't that interesting?

Saul: And I know a very good dentist in New Zealand, Graeme Milicich, who lectured at our meeting.

Howard: Yes, Graeme Milicich, I saw that Graeme Milicich in New Zealand, then I always think of one of his best friends in Australia is Jeffrey Knight.

Saul: Jeffrey Knight, sure.

Howard: Now I wanted to ask you about that. Is it my perception or not, is this right or wrong? It seems likes when you meet the 2 million dentists around the world, as they get closer to Tokyo, Japan, where GC, General Chemical is that makes glass ionomer, whether it's New Zealand, Australia, Hong Kong, you see much more glass ionomer used by dentists as they get closer to Japan. As they get further and further away from Japan, like by the time you get to Kansas, it's pretty much gone. What do you think about that?

Saul: Well I think glass ionomer has its place. I agree with you, I don't use it much. I think that you get much better bond strengths with dentin bonding materials, self-etching primers for example. I don't use glass ionomer that much except in certain cervical classified cavities.

Howard: But it seem like that's the trade. It seems like when you get really far away from Japan, they say, "Well I just get better strengths with resin," so it's more of a civil mechanical engineer approach. Then when you get closer to Japan and Graeme Milicich and Jeffrey Knight in Australia and New Zealand, they say, "Well we're fighting termites and I want this barn to be antibacterial and I'd rather have some kind of active ingredient in my restorative material and you Americans are always trying to build a house and it's always going to get destroyed by termites and we're trying to build an aluminum barn that's more anti-bacterial towards the [inaudible 00:11:19] trying to eat it." Do you think glass ionomer gives you a anti-microbial edge?

Saul: I think it does for a period of time, but I use Kuraray protect bond, a self-etching primer, and that has an antibacterial component to it as well, as well as releasing some fluorides.

Howard: And that's Japanese too?

Saul: Yes it is, that's correct. Yes. I prefer that product because it's got better dentin bond strength than ...

Howard: And what's the name of that product? Kuraray what?

Saul: Kuraray protect bond.

Howard: Kuraray protect bond. Yeah I think the Japanese got this figured out better than anyone.

Saul: They're great. Their materials are wonderful.

Howard: The most Japanese dentist in know in the United States is our good buddy, Ray Bertolotti.

Saul: Absolutely, who also spoke at our conference, yes.

Howard: Yeah, he should have been born in Tokyo. He's a misplanted, he's a misfit, like remember the Santa Class reindeer where they had the island of misfit toys? Ray Bertolotti was born in the wrong country, because he really does think Japanese, don't you think?

Saul: He does, and actually he studied with Professor Fusiyama many years ago. At our meeting, we just had Professor Inokoshi, who also studied with Profession Fusiyama. Ray really brought a lot of the Japanese philosophies to the United States in terms of total [inaudible 00:12:47] He's brought self-etching technologies too and he's really gotten onboard with the biomimetic approach as well.

Howard: Go through some of your other speakers. Charles Cox.

Saul: Yeah, Charlie Cox actually did a lot of definitive histologist studies on dentin and the smear layer, hybrid layer. I remember hearing about Charlie Cox first during Ray Bertolotti's lectures. I've been taking Ray's courses for over 30 years. Charlie is an excellent dental histologist and he spoke about the anatomy of dentin and the hybrid zone, and how the dentin enamel junction is a transition zone. He just gave us the background and the histology. He also studied with Profession Fusiyama in Japan.

Howard: Does he still practice, Dr. ...

Saul: No he teaches part-time and does research.

Howard: In Tokyo?

Saul: No, well he does it at University of Michigan, but he spends time in Tokyo as well doing research projects with some other Japanese researchers such as Profession Inokoshi, Professor Togami, and he's in the midst of doing some research with Kuraray as well.

Howard: But he works with the University of Michigan?

Saul: Yes. 

Howard: Do you ever see him when he comes over to Michigan?

Saul: Actually I only see him when he comes to my meetings, but I speak to him regularly. He's actually also going to be the Editor-In-Chief of our new Academy of Biomimetic Dentistry journal. He's going to be compiling the articles which we're going to do on an annual basis.

Howard: Wow, can you email me and cc me Howard@Dentaltown and I'll try to get him on one of these too, podcast?

Saul: Sure, I will make a note. Absolutely, love to.

Howard: Tell us about Marcus Blatz.

Saul: Great guy. He's head of restorative sciences at Penn, and I went to Penn for dental school. Marcus knew that I had been lecturing a little bit about biomimetic dentistry. There are two schools in the United States at the present time, and others are following, that are trying to educate their students in more conservative techniques. Penn is one of them and USC is the other one. Pascal Mon is at USC. Marcus has been trying to teach his students to do partial coverage restorations. He gave a lecture at our meeting as well.

The message is simple. Studies show that the more tooth structure you preserve, the longer the tooth is going to last in the patient's mouth. It's better economically and physiologically for the patient to have their own teeth. Implants don't always work. Implants are really a treatment of last resort in my opinion. If it were me, I'd much rather hold onto my tooth. You're much more likely to hold onto your tooth is you do a partial coverage restoration and than a full cover one. Marcus is more interested in indirect restorations; but in our academy, there is room for variation in terms of preferences and techniques. Not everyone owns a CAD/CAM or E4D machine. It's too expensive for some dentists and it's just not warranted. I don't own one myself. I do a lot of direct composites. 

Simone Deliperi, who was one of our other lecturers, lectured on direct composite, fiber reinforced restorations. A lot of these restorations can last many years. You don't necessarily have to own a CAD/CAM machine to practice biomimetic dentistry and good dentistry.

Howard: But wouldn't you say the opposite, that a CAD/CAM machine is the opposite of minimally invasive dentistry or biomimetic dentistry ...

Saul: No.

Howard: Well you're having to drill down and destroy more tooth structure to fit your technology. I mean that indirect restoration has to draw. When I do directs, I just remove the decay and put in my direct. But when you have to sit there and destroy all this tooth structure, just so that your optical scanning and indirect machine works, I mean who's the doctor? The RTD2 CAD/CAM or me?

Saul: I'm in agreement with you, which is why I don't use one. I chase the decay and I preserve more tooth structure that way. I'm with you. However, with CAD/CAM technology, from what I understand, you can still preserve more tooth structure if you're doing a partial coverage restoration than you would if you're doing a full coverage restoration. There are compromises that dentists have to ...

Howard: Repeat that what you just said.

Saul: All I'm saying is that you can do a CAD/CAM partial coverage restoration as well. It doesn't have to be full coverage. But ...

Howard: It still has to draw. An indirect still has to draw.

Saul: It still has to draw. I prefer doing it direct for the reasons that you mentioned, but that's my preference.

Howard: I want to ask you another thing, this whole business of starting with a guy named G.V. Black, who talked about extension for prevention, but I was wondering today, if your grandson came in and he had an occlusal on number 30. Would you prepare out all the pits and fissures before you did an occlusal? And then number 2, what if your grandson was extra bad and had an [inaudible 00:18:17] flossing cavity. If you took at that mesial decay, would you extend the box out so it could be reached by the toothbrush bristles? Talk about both of those, extension for prevention on the occlusal and would you bring out the box [inaudible 00:18:32] so it could be cleaned by a toothbrush?

Saul: Right, I would not do that. I'm sure you've heard of Tim Rainey, right?

Howard: Sure, in Refugio, Texas.

Saul: Yes, well Tim Rainey was one of the early advocates of air abrasion. So if my grandson had an occlusal cavity on number 30, let's say ...

Howard: Would you spank him first?

Saul: I don't believe in that. But I would uses air abrasion to clean out the occlusal decay and I would do a separation restoration there. Then I would do a little slot preparation on the mesial and not extend it necessarily to the buckle or lingual breaking the contact. Because with good adhesion and with good flossing it should last.

Howard: What is your air abrasion machine now, what are you using?

Saul: I actually use a micro-etcher by Danville.

Howard: That's what I use. You mean the little one, the little Danville?

Saul: Yeah, that's what I use. It works.

Howard: And what's the aluminum silicate is the powder?

Saul: Aluminum oxide.

Howard: Aluminum oxide. And isn't that the second hardest substance on earth next to a diamond?

Saul: I didn't know that to be honest with you.

Howard: I read that. I could be wrong. But I love that thing. Now in all honesty, my dental assistant, Jan, hates it because it makes a mess.

Saul: It does. I know.

Howard: And I say you haven't seen a mess until you've gone to my home. What do you think of that? It just cleans everything off, that aluminum oxide man it's nice. I don't care that there's white aluminum oxide powder everywhere. I just don't care.

Saul: I don't care either and I try to use a rubber damn whenever possible. I use high speed suction. And usually when you're doing it, if it's an occlusal for example, oftentimes you don't need anesthesia and it's minimally invasive.

Howard: A lot of times when the staff or someone's getting upset because I'm making a messing, I say, "You know have you ever seen a hospital when they do a bypass?" These people are naked and filleted open. If you come to the dental office dressed for church on ...

Saul: Wrong idea.

Howard: Yeah, maybe that's the wrong idea. Maybe you shouldn't dress for your dental appointment. Maybe you should dress like you go to gym, or running 5 miles, and not going to church. You're talking to a thousand dentists and I believe a lot of them don't know what biomimetic dentistry are, I'm talking to the president. What if someone's listening and says, "I want to learn more about biomimetic dentistry. What would you tell them?

Saul: I would have them go the website, www.AcademyofBiomimeticDent.org. They can call me, they can call me in my office, I would be glad to talk to them. My office number's 212-249-8999 and I'd be happy to ...

Howard: 212-249- ...

Saul: 8999.

Howard: 8999. Boy you like 9's. 249-8999.

Saul: I was born on the 9th of the month I was born in, so I guess that's why. I don't know. But I'm happy to talk to anybody about it and tell them the advantages. I mentor people and it's my pleasure because I think ultimately we're here to serve the public and do what's in the best interest of the patient. It's not about economic gain, it's about doing the right thing. The economic gain will come if you do the right thing by patients and do no harm. That's really what I feel.

Howard: And you'll get more word-of-mouth referrals.

Saul: Yeah. Exactly.

Howard: That's AcademyofBiomimeticDent.org. AcademyofBiomimetic, "mimetic" is M-I-M-E-T-I-C, "dent" D-E-N-T dot org.

Saul: Correct.

Howard: Yeah, so you talk to Ray Bertolotti much any more?

Saul: I do, I speak to him a fair amount. He spoke at our meeting. I didn't make it out to Yosemite this year, but I heard him speak in Tahoe in June. He's a great guy. Ray really is responsible for me getting involved in this. I took my first course with Ray over 30 years ago and he changed the way I looked at dentistry.

About 10 years ago, I noticed on Ray's website, I was about to sign up for another one of his update courses and I noticed something about David Alleman. Have you heard of David Alleman, by the way, Howard?

Howard: David Alleman. Spell it.

Saul: A-L-L-E-M-A-N.

Howard: Okay, not ringing a bell.

Saul: Okay. Well David Alleman ...

Howard: Don't tell him I said that.

Saul: I won't say a word. But David Alleman was mentioned on Ray's website as a recommended course that Ray thought people would benefit from. So I called Ray and asked him about it. Ray said, "Well it basically what I do but 2.0. it's just more involved but very interesting and you should give him a call." So I did. I ended up taking David Alleman's course called Six Lessons. He practices in Provo, Utah. He is the one who went through the literature and came up with these biomimetic protocols.

Howard: Say his name again?

Saul: David Alleman. A-L-L-E-M-A-N. 

Howard: A-L-L

Saul: E-M-A-N.

Howard: And he's in Provo, Utah?

Saul: He's in Provo, Utah.

Howard: That's where Gordon Christian is.

Saul: Yes, he's not far from Gordon, correct.

Howard: And Dentsfly, or Dentrix.

Saul: Ultra-Dent.

Howard: Ultra-Dent. Dan Fisher. Okay.

Saul: Yeah, Dan Fisher, right. I took Dave Alleman's Six Lessons course and it just gave even more scientific back-up for what Ray had been preaching and teaching all these years. That really got me turned on and I took some other courses from Dave. Then I went to Italy to Sarginio twice to take courses from Dave' partner, Simone Deliperi. He really has developed wonderful protocols for restoring posterior teeth directly with composite with using ribbon fibers. You know David [Rudolph 00:24:34] too I believe.

Howard: Right. The guy that looks like Einstein that's always riding a bicycle at dental conventions.

Saul: That's him, yep, he's great. Same birthday as my father. It's so funny. Anyway I took those courses from Simone Deliperi as well and I just became better versed in the literature and in the techniques so I began to lecture a little bit about it. I lectured at Penn, I lectured at Columbia, and I've lectured to a few study clubs. I'm basically a novice lecturer, I've only lectured about half a dozen times bout biomimetic dentistry. But I became involved with the academy. We helped, through Dave Alleman's blessing, we helped develop this academy to try to reach out to more dentists and teach them the techniques. That's been the evolution for me.

Howard: That is a wild evolution. Is there any principles of biomimetics dentistry that you can teach on, like names and procedures, or materials or techniques, that you're more likely to do if you're a biomimetic dentist than a non.

Saul: We try to reduce the C factor as much as possible. We try to have gengival margin elevation.

Howard: What do you mean reduce the C factor? Of inflammation?

Saul: No, C factor, the ratio of bonded to unbonded surfaces within the composite, we try to create cavities that cause less stress for the restorative material and for the tooth structure surrounding it. So if you have a lower ratio of bonded to unbonded surface, you have less likelihood of the composite fracturing or the tooth fracturing. So these are one of the things that's taught in these biomimetic principles.

Howard: Can you try to explain that a little bit more? How do you reduce the C factor, 101? Because when you said, "reduce the C factor," the first things I thought of was the C reactive protein.

Saul: Yeah right. We want to worry about that also. We basically try to make smooth line angles. We try not to create deep boxes. If you have a deep box, we try to elevate the box using good isolation techniques so that the composite is placed incrementally and, it's hard for me to explain it more than that. I'm not such a great lecturer, but we basically try to reduce the stresses within the composite by creating less surface area to bond to. We try to create bonding to the best surface. I'm not explaining it that well I don't think.

Howard: That's okay. Does your group like any of these new materials, like you see all of these bulk fill composites releasing now.

Saul: Yes, one of the ways of reducing C factor is by placing composite incrementally. We don't really believe in bulk fills at this point because bulk fills cause more stresses within the composite and within the surrounding tooth structure. Studies show that incremental filling with composites is better for the long term longevity of the restoration. However some of these bulk fill composites have good material properties so maybe using some of these bulk fill materials in an incremental way might be a good thing but that kind of defects the purpose of the marketing of these bulk fill materials. I don't personally believe in bulk fill materials at this point.

Howard: A lot of people say the two biggest pitfalls of adhesive dentistry is that they're not isolating, their not using rubber dam, they're not using Isolite they can't do adhesive dentistry because they don't have an isolated environment, do you always use a rubber dam or an Isolite or what do you do to keep a clean tooth to do adhesive dentistry?

Saul: I usually use a rubber dam on lower teeth because I prefer that to the Isolite. It's very important to have a good result to get good isolation, especially in the mandible. The maxilla truthfully I don't always use a rubber dam because I can get pretty good isolation in the maxilla but I think wherever you can use a rubber dam or the Isolite if that's the preference, is good for the long term prognosis of the restoration.

Howard: Then a lot of people are saying that if they go into 100 dental offices, like they follow the Benko rep, and they'll just follow a Benko rep for a week and they go into the offices and test their lights. A lot of people are saying that half the curing lights don't even work.

Saul: Yeah, you have to monitor your curing light with a meter on a regular basis, like on a weekly basis.

Howard: So what curing light do you have and do you monitor your curing light? Do you measure your curing light?

Saul: I'll be honest with you, I probably don't measure it enough.

Howard: But do you order supplies online or do you have a rep that comes by?

Saul: I have a rep from Henry Schein or Benko, both of them that comes by and I order from them. I let me dental assistant order.

Howard: But they'll measure your light if you ask them.

Saul: I'm sure they would. I do have a meter, I test it every several weeks. I probably should do it every week optimally. 

Howard: Is there any composite material name brands that you like?

Saul: Yeah, I like Tokoyama Estalite Sigma Quick I can use it anteriorly and posteriorly.

Howard: Who makes that? That's got to be Japan.

Saul: Yeah, there you go. Tokoyama. I found out about that through Ray Bertolotti.

Howard: Is that a name brand?

Saul: Yeah, it's a name brand. It's Tokoyama, it's a ...

Howard: I'm going to have to ask you to spell that.

Saul: T-O-K-O-Y-A-M-A and Estalite, E-S-T-E-L-I-T-E, Sigma Quick. It's a composite that can be used anteriorly and posteriorly. It polishes really well and it has very good wear strength. [crosstalk 00:31:01]

Howard: That is interesting. I never heard of that. So Ray Bertolotti turned you onto that?

Saul: He did and as I said, I use self-etching primers a lot, so I use Protect Prime and Bond, which is a very good antibacterial material. It bonds very well to dentin as well. I still etch the enamel though because you're supposed to etch the enamel. You do not get as good a bond with self-etching primers on enamel as you do onto dentin. So I still etch enamel first prior to bonding the dentin.

Howard: So what other products do you like? For your crowns, if you're going to do an inlay onlay crown, are you doing chair side CAD/CAM, are or you take an impression, send to a lab, or how are you doing that?

Saul: I take impressions and send to a lab. I usually use Emax for anteriors and premolars. I actually still on lower second molars I still use gold. I love gold.

Howard: On lower second molars?

Saul: I still do gold. I have a great lab that does beautiful gold work.

Howard: Why just lower second molars? Why not upper second molars?

Saul: I have a tough time convincing patients, I would love to do it on upper second molars, but sometimes you can maybe see a little metal more in an upper molar, so I have a little difficulty selling a patient on gold on an upper molar.

Howard: This is dentistry uncensored and you're never supposed to talk about race, religion, politics, sex, so let's start with race. I've had a lot of success talking Hispanics, Native American Indians, I mean we're talking females, on all of mine or gold. I can always get a short fat bald guy that looks like me to go with gold. I tell him, "Dude, if you go gold, you'll take it to heaven. If I make it all pretty for you, I can't guarantee you'll take it to there." 

Saul: I agree.

Howard: And old, fat, bald, ugly guys like me say, "Yeah, do what's best." But with women, I have no success with white European women, but I can get a lot of my African American women, a lot of my Latinos, and a lot of the Native American Indians. I'm across the street from the Guadelupan Indian reservation. Those girls they're like, "Oh, gold better, go for it." But man, white women, you can't get a white, and she'll have 7 gold earrings, a gold necklace, a gold bone through her nose, gold around her ankle, gold navel, gold sticking out of 14 body parts and I'll try to say second molar gold and she looks like I'm a Martian. Is that the way it is in Manhattan?

Saul: Same, yeah, it's the same. They look at me like I'm from Mars.

Howard: But is that only with white European women in Manhattan? Are you getting Puerto Ricans, Hispanic, will they go gold?

Saul: I would say they're more likely to. I would say white European women will not. They want tooth colored materials. Even though they won't last as long. And I tell them, I give patients the advantages and disadvantages of every material and every procedure that they can have on their tooth because I think that's only fair to inform them and then they can make the a informed decision.

Howard: You know what I think you should do? You're in New York, that's the cultural center of North American. I can still remember, I grew up in Kansas where the tallest thing was grain cellar. I still remember, I was with Craig Styken, it was August 9, 1990, we flew to Manhattan. When I first saw it out of the window, I thought it was Star Wars. It was like the Grand Canyon inverted. We were just looking at that thing, staring out the window, we were 24 years old, no we were 27, just looking at that thing going, "Damn." 

Then we got off the plane and we hit Manhattan and we're just all excited. We threw our bags in the room. We walk [inaudible 00:35:10] we're just walking block to block. Next thing we knew I said to Styke, I said, "God my feet are kind of sore." We look at the clock, it was 3 in the morning. We had just been running from block to block, we lost all concept of time.

But you know what? What if found like Lady Gaga and talked her into going with a gold bicuspid crown. Or some white woman role model that tells these girls, "Look you wear gold everywhere else on your body. It lasts forever. Why do you have a gold wedding ring on and you won't have a gold bicuspid?" So that woman is intellectually ... I always thought it was funny that Marilyn Manson and Lady Gaga, the press makes them out to be crazy; but when you hear them interviewed, they're probably 2 of the smartest people I've ever heard on an interview. Have you noticed that?

Saul: I'm sure that's true.

Howard: So you're taking impressions and sending them to a lab? Or are you doing oral scanning?

Saul: Yes.

Howard: And what is your impression technique? What impression?

Saul: I use a lot of Danville materials. Actually do you know Jeffrey Hoos?

Howard: Yeah, his impression technique where ... talk about that.

Saul: H & H technique. I love it. Actually, I'm a friend of his now, I learned about that from him at one of Ray's courses in Manhattan. He went through it. I use Stiff Bite which is similar to Blue Moose. Have the patient bite down in a triple tray for about a minute, then I have the patient open and I hold the impression in the opposing arch, then I inject [inaudible 00:36:46] which is also a Danville material, have the patient bite down again for about a minute and half, and then I have a beautiful impression. I often don't use retraction cord. But I also don't have the need to do full coverage much. Most of the crowns that I do are retreatments of old crowns that have had recurrent decay.

Howard: He called that impression material HT?

Saul: Well the impression technique of Jeff Hoos is H & H.

Howard: What does that stand for, H & H?

Saul: You know what, I don't remember. I'm sorry. I don't remember, it was a long time ago.

Howard: But basally the concept of Jeffrey Hoos impression was you take an impression first and then you shoot in a softer lighter body under, and it goes in under pressure.

Saul: Yes correct, exactly. [inaudible 00:37:34] very well because when you use a Blue Moose like material which Stiff Bite is by Danville, it has no resistance when you put it in and you're able to monitor the patient's closure very well on the opposite side. Then you have the patient open, and you put in a light body material. That material, the first material sets it very hard and, just as you've said, the compression presses the light body material into the sulcus and you get a very accurate impression.

Howard: And you think that's a good impression technique?

Saul: It's excellent. I rarely have remix. Yes.

Howard: These are Danville Materials. Wasn't Ray Bertolloti, wasn't he part of Danville Materials, that's kind of a suburb, it's actually Danville, California. Isn't that a suburb of San Fran or near San Fran?

Saul: It is, yeah. Cause Ray lives near there and practices near there. Yes, exactly. Yeah. I'm not sure if he is still part of the company or not; but he was a part of the company and he certainly helps them develop materials to this day.

Howard: A lot of that help, he's finding it overseas in Japan, right? I mean that's his big area of exploration?

Saul: Yes, and the Japanese I think are so methodical and thorough in their research and in their materials that a lot of their materials are just superior to ours in my opinion.

Howard: It's funny, my opinion of looking at dental companies around the world, the Americans believe that, you go into American companies and their marketing department is the biggest department in the whole company. They might not even have one single PhD researcher and they're doing a hundred million a year. It's just they've got a 30 person call center, they could sell anything to any dentist on earth. Then you go to Germany and Japan and they just have all PhD scientists They don't even have a marketing department. They just believe that if you make the best product in the world it will sell itself.

Saul: It's more pure. That's what I believe in, exactly. I want to use the best material. I don't care about marketing.

Howard: And then you go to China and they just believe that if you make this so cheap and so inexpensive and so low cost, people will just buy it [inaudible 00:39:53] I always think the Americans, the Germans and the Japs, they all need to learn from each other. The Americans all need to add double down on PhDs and research. The Germans and the Japanese need to learn for the first time how to market and advertise. They still are completely clueless when it comes to marketing and advertising.

Saul: Right. It would be a perfect marriage. I agree with you.

Howard: Oh my God. All the American companies should buy a German and a Japanese company and the Americans will bring the advertising and marketing, and the Germans will bring the PhDs, it'd be perfect marriage.

Saul: And the quality. Exactly, I agree. 

Howard: But it's true. I remember going lecturing to a company in Switzerland right at the base of that big old mountain, the Matterhorn. These guys, they didn't even have a marketing department. The guy was looking at me like, "Well can't you just go back and tell your friends?" That was their understanding of marketing. Unbelievable.

So this mimetic dentistry, what lab do you use?

Saul: I use a lab who I've used, it's a one person lab, for about 30 years. He's in New Jersey. I'd rather not give the name on this podcast, but if someone calls me I will give them the lab because I want him to have time to do my work. He does beautiful work anteriorly and posteriorly. He's about my age, so I plan to practice for many more years and he does too.

Howard: Well, what is your age?

Saul: I'm 62. 

Howard: And how many years do you want to still practice?

Saul: If I'm healthy, which I seem to be, I'd like to practice 'til I'm 80. I mean I may not want to practice quite as long hours as I do now; but I really love what I do. I'm just trying to make a difference and do the right thing for my patients. I love my patients.

Howard: So what is it, everybody that's wrote a book in my library here, they were all found dead at their desk or at their job, or the battlefield, none of them retired. The thing that's interesting, you're 62 and you want to go to 80. Don't you think it's a red flag when some 40 or 50 year old dentist says I want to be retired in 5 years and he's just socking away all this money, just wants to get out and he wants to retire. Mother Teresa of Calcutta never retired. Popes die in the office. Don't you think, when I listen to a guy like you, dentistry is a vocation. You have a purpose, a cause, you're helping people, and you just want to die in the opertory. 

The ones that just want to get the hell out of dentistry today, I don't think they have a vocation. I think it's an occupation, they hate it, their trading time for money. What would you say to that 40, 50 year old kid 'cause I'm thinking maybe joining your biomimetic dentistry, I just want the dentist to be happy and healthy. Sometimes if they buy a laser, or they go to LVI, or they get into sleep medicine or seek some into ortho, I just see so many dentists that weren't having fun, and then they added something and it just gave them vitality and life.

Saul: This has done that for me. It's really honed my skills. It's given me a scientific basis for what I do so I feel better about what I'm doing for my patients. I also feel that I'm doing something that's more economically viable for them. A lot of dentists burn out, I think, because they're doing all these crowns, they're doing all these laminate cases, and they're exhausted. I think at the end of the day, their inner soul is telling them maybe I could have done this more conservatively and for less money for my patients and it would have been a better service. Less is more often. 

Maybe that's why I feel like I can practice till I'm 80. I do yoga everyday, I meditate, I exercise, and I try to eat right, and I try to do things in line with what I think is proper for our patients. We're supposed to do no harm. I see a lot of young dentists unfortunately they're in a lot of debt coming out of dentistry, so they go to these mills and it doesn't feel good necessarily at the end of the day what they've done. 

I think this is a good answer. You can build your practice by doing the right thing for patients. You won't make as much money necessarily but you may be able to practice longer and you'll feel better about yourself at the end of the day. That's my feeling.

Howard: That was just poetry. Whenever you do something you don't feel good about for money, it's always going to have a rebound effect and come back and bite you in depression, substance abuse, irritability, anger issues, every single monkey on earth is going to die some day and be dead anyway. We're all going to die anyway, you might as well spend your life doing something you feel good about.

Saul: Exactly. It's much better. I can sleep at night.

Howard: Yeah, and if you live our life with purpose and when take your last breath, you say, "Wow, that was great. I left the playground better than I found it. I did a good job. I tried to help. I lived with love and passion and purpose and it's all good."

Saul: That's right. Exactly.

Howard: But when you're sitting there doing things you don't like to do for money so you can get to the top of the hill, you're just going be living a life of misery and depression and disease and all of that.

Saul: I totally agree Howard. It's true. Very good. Thank you.

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