Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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1123 Richard G. Stevenson III, DDS, FAGD, ABOD, Founder of Stevenson Dental Solutions : Dentistry Uncensored with Howard Farran

1123 Richard G. Stevenson III, DDS, FAGD, ABOD, Founder of Stevenson Dental Solutions : Dentistry Uncensored with Howard Farran

1/11/2019 11:03:28 AM   |   Comments: 0   |   Views: 384
Doctor Stevenson received his Bachelors Degree in Chemistry from UCLA in 1982 and his Doctor of Dental Surgery from the UCLA School of Dentistry in 1986.  After practicing general dentistry for 7 years in Laguna Niguel, California, he accepted a full time teaching position at the UCLA School of Dentistry, as an Assistant Professor in the Section of Operative Dentistry.

VIDEO - DUwHF #1123 - Dr. Richard G. Stevenson III

AUDIO - DUwHF #1123 - Dr. Richard G. Stevenson III

Howard: My oh my do I have a treat for you today. We are gonna podcast Richard Grey Stevenson the third DDS. He has his bachelor's degree in chemistry from UCLA, in 1982 is Dr. dental surgery from UCLA and 86, after practicing general dentistry for seven years in Laguna Niguel, California, he accepted a full-time teaching position at the UCLA School of Dentistry as an assistant professor in the section of operative dentistry, for four years he served as the chair of the preclinical operative dentistry course reauthorizes Illustrated syllabus of operative dentistry. Dr. Stevenson has been recognized by his students on five occasions as the Teacher of the Year and has received numerous additional teaching awards from 20 different classes of students. He also received the UCLA Academic Senate Distinguished Lecture award for non Senate faculty in 2003. In 2009 he received the ADA distinguished Golden Apple teaching award in both the pre-doctoral and postdoctoral categories, in 2005 he received a fellowship in medical education from UCLA School of Medicine. He has over he has published over 30 articles on dental materials and the principles of evidence-based dentistry and restorative techniques in peer-reviewed journals including operative dentistry, evidence-based dentistry, the Journal of aesthetics and restorative dentistry. He's the co-author of a book chapter on Cast Gold restorations in summits fourth edition of "Fundamentals of Operative Dentistry" the chapter on implant occlusion in the new book "Implants in the Aesthetic Zone" and the chapter on complications and restorative dentistry best practices. He has authored numerous syllable guide instructional guides and all aspects of restorative dentistry for UCLA and other schools. He is the inventor of the RGS instruments, a series of for calibration adjuncts to assist students in Venice with evaluating preparation parameters. He is a reviewer for the Journal of Operative Dentistry and the ADA professional product review. He's a member of numerous dental organizations, since 2008 he has been the secretary of the academy of operative dentistry where he previously won an executive counselor then president and a second secretary. He is a fellow of the Academy of General Dentistry and the American College of dentists, he has been a charter member and past president of the Orange County RV Tucker Cast Gold study club since 92 and has demonstrated cast and direct gold techniques internationally of both the Academy of RV Tucker study clubs of the american academy of gold foil operators. In 2003 he was appointed as a mentor of the Los Angeles cast study club additionally Dr. Stevenson has been mentoring four other casts gold study clubs, two in peru one to the pre-doctoral UCLA students and one in Tokyo, Japan. Dr. Stevenson was the secretary of the academy of RV Tucker cast gold study club for six years until 2011. He is both a lecture and instructor in the UCLA aesthetic continuum the surgical and restorative implant continuum and has led numerous hands-on aesthetic sessions for visiting academics and study clubs at UCLA and abroad. Dr. Stevenson has given over 500 continuing education presentations and table clinics and restorative dentistry internationally including the Philippines, Peru, Japan, China, Korea, Canada. In 2007 he became the 58th board-certified operative dentist of the American Board of operative dentistry, in 2006 he was inducted as a member in the American Academy of restorative dentistry the only other UCLA faculty to achieve this honor was the late Professor Robert Wolcott. In 2011 he was named the UCLA School of Dentistry alumnus of the year in recognition of his outstanding contributions to organized dentistry, the school, the community and the UCLA Dental Alumni Association. He is currently professor emeritus of clinical dentistry and served as chair of the section of restorative dentistry with over 100 faculty members for 17 years, he has made numerous instructional videos and restorative dentistry techniques including ceramic inlays and onlays dental materials, impressions and dental photography. These videos have been viewed by thousands of dentists at internationally. In 2009 he created the two-year postdoctoral advanced restorative clinical training program, he practices dentistry in West Los Angeles with a focus on microscope dentistry implant restoration and aesthetics. He started a YouTube channel which I love in june of 2018 and in six months has over seven thousand subscribers, in 2015 he started Stephenson Dental Solutions a teaching Institute and master billing Center a dental laboratory in 2014. He lives in Los Angeles with his wife Savi did I pronounce that right Savi?

Richard: Perfect

Howard: Thank God, seriously I am so honored, when you emailed me back and said you would come on the show I literally yelled yay. Thank you so much for coming on the show today.

 Richard: It's a pleasure Howard.

Howard: So restorative dentistry gosh darn I graduated in 87 and the hot new thing was the PFM and we did mostly amalgams and composites and when I tell you this I don't know if you're old enough to believe this or not but our operative dentistry instructor made a sign of ethical pledge that amalgams and gold were superior and these newfangled composites were unproven garbage and he told us when we left, if you are an ethical dentists you'll stay away from these new composite plastic things and stick with their gold and in my all seven of my restorations or gold inlays onlays I don't have a compositem so man things have changed in our careers haven't they?

Richard: They sure have and for the better I think.

Howard: So is gold now you're out there and Los Angeles and Hollywood ville I've always what is gold there's anybody like gold restorations or that just no...

Richard: I think it's both because theirs a group of people out there that are seeking longest lasting restorations and  they find people like me that can do gold restorations. In Los Angeles where you would think that everything is focused on the aesthetics and those maxillary anterior teeth looking absolutely beautiful and that'd B-1 shade you'd be surprised how many of those very same patients will say okay to a golden inlay on a second molar or an inlay on a first molar. So I think it has its place in dentistry and unfortunately it's pretty much lost its traction in dental schools at this time, very very few schools are teaching the kind of gold work the you and I did routinely when we were in dental school.

Howard: Well one of the things I've noticed on Dentaltown is that when anybody publishes a study that says posterior composites last six or seven years and amalgams last 30 or 38 years, every single dentist on earth says well not my composites, maybe everyone else's composites last six or seven years for mine lasts as long as amalgams or gold. Do you think the average MOD composite is lasting as long as the average MOD amalgam or MOD gold inlay or onlay?

Richard: Well it's not what I think it's what the literature shows us and that's simply not the case, the amalgams do outlast those routine average restorations but I think your point of your members and is well taken that if they're done exquisitely well I think composite restorations have very long durability and very long lifetime but doing really well means doing things like placing rubber Dam, means using high magnification it means making sure that you're curing lights are calibrated properly. Curing the composite, it means layering techniques, it means understanding the occlusion and polishing the occlusal surface really well, it means a lot of things and I think that may not be the case in the average composite. I think that the average amalgam on the other hand boy it's a very user-friendly material you know you can place it under water even it still works and I have seen very average operators place amalgams that last many many many years but have a lot of trouble with composites but after they get some education in composites they can usually plays some quite well but I think the proviso is and other manufacturers say this and all the studies that look at composite longevity are looking that lasts as long as amalgams for example are looking at the ideal placement of these restorations. So I think that's important for people to realize.

Howard: So podcasters tend to be young, about a quarter of our audience is still in dental school it seems like almost all the rest of them are under 30 in fact please leave comments and your watches on youtube leave a comment tell me how old you are, what country live in or email me but what advice would you give to a youngster that, there's a big threat on Dentaltown this weekend and this dentist said he just graduated he's afraid to get a job as an associate at any of these big national chains because it just takes them so long to do an MOD composite. So I know what he's thinking listening to you right now, he's thinking well you will you walk me through MOD composite and the reason the way I'm asked is question is when I look at insurance claims filed of the 32 teeth or just these four big spikes on the first molars I mean what's the tooth most likely be root canal, crown, extracted, replaced. So will you just walk through an MOD composite on a first-year molar.

Richard: So you're asking me to walk through the process of how you'd actually technically do that?

Howard: Yeah because they want to know like name brands, now you got a lot of YouTube videos how many YouTube videos do you have on your channel?

Richard: I think I have about 45 right now

 Howard: and how do they and what's the name of your YouTube channel


Howard: So that's the same as your website Stevenson, by the way and that's why I called you to be on the show, I am so impressed by your YouTube channel I mean you just you can tell you really really put a lot of time and effort and work on those that's amazing. So is there a particular video in but you got a lot of videos on the YouTube channel but going through the deal like is there yeah just go do your technique in general.

Richard: Sure okay so I you know first of all I can totally relate to this student that is concerned about working in a majorchain like this, because they're he's gonna be pushed beyond his capabilities by the system that exists in those types of practices and I share his concern. I actually started out in dentistry the same way I graduated in 1986, I couldn't get a good associate job the only place that was hiring was more of these corporate large dental practices, they've been around a long time and while I was building my private practice I had to work to pay the bills so yeah. I almost got sick to my stomach walking in these places and in seeing that I had three or four operatories with patients all in them already and they're saying okay get him done and then as soon as I finish a patient at room another patient be plopped in the chair and it was it was hard to do. I mean you're used to doing restoration in three hours and now you have to get it done and I don't know how short of a time it just you could never be fast enough you were always being pushed and I had a hard time with that I really did. I always thought to myself I'm not going to be the fastest person in this clinic but I'm gonna be the best so at least I had that and that was my approach for those first few years when I was doing that and I advise my students the same thing. I mean the reality is you graduate from dental school today many of them have $500,000 in debt I mean that's that's a mortgage payment. I mean back when we were in school we graduate with maybe thirty or forty thousand in debt and we paid it off in five years now they're paying off these loans in 30 years and that's it's a huge huge burden for them so I think that the reality is they're gonna have to find jobs wherever they can and my recommendation has always been this be the best don't be the fastest be on the verge of being fired at all times and then you'll probably do the job right because you're just a little too slow. I didn't think that that's probably what we should be doing don't get pushed on your abilities. Now for the MOD composite the procedure doesn't have to take an hour, you can do this procedure quicker you can isolate fewer teeth with a rubber dam and I think it actually will save you time once the rubber dam is in place and then once you've done that you just need to follow a systematic approach. So we start with our burs we remove the old restoration or we start the procedure and then we obtain the extensions as we would in and all of our board exams stuff we know how to do quite well but once that's all been established I think that we ought to use the manufacturers bonding agents exactly as they're intended so whether you're using a fourth generation, fifth generation, six generations, seventh generation, a universal I think that what's really important is that you use it properly. I personally prefer using Total Etch or Self Edged System with multiple bottles I like that I was raised on that I think that that's probably the the king of the bonding agents but whatever system that you're provided at one of these clinics or that you choose to go for what can be used quite well if you follow the manufacturers recommendations. Okay so the tooth is isolated, the caries have been removed you got your prep done you're feeling pretty good about it and that shouldn't take you more than about five or ten minutes even for a dental student if you're really pushed without anyone having to check every little step you do you can get it done pretty quick, We've done this experiment at UCLA years ago we gave students we said you have five minutes to do a class two and the entire class after five minutes had to get up and leave the room and we saw some amazing preparations it's almost no dinking you just gotta get right down to business. In any event what I like to use are one of the sectional matrix systems and there are many out there I think that they all have different nuances they're very expensive so I recommend that you probably just invest in a couple of them ones that you like. I like Garrison's product the fusion system is amazing but it's quite expensive the system by ultradent called the Vring system is very very good also quite expensive. Their are others that you can shop around for that are significantly cheaper that I think are quite good. So once this material section matrix is placed I would recommend utilizing a centripetal wall technique so the composite could be placed in the box and then pushed over towards the band light cured and then that band and matrix assembly can be removed and then you have the opportunity to do the same thing on the distal side and then you turned your class 2 into a class one and I have at least two or three videos showing this particular technique on my youtube channel and I go through each and every step. This relieves you of the need to use a bulk fill product or tophameyer system. You don't need to use a flowable composite for this particular technique you can use good Micro hybrids nano hybrids or hybrid resins and this is so predictable now you've turned this class 2 into class 1 and at this point you build up the lobes, rather than thinking about pushing it in like you would amalgam think about building the morphology the tooth back incrementally and usually you can accomplish this in about 4 steps and then you've got your beautiful Anatomy completed. If you follow this you can save a lot of time in the occlusal adjustment aspects of things. So people say well why that's just so tedious you have all these little steps but I'm thinking no it's it's not tedious ultimately because your occlusion is going to be closer to ideal you're not gonna have flash to clean up you're not gonna have blood in the way because of the rubber dam protecting you, so I think that this can work really really quite well it's a system and the key is don't shortcut the system, think about the system as being a step one through ten and we can't just do from one to four to nine to ten, it's not going to work consistently for you. Cou can have problems like post-op sensitivity issues, you're going to have other dentists in your same group having to replace your dentistry. You're going to get the stink eye of the office managers for problems like this. So I think that it's really critical that you follow a system and the thing that's amazing is that the system gets shorter and shorter and shorter but you don't skip steps and that's the thing that that happens with continued competency and with this quest towards mastery it's not that you're short cutting those steps is that you're able to do those steps more seamlessly in a shorter period of time and have the same quality output.

Howard: What brand of compositor they all what bonding agent in composite do you recommend?

Richard: I am a big fan of hers product called optibond FL it is a fourth generation total edge system and I've been using that for many many years and I was we researched all the products that we could use at UCLA and this is the product that we chose for our own students to learn with and so if problems were occurring based on you know this product not being user-friendly or issues with the students we'd hear about it really quickly. So you know we have a hundred students operating in the clinic and in any given day and we would see that there would be issues. So the dental school environment was a great place for this  - it means proof of concept and I happen to find this to be an amazing product. It's just one extra step in the bonding procedure compared to a single step procedure and it doesn't take a lot of time and post-op sensitivity is quite minimal. The composites that I use are various and I do like 3m products I like to fill tech Supremes, I think that they tend to be a little bit translucent for anterior work and they're a little fussy in that respect. So sometimes I fall back on tried-and-true products like percolate xrv, one of the older hybrid composites, a very versatile product it doesn't polish as well in the anterior but it does provide us with the opacity we need for maybe a class for restoration. Well sometimes it's even good to have a couple different types of composites so have a nice hybrid composite for building that class four a restoration on the lingual and then adding a micro nano fill for the facial aspect of it for the surface so that we can have a nicer finish and a better looking restoration down the road because it's true that the micro fills and nano fills hold a better polish than the old hybrid composite materials.

Howard: Well if I asked dentists what is the biggest stress about an MOD posterior composite they always say contacts or sensitivity. You know you talked at the beginning about how you like the Garrison Diffusion system and the V ring, so again will you just go back over contacts and sensitivity since those are the two biggest complaints.

Richard:  Right,

Howard: First of all do you agree that's the two biggest complaints?

Richard: I do I think it's exactly what's happening and their's about 10 reasons for sensitivity to occur and sometimes we focus on well maybe it's just the bonding material and I didn't get a good seal but there are many other reasons for example you could be etching the adjacent tooth inadvertently which could cause sensitivity. You can leave the occlusion slightly high, you can have gaps, you can have a light system that's not curing the composite adequately which leads to all kinds of sensitivity, perhaps you're not incrementally building up the composite so you're putting stresses on the composite you're not considering the C factor the configuration factor. So all of these things can contribute to to sensitivity and I just think it's just follow this, follow the steps you know one through whatever step you're doing and do it the same way every time and I think that if you follow the manufacturers recommendations and like I said on my videos I've got the techniques very well explained. I think you're going to avoid sensitivity when it comes to contacts, I think that we pretty much solve that problem with the sectional matrices and as long as you are using a good spring on these sectional matrices not a used one that's old and not doesn't have a capable of providing adequate tension. I believe that these are very predictable ways of ensuring proper context is, what's really key here is you cannot rely on a traditional Tofflemire matrix system it's not going to provide you consistent contacts that we were able to achieve for example with our amalgam restorations that was easy because you're able to compact the amalgam against the band you're able to burnish the man it works very differently. Composite as much as we think, it's packable, is a very passive material it goes where the walls tell it to go. You can't have composite push the band into position the band is going to push the composite. So whatever you set up before you start restoring has got to be forming a potential tight contact before you even place the composite and I think that those are just you know little tips to help us with those two issues and I completely agree those are killers and if we finish a composite we have an open contact game over that's a failing restoration from day one patients going to complain they're gonna get food packed in there and then it's embarrassing for us we have to do another restoration we have to do it for free and the patients losing confidence in us and what's it ensure that we're gonna get it right the second time right. I mean so this is this is a big issue and I think that just takes a little bit of time to make sure we manage to sectional matrices and the G rings or V rings properly and we can accomplish predictable interproximal contents.

Howard: You know their seems to be two strategies in dentistry, either they're low cost high volume dentists or they're high cost low volume and man I just don't think dental surgery and operatory is a game of volume and when I started hearing dentists talking about well I don't want to use this bonding agent because it's two step, I'm going to use only a one step. It's like could you imagine me being a 56 year old grandpa going in for a prostate surgery or a bypass the guys saying well want to do this better prostate surgery, I want to use this one because it's one step slower and so that's my trends, a guy like yous got a microscope which leads me into my question about bulk fill these guys say oh I don't want to have I don't want to use a two step bonding agent, I can use a one step and why would I want to put an increment if I can just fill that with bulk fill. So what is your words of wisdom to somebody using it once that bonding agent want to do bulk fill is it is that good enough for your children and grandchildren or...

Richard: No I it Howard it isn't and I always laugh because the amount of time you're saving in the operatory I don't think any study has shown that that has provided the patient where the better service or even an equal service, it hasn't allowed you to make a better income I don't think it allows you to sleep better at night either. I think that the joy of dentistry is in our quest for mastery and our quest for excellence and I think that's one of the beautiful things about our profession, is we're like that we want to be that way we were like that way in school, we were hungry we wanted to learn. I think that students today are very very potentially amazing dentists I think that we're putting out the best potential masters right now in dental schools the educational system is incredibly good at doing what they do. The problem is once they get out of school the pressures are on and it's very difficult to create this consistency that I think you and I experienced. When I had got out of dental school 1986 about the same time you did if I spent an hour on amalgam that was the way was that was fine. I made a living I made a good living and things were working quite well in that particular practice model. Today am I slow maybe a little bit slow compared to some of the fastest operators in those clinics but I don't think that the speed, but I agree with you I think that if you treat every patient as though where they were your spouse, mother, father, or kid I think that you're gonna perform the best possible dentistry and you're gonna see time as being irrelevant because we have to provide quality dental care for our patients. So we just we're bound by that, that's an oath we basically taken.

Howard: but by the way and not that you don't need any marketing at all I mean you guys haven't you have over seven thousand subscribers on your YouTube channel but on Dentaltown when you make a post, you know the YouTube channel huge share and first it shows you link and the next button over embed that's your code and on Dentaltown you can click that embed and drop that embed video in a post. So your YouTube channel is in the post and every dentist who starts posting their YouTube channels on Dentaltown, their YouTube channel will double because their's a quarter-million dentists on dental town and my job is to point them in the direction of great content and I think your videos are just amazing and I think you should and if you're shy I'm just saying Howard told me to do this dentist guy told me to do this but I wish people look at your YouTube channel videos because the attention to detail is amazing. I want to only switch gears completely talk about your journey to start your Stevenson Dental Solutions continued Education Center. Tell us about your journey. By the way on Instagram he's "Stevenson Dental Solutions" and thank you so much to the 25,000 dentists who follow me on Twitter @Howardfarran I just retweeted he's @doctor_RGSIII so that's that's his name Richard Grey Stevenson the third and I just retweeted your day, he just said I added a youtube video and by the way it's a class two amalgam preparation. So is the amalgam I mean you just did a video on amalgam preparation you're out there in LA is amalgam still alive is it still a restoration out there in LA?

Richard: Barely barely alive barely alive but you know one of the things about amalgams is it teaches us how to use our instruments and our hands really well, it's a great skills training exercise. So dental schools that aren't even teaching amalgams formerly in the in the clinic are still holding their students to this to the standards of trying to achieve that ideal amalgam preparation.

Howard: I just have one one thing I want to remind people when it comes to amalgam is I've had the honour to lecture in 50 countries and I'll never forget being in some developing nations one time was in Tanzania and this dentist wanted to show me his office and he wanted to do he wouldn't be a cosmetic dentist and he did the preparation and the patient would sit up rinse and spit in a pickle bucket and then he would put on the acid etch and during every step this this little girl kept leaning forward and swishing and saying no rubber dam no assistant no high-speed suction and I was looking at this and I mean it was an amalgam on this poor little girl probably would have lasted 30, 40 years. No suction no rubber dam and I watched the whole procedure it just couldn't have been anything but junk and this poor little girl paid all this money but what's this guy doing he's on the internet he's on YouTube he's hearing people in rich countries like United States and Canada and Australia, New Zealand trash-talk amalgam and it's like dude their's seven and a half billion people on earth their's two million dentists and over 1 million of them practice without high-speed suction, a dental assistant and so you know it really makes me cringe when people trash talk amalgam and then when countries say that they should ban amalgam, it's like well if you forced a hundred poor developing country and got rid of their amalgam and then those dentists are doing direct composites without high-speed suction and dental chairs, rubber dams, what do you think would happen to the quality of that country's dentistry so-so but anyway so what possessed you to make the amalgam preparation just for just good skills to know?

Richard: Good skills to know, I think it is a viable restorative technique that should stay alive in some way. You know the pressures politically here in Los Angeles are extreme not to do amalgam, so we have water line management we have disposal management it is so tricky nowadays I don't know Howard I think that that your feelings of my feelings are very similar about this but what's going to change I mean how is it going to change. You know you mentioned developing countries not having the adequate technology to perform composites properly, I totally agree with that. I think that an amalgam in those particular situations is the best procedure possible for that little girl. Its it's sad to see this happen. I won't say that I've completely given up, you can see that in my own subtle little way I'm putting out videos on amalgams and amalgam finishing and polishing. I have a three-part series on the large amalgam including how to finish and polish it and that has been an extremely popular video. So I think that their's perhaps some hope that it's going to stay around but the political culture environment is so very strong and social media has really helped to basically put the amalgam as the least likely procedure to be done by pit that patients are going to ask for so I I don't know what the answer is. I think that having the amalgam out there and just saying hey look this is a possible procedure for you, this is how they look when they're done properly and they can last that patient many many years. You know on the cover of the ADA Journal I think it was probably about 15 years ago there is a picture of a premolar with a class-two amalgam in it and it was a close-up and the amalgam was done by Dr. Miles Mark Lee and Dr. Miles Mark Lee was a master clinician and he use to teach at University Colorado and he was a big fan of amalgam and you looked at the amalgam you said yeah that's an old amalgam but gosh it's a pretty good man, it has a nice contact the margins are sealed it has really nice Anatomy and you can tell that it had been polished at one point now it's a little bit worse for the wear but their's no need to replace it and the caption at the bottom of the page said this is a this amalgam is 58 years old and I don't believe that we're going to and I think that it's sad that that's happened but what can we do other than try to get people to do composites are better and maybe consider amalgams and patients that are looking for some kind of different solution.

Howard: Well talk about your journey that led to the Stephenson dental solutions on continued education center in west LA.

Richard: Well I got to tell you I love teaching at UCLA, UCLA it was a very good for me and good to me and I love the students in all dental education environments their's a changing political regime, their's an administrative branch that you know the one year it's very conservative, one year it's very liberal and you just have to sort of navigate through that process and I think after doing that for 26 years I was pretty much ready to branch out on my own because I felt like in the academic world you're a little bit held back from really doing the teaching and creating new things the way you really want to because the realities of the dental school environment, you mean you have to teach, of courses, you have faculty you have a lot of administrative responsibilities. So I just have to ask myself what do I love doing the most well I love dentistry and I love teaching and when I looked at my job walking in every day as chairman of restorative dentistry I said Wow I'm not able to teach very much and I'm not able to do that much dentistry. I'm a late seeing patients a day a week, I'm only able to teach maybe a day a week in the clinic the rest of the time I'm doing administrative work. So I said what can I do to change this and the only solution I could come up with I just had to retire, so I actually retired early after 26 years but actually in the academic world that's still kind of early but I found the solution in teaching outside the school teaching the way I want to teach. Teaching in a I think in a way that probably challenges students more, provides students with more of a gut check when things aren't going well in other words photographing their work midway through a project and then showing that work on the screen for all the other students to see and critiquing what's right and what's wrong about the procedure and giving helpful hints. Do you think you can do that in dental school, no way that never can happen but in my Center I can do that. I can show them live demonstrations, I've got multiple video cameras I have different types of magnification systems I've got you know HD TVs so we're showing the procedures live I'm doing them the students are watching me make mistakes they were watching me struggle through certain aspects they're seeing that I have to change strategies they're seeing an honest approach to the fact that dentistry is not easy and they love it they absolutely love it because they're liking here this guy with all this experience he's struggling and he's showing me ways to come up to - you know conquer over these these shortfalls and errors that he's making and this is really cool and so there's a certain approach ability with that. Their's a friendship that can occur in a small environment and I only take 12 people, my courses are always limited to 12. So I get to know everybody really well and we spend most of our time doing the work. It's not about talking about it you know you go to a dental conference today and you're gonna see highly photoshopped beautiful european-style gorgeous dentistry and I got to tell you that's not the real world. That probably took that clinician three days to prep that tooth and make that final restoration with the laboratory technicians standing by in the entire time and to present that as though this is what's achievable. I think it's inspiring but at the same time it's certainly doing a disservice to us because it makes us feel like gee I'm not that good and so what I try to do is tell everybody hey look you probably can't be that good in a real world situation but let's strive for that and let me show you the ways that we can get a little closer to that in a real world way. You know in our private practices, it doesn't have to be expensive, it doesn't have to involve these unreachable levels of ceramic you know mastery we can do this in our own practices if we understand the techniques. So that's our approach and I do courses for general dentists that have many years of experience they love getting new techniques for example, we do posterior ceramics courses where maybe a dentist is a little bit unsure about a certain immediate dentin sealing or how to handle covering a cusb just exactly the right way. So they'll come to the course and they'll be sitting next to a student that's just graduated six months before and the two of them are learning simultaneously new techniques and this is hey we're all in this together type of a feeling and the like I said the first thing I do is all prep a tooth and I'll make a mistake and everyone goes ah cool mistakes can be made how does he overcome the mistake, yeah oh I get it and so this does this process is really really fun it's hard to do that in a dental school environment it's really hard to do that in a CE course for that matter as well. Most CE courses and you know I'm thinking, speaking of the ones that I've taught all over the place typically try to fill the classroom with a lot of people and so you'll get 25, 35 people and a hands-on course and the structure doesn't get to know anybody's name they don't really get to push people they don't have the opportunity to take for it to you know make videos live or photographs and show the work that's being done by the participants and they have to it's a different model. So that's been my approach, so I think that my niche is is definitely one that has not been filled previously, it's gaining a lot of traction I'm absolutely shocked at the growth of my YouTube videos. I cannot believe it that in just six months I went from zero subscribers to over seven thousand and it doesn't seem to be letting up I'm picking up about 50 subs every day. I have about 50 videos that I already have in the queue that I'm going to be putting out I'm digging this, it is a superfun. The comments I get are awesome and when I'm wrong and I get a comment that someone has a different opinion I'm always happy to entertain it and say hey that's a really good piece of information and it's all include that in a future video and I think that that's how we all learn. So that's the inspiration Howard, I wanted to take the skills that I had learned from my mentors the methodologies in teaching that I learned from my dental educator mentors at UCLA and my passion for continuous hard work and improvement has those three things have really formed my motivation to start my own Center for teaching.

Howard: and your courses are at on San Dimas California you say 15 miles west of Ontario International Airport is that Toronto Ontario Canada oh haha

Richard: San Dimas is famous for two things Bill & Ted's adventure and the waterslide it was the first big waterslide in the United States so and it's a sleepy little town of about 35,000 it hasn't grown or shrunk in the last thirty years and it's a very nice non LA type environment and we have a great Center there with very large hands-on stations and my wife makes lunch for everybody, we get to know everybody quite well we go out to lunch together when she's not cooking and it's worked out really well for us.

Howard: Now the ontario International Airport, is that the one that's also called John Wayne?

Richard: No that's an Orange County so Ontario International Airport is about 40 miles maybe about 35 40 miles east of downtown LA and it's an airport where you land and you can walk to your car and there's no traffic and so you get airport there's no traffic it's the only problem with Ontario International Airport is we don't have flights from every city yet so it's you know harder to get to the airport.

Howard: So another thing I wanted to ask you and by the way this is not a commercial I asked you to come on the show you didn't ask me I'm a big fan of your YouTube channel and I hope you post a lot of these YouTube videos in a thread because you said you have 7,000, I think you can pick up several thousand more by this podcast and posting these on some of these on dental town but is there any order? I'm looking at your 2019 courses March one posterior ceramics, April anterior ceramic veneers April Cast gold restorations and then you have anterior composites, you have diagnostic diamonds, posterior composites, implant, restorative, posterior ceramics, anterior ceramics, anterior composites, diagnostic. I mean is there any order like do you recommend they have to take the diagnostic diamond where they start drilling filling in

Richard: No, not at all.

Howard: Well I did I want to go through these courses and just tell me some. So you're saying there's no order you have to take them in?

Richard: It's nice to take the diagnostic diamond first but it's not absolutely necessary

Howard: Okay well let's talk about something square, posterior ceramics I mean whenever you say ceramics is that an indirect are you a big fan of CAD/CAM oral scanning? Talk about posterior ceramics.

Richard: I'm a fan of all of it, I scan, I've been scanning since the early early days I've been a trained in CERIC 26 or 27 years ago and have gone through all the evolutions. I was the one that brought the cad/cam technology to UCLA in the restorative department years ago

Howard: From France?

Richard: No I brought the Sirona CEREC technology to UCLA as a teaching and clinical treatment option years ago. So we basically went from impressions with traditional materials to scanning as an option the students do both. I personally am going to be teaching the course with scanning as an option to conventional impressions, so both can be done I think that you need to know how to do both and the the key is that the tissue management for scanning and the tissue management for taking a conventional impression are exactly the same and that is the hardest part about impressions. So whether you scan it and you get this incredibly accurate scan that you work from or whether you take a conventional impression you need to manage the tissues properly and that's a big part of what we talk about. We talk about indications for onlays and partial coverage ceramic materials. When can you do something less than a full crown, when is it okay to keep things super foreign gingival what about bonding do we have to bond every crown we do or can we use conventional cements on some and bond others and what are the indications for those, how did we polish these materials, how do you polish zirconia. I mean this hard hard product how do you polish that compared to Emacs how do you deal with feldspathic materials and so their's a lot of confusion their are a lot of materials their's a lot of things evolving, a lot it's a significantly you know evolving science. So we stay on top of it I'm constantly going to conferences I'm educating myself bringing new information to our courses but the course is pretty robust because it's many many hours of hands-on training where they actually get to prepare the teeth and fabricate restorations out of ceramic and cement them. So they get to go to go through the entire process and if you are somebody that's never done an indirect posterior ceramic restoration and you read an article or watch a YouTube video you're not going to have the confidence or the abilities to really do that predictably in your practice. You've got to be taken to the next level you need a mentor you need to be able to prove that you can do it you need to sit down and go through the steps and not just listen to somebody talk about it and try it on a patient. I think it needs to be taught at a higher level and that's  where our courses are coming from. I start the day with a very short lecture probably 45 minutes to an hour that's it and then we get right into the hands-on and then we stop people at times when we bring up little five-minute lectures or little demos or such such and such and this is how the the the courses generally go they're not filled with six hours of lecture in a two hour time slot to throw in a little little practice on an extracted tooth. I do think that that's typically what most hands-on courses do in the CE community and I think that that's a much less effective than than what we're doing.

Howard: So and by the way when you get your FAGD it's 500 hours of continuing education in five years all day exam but when you get your masters in the HD it's another 600 hours that 400 hours of those have to be hands-on, you could get a lot of hands-on hours going through these courses. I'm gonna go back to, this is dentistry uncensored I don't want to talk about anything everyone agrees on. It's really stressful when these kids have four or five hundred thousand dollars of student loans and then they're looking at a hundred and forty five thousand dollar cad/cam and they're already half a million dollars in debt. Would you say just go for it and spend another 145 which is another year a dental school.

Richard: No I wouldn't I don't think that's a smart move at all. I think that if you're gonna first of all you have to understand when you have a CAD/CAM and a chair sight milling machine you are the laboratory and if you really want to be the laboratory and if that is your passion then fine go for it and get yourself in more debt and it's going to take you a long long time to see the return on that investment. My recommendation is this, go into the digital world a little bit more carefully, go into the digital world slowly you can purchase scanners with open platforms that can be purchased for a fraction of the cost of the milling machines and then you can start scanning and outsourcing those to laboratories who will then take the STL files and fabricate the restorations and see how that goes first and if that is something that you're just loving but you want to be able to provide the patients with a faster turnaround time, okay buy the milling machine but once you bought that milling machine you have just committed yourself to a big expensive piece of equipment. It is going to break down, it is going to have the need to replace the milling ends, the tips, they're fussy. I've got four milling machines and I know how these work and they are a pain in the butt. So I mean it's a say that in at UCLA we had many more than that and we were constantly having to upkeep these things and to the point where we almost needed a full-time person just to keep the machines running. So new doctors I know it looks really appealing to get into the CAD/CAM world, I know it looks really great to get a CBCT in your office. I know that sounds like what you've got to do but I would recommend against it, I think that you can outsource your cone beam radiography you can save a lot of money and don't buy a milling machine, I'm sorry Sirona but I just don't think it's the right move for a new practitioner.

Howard: Yeah word to your mother. I mean yeah oh the same question 3M I've been using Impergum which originally was SP out of Germany than 3M bought it but I mean I could do an impregum impression for seventeen bucks and 3m wants to sell me a $17,000 true def scanner we're just the just the software support is $200 a month. I mean so $200 a month if you're averaging a $17 impression 200 divided by 17 and that's another 12 impressions so my question to you is how do I justify going from a $17 Impregum impression to a $17,000 true def scanner  and when you said scanning you recommended open platforms but that might whoosh over someone's head and you didn't give a name brand, so their what I like to do is throw like five questions at you hoping that maybe one of them is good enough for you to bite on.

Richard: Well I think that I like the trio scanner, I think it's an amazing a piece of equipment we get scans at my laboratory from different scanning platforms and we're able to mill with whatever we get it's not a problem but design and mill but I said if you absolutely believe that you must get into this this impression capturing technology. Great let's start slow but I completely agree with you right you know for a guy that has four milling machines and I mill every material that dentistry makes from titanium, gold, chromium cobalt ,and all the ceramic materials. From a guy that is a 27-year user of CERIC technology how do I perform dentistry in my practice, impressions conventional impressions. Why do I do it that way because I it's predictable I don't have an extra piece of equipment sitting in the operatory it's very very simple for me to do and I believe that it's quite cost effect and I'm not doing it this way because I'm an old-school guy I'm doing it this way because I'm a new-school guy. I actually believe that I am able to capture consistently better impressions when I'm using polyvinyl materials or ether materials than I can when I'm scanning because that the dimension this sort of fourth dimension of impression taking is that's not talked about is that you've got an open sulcus and now you've got to grab a scanner and you've got to scan that sulcus and until they develop a sulcu scanner they can scan through soft tissue and blood man you are in a hurry and now you've got the patient holding their mouth open and rather than inserting a material into the sulcus with pressure and a volumetric change occurring in that sulcus with them a tray being inserted now you're in this passive mode. So now you can't do anything with a tissue anymore the tissue has to be completely retracted and now you've got a scan that area with usually a quite large scanning wand you know even the small ones are large compared to the simple procedure of injecting around the tooth with impression material. So I think that you know you you you find yourself in that situation with crown and bridge and inlays and onlays and things like that. Where I do think scanning has a great places for clear aligner technology and you know whenever we're doing any non braces versions these clear aligners, Invisalign things like that. I think that scanning has a tremendous benefit for the practice if that's the direction you want to go.

Howard: and if they wanted to go to clear aligners scanning because they're doing clear aligners align technology owns Invisalign and Itero is that where you would go?

Richard: Yeah it is, it's where I would go and it's also where I'd buy stock too because if you've looked at align technologies has just been an incredibly successful company and I think that is you know go with the winners.

Howard: Yes and also you've lectured around the world and I was blown away at how little girl talked about Invisalign in Cambodia, Malaysia, South Africa . I mean women and men want to be more beautiful and when I read the fact that only 5% of Americans have had orthodontics man that's a lot of upside to that market, okay and I wonder also so you would go on that way. I want to talk about a couple more of your courses because I've heard nothing on Dentaltown everybody rents, raves about you. I'm gonna switch over to again to a diagnostic diamond because what I see I mean who cares if you did the perfect molar root canal but they didn't need a root canal and they had a sinus infection are you did the most ultimate retreat root canal but you didn't understand that the tooth was fractured. I mean I would rather my doctor or especially a surgeon get an A on the diagnosis and a C on the treatment than at A on the treatment and the wrong diagnosis. I'm talk about diagnostic dimond because I think I mean that's why you're a doctor and I gotta get the diagnosis right?

Richard: You're right and you know and it said that there are many different treatment options but there's only one correct diagnosis. One of the things that I do in the diagnostic diamond is I take people through a four-part approach to looking at every case, we look at the gums, we look at the teeth, we look at the occlusion and then we also look at the esthetics and these four areas make four corners of a diamond. So like a baseball diamond and that's been my my approach John quois, Frank Speer two of my amazing mentors that whom I have learned so much from use a very similar approach. So I think that

Howard: What would be home what would be home plate, first base, second base, and the third for this analogy?

Richard: yeah home base would be perio and then your first base would be your structure your biomechanics that's all all things about teeth, second base is is going to be the function and then third base would be the aesthetics and you know we have to start when we hit the ball we got to start on perio and then we can work our way around the bases to aesthetics and unfortunately what happens in diagnosis is people are kind of thinking about maybe that perio is absolutely the most important thing to treat first and yet they don't understand how aesthetics is what needs to be actually planned first. So it's a kind of an interesting reverse process every case should be planned based on the aesthetics but implemented based on the perio and starting with the eradication of periodontal disease or the control of that and then moving into structure understanding function and finally be able to deliver the aesthetics with all of those previous bases having been covered. So what we teach in the course is to look at the patient as a person in their smile position and make some determinations about what is okay and what needs to be changed with their smile, from there you can then go into function what needs to be changed functionally to make this work and then what needs reaching structurally and then what needs to be changed periodontaly but in terms of the implement of the implementation of that particular plan we start with the perio and I like to can I give you a different analogy. Let's imagine that you are going to build your dream house you found a piece of property that is exactly what you want and so you're just you're standing up from the property and you're envisioning what when you're looking at this piece of property, well you're looking at the house, you're looking at the final house sitting on that piece of property you know exactly where the front door is going to be where the garage is going to be where the master bedroom is going to be. You imagine that first do you look at that piece of property and in the plumbing do you look at that property imagine the framing and the the hinges and the working parts of the house of course not, so when we look at a patient let's look at them as the finished house but then let's go back and engineer how do we achieve that. Well we've got to start with the perio, we've got understand the teeth we've got understand what restorative procedures are our best for this patient and then how to make it work who cares if you have a house but the garage door doesn't open it gets stuck every time you push open, who cares of the windows don't if the windows don't slide open and closed or this light switches don't work that's all function. So function is incredibly important and then finally the aesthetics can be predictable if all of those things are done just right. So the diagnostic diamond is a it's a philosophical approach it but it's also practical approach where we can achieve a diagnosis for every aspect around the basis of that baseball diamond and we know what treatment options are going to be possible to achieve the solution to that diagnostic issue and what we teach in this court courses blows people's mind in in three days there their head is spinning because they have found out things that they believed in that were completely wrong. They have learned more about occlusion in three days than they've usually learned in the entire time they were in dental school and we bring in so many incredible concepts and it's such a simple way to understand them that you can implement in your practice right away that this diagnostic diamond course is a real important one I would love it if everyone took that course first but sometimes people have to ease into ease into these courses and decide well let me try them out and let's see how this composite course is first and if I like him maybe I'll come back and you know that's the way it works and I'm okay with that because I know that once they come we've got them because we're the real deal and we show people how to turn this new knowledge into better results right away.

Howard: I still have questions for you, I've gone over the hour can I keep you a little bit for overtime?

Richard: Sure

Howard: I want to ask you, you look at the nine specialties in dentistry and their's hardly any debate among like pediatric dentists they only debate really about silver diamond fluoride the endodontists you go to dinner with eight endodontists don't really argue about anything but why is occlusion so controversial? Why are there so many camps and I want you I'm gonna hold your feet to the fire because they asked specific questions well should I go learn Panky occlusion or neuromuscular. I mean their's lVI, their's neuromuscular some people say to learn occlusion you got to have $15,000 of equipment and T scans and they just want to know where do they go first? They know they want to learn more about occlusion but they feel like it's almost like you say to me you want to learn about religion I say we got a pick a religion first you are you gonna be a Hindu a Buddhist a Catholic. So why is it, do you agree that it's confusing?

Richard: I do I do and there are at least six different philosophies of occlusion and at least six and I have learned from many of those the Masters of those six and have taken courses in many different philosophies but it wasn't until I started getting mentored by John Coy's in Seattle and Frank Spier who's now in Scottsdale many many years ago that they were able to look past all of the the fervor that may exist in any one of these religious beliefs the about occlusion and get to the practical aspect of things and that really worked for me and I was able to see how well it works in my practice too and so I think that you know we need to be open-minded about change, we need to be open-minded about changing our philosophies. Now how do you change somebody's philosophy about occlusion that's written three text books on the subject and has their entire Institute based on one full if that person is being exposed to a new philosophy, if that person that makes sense they're gonna reject it because it undermines everything they built in the last 30 or 40 years so I wanted to find mentors that we're willing to say what I knew in the past is wrong and this is the direction we're headed and that's what I've subscribed to and so what I teach in my centers is a, an approach that actually works with works well within any of these other philosophies because it really at the if the foundation is the patients got to be comfortable chewing you know. When's the last time you went through a dentist and you sat in the chair and they said hey Howard how's your chewing going zero. Are dentist asking patients how well do you chew it's not happening and that's function that's really what it's all about so I I think that the approach we take is based on the philosophies these amazing philosophies these incredible science has been done all of these different positions about occlusion but perhaps in a way made it more clear not simple but clear and reproducible in your private practice and that's I think what really stuck with me it wasn't so much a philosophy as it was a practical approach which worked time and time again.

Howard: So you got to go to as YouTube channel I mean it's You also have them, so you have your lecture class in LA or near LA

Richard: Yeah, right

Howard: but you also have online continued education talk about your online courses.

Richard:  We have several, the online courses are basically you watch a video and we send you a quiz you answer the quiz and you grab a CE unit and we were really fortunate to get ADA SERP approval last year that's a very difficult process that also is transferable to pace for anyone in the Academy of General Dentistry going for mastership or fellowship and that's just how it works and we plan on releasing many many many more of these online versions simply watch a video watch a lecture and then answer a little quiz and you're good to go.

Howard: You know again I know you don't need any marketing or advertising but if I was you from a business point of view I would put one of those courses on Dentaltown we have online CE courses and then it would it would mass-market your name and brand and online CE courses and Howard Goldstein You've already got the courses I'd put one of them on Dentaltown and then say if you want to watch the other gazillion but I think what are you but I see what are your course doing it almost makes me want to cry you have an RPD design right?

Richard: Yeah

Howard: and so I don't know if anybody know this but a lot of labs they don't want to cast the partial framework so you think you're using your lab in Iowa but they're mailing it down to Nogales Arizona and then they drive them across the street in New Mexico and I Drive down there and I see this lab this lab down there I love the lab they get over 1,000 impressions a day and 90% of all the impression it's just the impression and it says lower parcel and I'm like dude you're a doctor and you just set an impression and said lower parcel. First of all what do you think of this and that's real I've seen this with my own eyes I'm in Phoenix Arizona it's a three and I love going down to Mexico what would you say to the doctors who take an impression and just put lower partial and send it to the lab.

Richard: I'm like come on guys please, you're not doing the patient any favor there. I mean you learned how to do partial dentures in dental school by your prosthodontist and maybe you thought that they were making it more complicated needs to be but I there is no easy way to make a partial denture proper. You've got to design it you have to have a cast you have to survey it and that's what we teach in this design course and it's very sad to learn that that's what that happens and you're right. I mean I think it probably happens more than 90% of the time that just lower impressions are taken and they're sent off make lower partial well we've got to do better we've got to do better as a profession, we were smarter than that we're capable and we have the skills let's not let the quest for the easy buck and practice be more important than what we know is right, let's always remember that we have taken an oath to do our patients the best service we possibly can and I you know I don't think anybody in the right mind would argue with what I just said. It is the approach that any one of us would want to have our doctors take when they were taking care of us.

Howard: Well said and I just one final question the one 4,000 pound elephant the room that no one talks about. Four and a half percent of Americans will and will finish their life out in a nursing home it's a little it's just a tad under five percent and geriatric dentistry doesn't get any headlines but they're selling us that in the nursing home they're getting one root surface cavity per month and I see dentists getting these patients and it's a big expensive pain to go pick up a lady a lot of times you get dementia, Alzheimer's, they take them to the dental office and he'll put in 12 class 5 composites and do you think when you have Alzheimer's, dementia, arthritis, can't brush, can't floss. Do you think a composite was the best restoration for resurface cavity.

Richard: No sir I do not, we would not do that I don't think I've ever treated a patient with those similar conditions in that way. I would place an amalgam if I could get some isolation I might place a glass ionomer restorations but I would never place a composite there. I think that's a, science has shown us otherwise.

Howard: But what percent of dentists say well I don't even have amalgam in my office. I'm like how do you have 2,000 patients be a Doctor of Dental Surgery and you don't even have an amalgam tool in your toolbox. I mean is that is that a well-rounded doctor?

Richard: I don't think it is, I think you know Howard, I think they need to know how to do amalgams, composite,s glass ionomer, gold work. We need to know how to do it all and we were taught all of this and if we weren't taught, learn and then you can offer your patients more options more appropriate options.

Howard: and the the one that gets me the most said I don't know whether to laugh or cry is to say well my entire office is metal-free. I'm like what are you flying a plastic airplane on Southwest oh I mean what is metal how is metal the new bad guy really. I mean is it that where we went from Stonehenge to advancing our civilization when we learn to work with metals.

Richard: Apparently that person doesn't do implants

Howard: Yeah well they're going too zirconium

Richard: Yeah zirconia is a new, the new ceramic but if you don't look if you look at zirconia zirconium the element on the periodic table it looks like aluminium, it is a metal, it is a metal oxide. So metal oxides are part of all of our ceramics it's interesting that people say they're metal free do you I don't know how they can avoid the the elements on the periodic table that are in every single one of our ceramics systems that we use.

Howard: So go to again I was so excited when you agreed to come on the show. I'm a big fan of yours and my gosh my homies enjoyed this so much thank you so much for coming on the show today.

Richard: It's been a pleasure

Howard: All right happy New Year. Yeah if you want ever want to write an article on anything we talked about for Dentaltown magazine please send it in because I like these kids to listen to the old guys, I am so old do you realize when I got out of dental school the the Dead Sea was only 6. All right have a great day.


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