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Hey guys, welcome back to the DOSEDENTAL podcast.
We are super excited to be joined by Dr. Nincastro, a general dentist, educator at the Silver
Book School of dental medicine, and a private practice owner.
We will be discussing Dr. Nincastro's journey to dentistry, as well as his advice and experience
in running a private practice.
If you liked the episode, be sure to follow us on Spotify and our podcast, and leave a
review of things that you liked and what you want to see more of.
Enjoy!
So, what's the right into it?
Siraj is an undergrad at Stony Brook University.
We actually met at the gym playing basketball years ago, at the sports club.
Siraj, I met Dr. Nincastro at the sports club.
Oh yeah, I see.
Dr. Kaplanow, yeah.
Yeah, yeah.
I was way back then.
I don't even think it's a gym anymore.
I think it's a ball.
I heard it though.
I heard it's a pickleball.
They do a pickleball place now.
We should go.
Sorry, I wrote the corner.
That's what I heard.
One of my buddies told me about it.
I'm like, yeah, you know.
So that was, yeah, that was our place, you know, five o'clock in the morning.
That's right.
I mean, I saw you mostly on weekends because it's over at seven.
Yeah, definitely.
Yeah, and so.
I couldn't make those five ends, but I went to Stonyburg dental school.
Dr. Nincastro went to Stonyburg dental school and then went to St. Charles for GPR residency
and then from there.
Who did?
I didn't go.
Did you go to St. Charles?
No, I was at Stonyburg AEGD.
AEGD.
Oh, okay.
Oh, no, no, no.
But you used to go to the OR, I thought, with Dr. Kaplanow at St. Charles.
So the OR, no, I never went to the OR with Dr. Kaplanow at St. Charles because I would
have to work at St. Charles too.
I met Dr. Kaplanow when I was a fourth year dental student going through Nassau County
Medical Center.
That's when, okay.
And I was going to an externship in oral surgery and he was the chief resident at the
time.
That's where we met.
So I was still a dental student when I met Dr. Kaplanow.
And he was a surgery resident.
God, sure.
Okay.
And he had a lot of pieces there.
And then, so AEGD at Stonyburg.
And then you went out into private practice.
Then I went out into private practice.
So my dad was a dentist and I went in with him.
So the funny thing is, and things have changed a little bit, but when I was in my fourth year,
it was a decision whether to do a residency or go right into private practice.
And I decided to do a residency.
And I got to tell you, it was the best thing I ever did.
And the reason why I decided to go into a residency is because I wanted to learn more
and I wanted to learn from different people.
I knew that my father could teach me, but like I wanted to have, I didn't want to just
become a clone.
I wanted to have different influences.
So I was very, very lucky that I trained under some really great faculty.
When I was in AEGD, Doug Firth, Mark Pancado, there's so many great faculty, Mark Slovin,
I mean, so many good dentists that I got such great training.
And so when I walked into private practice, I was ready to go.
I was ready to go, for sure.
And then I learned a lot from my father when I started practicing as an associate.
And the great thing about it was my dad was very big in implant dentistry.
And so I naturally had to be good at implant dentistry.
And the Sony Brook AEGD training with Mark Firth and Mark Pancado, they were big in implant
dentistry and they liked implant dentistry.
So I learned a lot from them.
So when I jumped in, I already had a head start and everything like that.
And then working with my dad was great.
I mean, I learned a lot.
He was a great teacher in certain things.
And we did not always agree.
And that was one of the great things about doing a residency because if I would have
came out just out of dental school, I would not have certain, I would have just become
a clone.
And now, so there were some instances where he would take what I learned and apply it
to what he was doing.
Really?
Make some changes.
Yeah.
Because what happens in private practice is, if you are not, you got to be careful in
private practice because you can get into this little box where you're not interacting.
And there's so much to learn from other people.
And so you always got to consistently learn.
I never stopped learning.
I still learn to this day.
It's just crazy.
I always try to surround myself with people who can teach me more and everything like
that.
And by fall, you never stop learning.
What's a consistent way for, so say you're, I mean, you do this every year, right?
I know you go on some trips where you take the courses, but are there any other methods
and if we could go into that even to continue learning and staying on the top of your game?
And just like you said, you don't get fixed in a box in your own private practice.
You're constantly taking from and learning from others and then applying it every day.
So I got to tell you, so there's online courses that you could take, which are great.
Okay.
And you could, you know, and I'm a big YouTube watcher.
I watch YouTube like, like I'm a dental geek.
I'm going to tell you right now, I'm a dental geek.
So like, like if I'm like, you know, we could be, everybody could be watching TV and I'm
on YouTube looking at a video on like, you know, a certain implant technique or something
like that.
And that's just like what I call passive learning, right?
Yeah.
So possibly learning stuff, active learning wise, especially when you're young.
The biggest mistake that I think young, young dentists make is they're afraid to invest
in their cell and themselves.
They're afraid to spend the money.
So you have to spend money on yourself.
You have to invest in yourself.
Okay.
So don't be afraid to take that hands.
The hands on courses are really the best courses to take because then you have somebody
watching and teaching you a technique.
It's not just didactic, which is very important.
Don't get me wrong.
But yeah, but the hands on technique is, is crucial.
Okay.
The best courses that I feel are the ones that set you up didactically for the first
couple of days.
And then now you go do hands on.
Those are the best courses.
But you, you could always passively learn all the time.
You could passively, I never like, you know, like if I'm doing a big case with Dr. Capuano
or Dr. Gish and they're doing something, I'm watching.
I'm watching the surgery.
I'm watching how you like, you know, how you do place implants, but I learned from them
all the time.
Right.
And I'm like, I'm just going to do it because they, you know, you just learn, you watch
people do things and you, and you ask questions and you just actively learn all the time and
everything like that.
So you never, you never stop learning.
But the biggest mistake I really think I see it all the time is like, you know, I really
want to take course on it, but it's really expensive.
Yeah.
But you're investing in yourselves and your dad will pay you back.
You will, you will, you will make headway just by doing that course.
There's no way you won't.
And I didn't take course.
I wish I took course.
Of course.
One of the biggest mistakes I felt as a young person was I didn't take a, so course is a
select like a series of courses and you graduate from their program.
Right.
And well, but like, so there's Dawson and one does it the same way and stuff like that.
But it really sets you up to understand certain principles like occlusion, which I don't think
you get enough of in dental school.
And then, then you jump into prosthetics and you can't really do prosthetics effectively
without understanding occlusion.
Right.
You know, you really can't.
And I feel like occlusion is just kind of past, you know, it's really just touched on
in dental school, not, you know, and everything.
That's true.
You know, we touch on it and we go into a lot didactically, but seeing it clinically
and then working with it clinically that you're right.
We miss out a lot of that.
And it's not the school's fault.
There's so much to teach, right?
So it's like, I'm big on occlusion in a click.
I mean, I'm sure you get to talk to some of the fourth year students now, like I tell
them the thing that will kill your work the fastest is occlusion.
If you don't have proper occlusion, right, if you'll work, it'll kill what you did and
stuff like that because, you know, it gets beat up all day long.
Yeah.
I mean, just think about it, you know.
It just gets beat up all day long.
So I mean, occlusion, I think it's just passed upon a little bit and like, I really felt
like TMJ, we didn't learn a lot of TMJ stuff, you know, but that could be a whole six months
course on itself in TMJ.
You know, it's a lot.
It's a lot, all right.
I'm going to think of it right now.
Yeah.
There's a lot going on there.
I mean, it's functional, there's myofascial pain, there's, we could go on for days and
that, but Dr. Cascio right now, and has this changed over the course of your career, your
favorite treatment to go into with a patient?
Yes, it has.
So I think when I was in the middle of my, like, so maybe five, six years in, I would
tend to complicate treatment, like get, try to get fancy, like try to do like, you know,
want those, that big laminate case or big stuff like that, or do this big thing.
What I find now is I try to simplify treatment.
I try to keep things simple and you always tend to have the better outcomes at Web A and
stuff like that.
And what I mean, keep simple, I'm not saying so like when, so like, you know, back in the
day, we used to do roundhouse bridges and stuff like that, which I was never a fan of,
but I always looked to break up work.
So if I could put implants in and separate work, like so well, if somebody needs a full
large restoration on natural tea, and instead of doing a whole bunch of bridge work, I'll
break it up with implants.
What I'm saying?
And you're keeping the dentistry smaller.
Right, right.
And that's, that's honestly what I try to do, but you have to understand when you're
treatment planning for patients, and I really feel like, you know, we teach this a lot with
the residents is they should have three options at least for treatment.
They should have like, you know, this is like, you know, the Ferrari of treatment, right?
This is like, you know, the Nissan and this is the Pinto.
But it's all good treatment, right?
And because now everybody could afford to do a full large of implants and stuff like
that.
So you have to be able and you have to be sensitive to that.
Right.
So you have to be sensitive to that.
So not one treatment plan fits one, but you have to give patients options and educate
them on the options and then let them make the decision what they want.
Right.
That's really, that's really important.
I mean, that's really important.
Because you're treating all kinds of patients, like, you know, and everything like that.
So, and you have to be sensitive to that.
100%.
I'm just learning about that sensitivity now and being able to divide things up based
on the patient's needs, which sometimes is financial, you know.
Yes.
And just like you said, they're all good treatment plans.
You know, that the car will get you from 8.8 to point B.
Right.
And I mean, and that's the whole thing is so and like, so you're doing right by the
patient and when people talk about like, you know, I have, you know, students ask me,
you know, the doctor, the doctor, what do you do for advertising?
I don't advertise at all.
Never I've never advertised in my life.
All my advertising was from other patients and I don't care.
I'm not saying it's bad to advertise.
It just wasn't my thing.
The advertising to your best referral or your best advertisement is going to be the patient
that leaves your office.
That's right.
We're now 100% is going to be that.
So what do you do for that?
So the only thing patients know, and this is the truth, your colleagues and your specialists
that you work with know if you do good work.
The patients don't know.
Right.
That's true.
The patients only know that you were nice and that you took care of them in a compassionate
and pathetic way.
That's it.
Okay.
But as I think it's a good thing, your colleagues will tell you if you're doing bad work.
Yeah.
Right.
So the specialists you work with won't refer anything to you if you're not doing good work.
You'll have work come back to you where they swear on another dentist and it wasn't good.
Okay.
I mean, so that's really like, so you have to do good work.
Okay.
But it's really, the patient doesn't look in their mouth and see how you, the anatomy
you put in a MOD composite restoration, right?
Right.
Which is, you know, it's, or doesn't know that the margins are so great around this crown.
Yeah.
If somebody else who else is looking at it knows if it was that, that's, so like that's
the difference.
So I, so you always, you always have to be empathetic.
You always have to be nice, right?
And you'll get more patience that way.
And when you do good work, you know, and you do do that cosmetic case or something like
that, that's where you get, so if it looks good, you're going to get a referral from,
it could be two years later.
Right.
Oh, I saw that you did, Mrs. Jones is deep and like, you know, and so they, they'll come
up to you and you did, you know, you did eight lab and it's on them.
And so I want that I'm like, but you don't need eight lab, you need this.
Right.
So like, you know, like, so that really gets the same case, but like something like that.
Like that's, that's kind of like how it worked.
And that's how I practice still, like, you know,
Yeah.
And I mean, and your practices, it's expanded in, in itself, because now in the beginning,
it was you and your dad, right?
Right.
100%.
Yeah.
So it was just you.
How, how many years was it just you two under the same roof like that?
13 years.
Yeah.
Okay.
Just you two.
Yeah.
I was, I was alone for two after that.
And then I got an associate after that.
And the problem was, is when he decided to retire, it was a two man practice.
And I was trying to find the right person.
And so like for two years, I was kind of, you know, doing, and I was kind of doing, I'm
learning a two man practice by myself and it was busy.
It was really a little bit too busy.
I always say this, it's good to be busy, but you don't want to be unproductively busy.
Now everybody can get your attention that you didn't, that they need.
So it's, so it is a, it's great to have, you know, to have another dentist working with
you.
I love it.
Having another dentist.
I always will love having another dentist work with me because it frees me up to do other
things.
Also, it's, it's good because you can talk about cases together, you know, and stuff
like that and, and, you know, like, I learned and teach from each other and everything
like that.
I mean, that's, so it's really like, I like a group practice model for sure now.
Right.
Because you don't, you tend not to get put in, you get locked into that little box when
you're, when you, when you have other people working with you, right?
So I mean, that's, you know,
Right.
It encourages that communication.
And then with that communication, you're learning what others needs are, what others
like to do with you, what you need to do for them, what they need to do for you.
Those two years alone, was it Dr. Felpo that came on?
If there was a different Dr. Felpo came in after that, right?
It was, oh, so this was, so when we had met, that was right around the time.
I mean, we're going back, what, like, we're going back a good 11, 12 years now.
That was when your father retired in this.
So he just about was out.
He was almost out, right?
So the people who's coming in, who's more going part-time and stuff like that.
And from there, yeah, it's tough.
I gotta tell you, so it's tough when you lose a partner.
Well, you know, he retired and I bought him out, right?
And, and now I have that owned the practice.
And it was, it was tough.
It was, it was a lot.
There was a lot.
It was a lot of like, you know, because, you know, I get calls on a Sunday morning, like
you know, you know, I mean, that happens and stuff like that.
So did you like, did you absorb his patience after that?
Yep, 100% of them.
Yep.
Well, so I mean, and, and like he was busy.
He wasn't like he wasn't a busy dentist.
He was busy and, uh, you re-bolt like I was busier than him by that time, but like he
still was busy enough where I needed help for sure.
Yeah.
And I was like, I'm gonna get a job like that.
And then I decided to take a, uh, a dentist fresh out of residency who couldn't, didn't
have the skillset yet that my father had, right?
But it was great because then you, you, then you teach him, right?
And then you, you know, or her, you know, and then you, and then you, you know, they,
they get better skillset.
They go, they move up and then you could see the progression and how they get better and
stuff like that.
And it's great watching and that's one of the reasons why I love teaching.
Uh, it's, it's great seeing light bulbs go on it.
It depends.
Like, you know, like they're, they're, so they've been sitting in dental school and
they're sitting in class and then like all of a sudden you tell them that they do something
and you say, well, I would, this is, you need to do this.
And then I'm, you say, well, they can see why, and then they do it.
And they're like, oh my God.
Now I know why I learned this, right?
Now I know why I did this, right?
So I mean, it kind of, when you see it all start to come together is, is pretty cool.
That's awesome to see.
I've seen that too.
And you know, you've had my light bulb go on, go on a bunch of times, you know, I've
learned so much over the years.
Um, I kind of wish in some ways I was still at Stony Brook, you know, so I could come
in and see him always.
So it's funny.
It's like you look back like everybody complains about dental school a little bit and stuff
you, you know, about it because it's definitely a lot of busy.
It's a lot of pressure.
It's like, you know, and I, you know, definitely when it's about board time, I could see like
everybody's a little uptight, but you look back on it and you're going to look back on
it and be like the connections you made, the friendships you had, faculty that you met.
I mean, all that you'll do, you'll never, you'll never forget it.
And it ends up being, it ends up being a good thing.
I can remember when I was in dental school, I'm walking the same hallways that I did when
I was, you know, 25 years old, like, right?
So I mean, it's right.
Yeah.
It's crazy.
You got your graduation picture on the wall too, right?
Yeah.
Behind my back.
It's going to be all right.
Exactly.
And everything like that.
And it's, yeah.
I loved Stony Brook.
I still love Stony Brook.
I think it's a great program.
You know, the faculty there are great.
I mean, you know, I have, you know, the ones that I work with all the time.
I just think the world of, I think they're great people and great people.
You work with Dr. Bruthi?
Do you know Dr. Bruthi?
I know Dr. Bruthi never worked with him because he's usually at the hospital.
I saw him always a couple of times.
He might be in the hospital.
Yeah.
He's in the hospital a lot.
And I'm only there Wednesday.
So he may be in the clinic on the World Surgeon thing on different days.
Or his office.
He's unbelievable surgeon for sure.
100%.
Right.
He's a great surgeon.
I mean, I do see that I do work with the World Surgeon Residence a lot because being
in the GPR, they work closely with us on certain cases and they have nothing but great
things to say about Dr. Bruthi.
The whole Ors surgery, attending, most of the attendings are just fantastic.
I mean, they really are.
And the Ors surgery residents are very good to the GPR residents.
And they bail them out of a lot of stuff.
They teach them a lot of stuff.
So I mean, it's great for Ors surgery residents to bail GPR residents out because that's what
we're going to do.
Because it's going to be, that's what you're going to, one of the parts of being an Ors
surgeon is that.
So it's good for both sides.
It's good for both.
It's good for both sides because first of all, like whenever an Ors surgery resident comes
over to help of GPR resident, I tell them, watch him like a log, see what he did.
Right?
Asking questions.
Right.
Asking questions.
Because you're learning.
That's what I'm saying.
You're always actively learning.
Right?
You know, that's part of it.
And what bugs me out is when I'm working in the GPR and I see one of the 40 students
that I worked with and they're about to graduate their Ors surgery residency and they're like,
it's like a different person.
Like they're still awesome and they're still great student, but they're just seeing how
far they've come.
It's unbelievable.
Yeah.
And like even seeing my GPR residents, if the ones that stay on and put their chief here,
if they stay on for a second, you've seen the change from them when they walked in the
first year to when they graduate.
It's unbelievable.
Speaking of Nadine, one of the best friends of mine too.
Yeah.
She stayed for a chief here.
She was great.
She was great chief.
Well, sure.
And everything like that.
I miss them all.
I gotta tell you, they're all really, really good.
It's sad to see them go, you know?
Yeah.
They get a whole new bunch of them in.
I mean, it's like...
Every year and that's the difference between dental school and GPR.
I mean, you know, with GPR, you get them one year, maybe two if they stay for a chief,
but at least in dental school, you can kind of see some in the hallways for a few years.
Right.
You see them in the hallway.
I tend to only to work with the fourth year.
You know, I only really see the fourth year.
I once in a while, I'll have the second year in the clinic and I'll come across working
with them just on, you know, other stuff.
But most of the time it's just the fourth year that I work with.
Right.
I think I had introduced you to Sean earlier on and also Sean apologized.
He couldn't make it tonight.
Of the while.
I still see Sean walk in the hallways.
So it's...
Yeah.
And that's good.
Good.
Shawaz, I'm sorry to cut you off.
No, no, I just said that Sean's there still.
So...
Yeah, absolutely.
So, you probably want to talk about private practice though, right?
So...
Yeah, yeah.
I mean, so private practice is a whole different animal than the whole teaching aspect of,
you know, of everything.
When you...
Private practice is, like I said, like some people advertise, I didn't.
The biggest thing about private practice is your skill set.
Okay.
And that's why I say you never stop learning.
You should be improving your skill set and you see what you...
And then you'll start to do treatments that you...
You'll tend to start doing things that you like.
You know what I'm saying?
And private practice will kind of go that way.
But what's really important is your staff.
Okay.
So staff is huge and you want to hire good people.
And when you...
To hire good people, you also have to pay good people and you have to pay them what they
deserve to be paid.
Right.
So when I...
So my sister is my office manager still and she's been there before I was even there.
But she's still there.
The two hygienists I worked...
That worked for me stayed on.
They both retired now and they both with me over 20 years.
Right.
So, I mean, when they retired, it was like heartbreaking.
Like, you know, I mean...
Yeah.
Well, heartbreaking.
But they had, you know, it's the way life works and everything like that.
Nicole, you remember Nicole who used to work in town.
So like, she was great.
She was great.
And so it was a very family-like atmosphere.
So as a dentist, you have to hire good people and have good systems in place.
Okay.
And be good to those people.
Right.
Okay.
Because when you're good to people, they're gonna be good back to you generally.
Okay.
And if they're not, then you know what?
You did the right thing and then you moved past it.
But that's a big thing.
You have to be...
You have to have a great staff.
You have to train them to do how you want to practice.
But you have to be good to them.
You have to be good to them.
What are some ways...
Because, I mean, well, the hospital is different, right?
No one's getting a good paycheck there.
But what are some ways, other than financial reimbursement, salaries, etc., to kind of keep
so unmotivated, being good to someone on the team?
It's not even about being an employee.
It's about someone on your team, right?
What's one way, other than like, you know, the salary or financials, to kind of keep
so unmotivated, keep them on the team and you know what I mean?
Well, at least once every three months, we do happy hours.
We go out as an office, right?
And not really be like in the whole dental environment and like happy hour.
You do that, you get involved with there.
You get in contact.
You just got to be in touch with their families and like and care about them as a person.
I think that's the real thing.
You have to make that connection with them in a personal level, right?
You know, and everything like that.
You have to make it a fun work environment, not so serious all the time.
It doesn't have to be so serious all the time.
You know, patients like when you walk, when they walk into an office and the whole feeling
is a relaxed feel.
Yeah, yeah.
Right?
If it's ultra uptight and like, you know, then that's not that's not a really good, the
patients could pick up on that.
Okay.
I know dentists who like big bread in their office to get that just a different smell
in the office.
I mean, I'm not kidding.
I know what the dentist does that and it's not a bad, yeah, right?
It's not a bad idea because you like it brings like a home feel to it and stuff like that.
There's a whole different ways.
But to keep your staff happy, you have to interact with them.
You have to hold them accountable for the document.
You have to hold them accountable for when things aren't right.
But I got to tell you, so you lead by example.
I mean, so I mean, that's basically what it is.
I mean, like, if you hold yourself accountable for certain things that your staff will tend
to hold themselves accountable.
But if you did something wrong and we all do something wrong and you don't take accountability
for it, then you're not showing them the right way to do, right?
You know, leaders don't tell people what to do.
Leaders act and show them how to do it.
Like what I'm not, that's basically what it is.
So like, you lead by example.
And I think that's really the way it is.
So when a dentist is relaxed, the staff tends to be relaxed.
So I used to always say to myself, I set the tone.
Like so like, if I walk in there in a bad mood, everybody's day is going to be in a
bad mood.
I'm not a yellower, but if I'm quiet, I get quiet.
When I'm annoyed or upset, I get quiet.
And they used to know if I'm quiet, something's like I'm upset about something.
I'm not detected just start screaming through the office and stuff like that.
But like, right, right.
And so it's all made to set the tone, right?
You know, were there a lot of quiet days in those, those two years when you were the
sole partner?
The, uh, so, you know, I got to tell you, there, there was, it was definitely more stressful.
Um, stress, like everybody handles stress in different ways.
Uh, there was, there was definitely some tougher days, but I still enjoyed it.
I look at, you know, and everything like that.
And when you have a good staff, they help take the pressure off you.
Right.
And stuff like that.
So I mean, you know, that that they're physically doing the work for you, but like, you know,
it's, it's, you know, it's something you got, you know, it's good to be busy, like
I said, but you don't want to be unproductive with busy.
Right.
You want to be always productive and you want to be, you want every patient to have
your full attention and you want them to, you know, and everything like that.
And sometimes when you're over busy, you're getting pulled in so many directions, it's
hard to pay, you want to pay attention to detail, you want to pay, you know, and, and,
and that can get tough and that can get tough.
So that's what, that's what I did not like about it.
That's the only thing I didn't, the only thing I didn't like about it is like, I, I just
felt I wasn't spending enough time.
And that's, that's, that's my fault.
And that's the accountability.
Right.
So that like, that's where I struggle.
That's what I,
And you mentioned earlier, not enough time with patients in some circumstances, right?
What about time with employees, with that kind of fall into the umbrella too?
Or team, you know, nonemployee bill, like your team.
So, you know, everybody kind of worked together.
So like, you know, it's a, you saw my office is not very big, you know, and that's what
I mean.
Everybody was around each other.
So there was always time that we were talking or something is happening.
The hardest part is keeping the staff nice to each other.
Is that so much nice to me, right?
Like, how often politics go?
Like, you know, this one's mad about this cause she did this and then like, you know,
that, I mean, so that stuff, stuff that like, you need a good office manager to be able
to keep them back on track and stuff like that.
And they, like,
They're leverage.
Right.
I was going to say, Siraj, one of the first things that Dr. Kasha taught me, it was at
the gym, it was a Sunday morning.
This is, this is while I was in undergrad, right?
And I was like, how's everything going?
And he's like, you know, when you really boil it down, I'm just a firefighter all day.
I'm just putting out fires.
And I was like, I didn't really understand at the time as though, I guess, you know,
busy, a lot of stuff going on.
And now, and now I know.
You know, right?
And I mean, like, so what happens is, the longer you're in practice, the more patients
you have treated, right?
The more, I mean, I could see it all of a sudden, I'll see a patient that I treated 10 years
ago, and I haven't seen them.
And now they're having a problem.
Right.
And it's like, you know, and so, I mean, that's the whole thing.
So now you have to squeeze this into where you're doing this and stuff like that.
If it's a real emergency, like, you know, and stuff like that, you know, it's funny.
Like I always have something I have to my office.
I should take a picture of it in shorts here.
It says, what does it say?
It's something funny.
It says, procrastination on your part is not an emergency on my part.
But I didn't say it to a patient.
No, but I always say that it calms me down.
Okay.
So listen, it's like, because them just want to blame themselves for everything.
I don't know where we learned this.
But like, you know, you got a case that you did 15 years ago and if something's going
bad with the case, you feel bad, right?
You feel bad, right?
And it's like, it's not your fault.
I mean, things what God gave them didn't work full time.
Right.
So in New York, you know, and we're not God, like, you know, and everything like that.
But it's, so, I mean, that's, so you would never, I would never say it to a patient.
Right.
You wouldn't say that to a patient.
I say it to patients, not that, but I say to a patient all the time.
And I was like, so when was the last time you saw a dentist?
And it's like, well, you know, COVID happened.
And I was like, okay, let's type of for COVID.
And they're like, well, I, I don't know, you know, the recession happened.
They way never better than that.
Yeah, no, it's, it's true.
It's true.
You know, people, people don't take care, a lot of people don't take care of their
teeth.
We see it all the time, right?
They don't take, they don't take care of their teeth.
And they get themselves in a lot of trouble for not doing that.
I mean, like, you know, you know, facial swellings and big, big time stuff that can go wrong.
Or like usually, you know, one of the big things when you're doing a case, like say
we're doing a big crime of ridge case, you have to take in account the patient's hygiene,
because they have to maintain this.
If they, if they're not maintaining my big thing that I say to them, and I will say this
is I get to see you every six months.
Right.
And they clean your teeth every six months.
You have to clean your teeth every day.
In between those six months.
Right.
Every three months.
So like, you're, you're, I need your help to maintain this.
Right.
You know, basically what, what if I'm sound to?
You can help?
Yeah.
It's hard.
Changing people's habits is hard.
You know, and stuff like that.
That's a hard thing to do.
You know, patient come in and like, you know, you took out, you took out a wisdom tooth.
They get a dry socket.
Did you smoke?
Yes.
Did I tell you not to smoke?
Yes.
I can't.
Okay.
I mean, that's it.
So that's like, you know, that's like 50% your guys's job, 50% of the patient, right?
Right.
It's so immediate.
So at our office, we do all the birth surgeries, which I'm pretty sure you're in labor with
or so, like coming in like every six months for like a implant maintenance treatment.
And like, sometimes patients will come in.
They just don't, they haven't taken care of it.
Their bridges are all yellow.
They're just, it just smells like smoke.
Right.
Well, you know, docs just like, come on, man, what's going on?
Yeah.
It's a point in other dollar investment for yourself.
Right.
It's frustrating.
It's definitely frustrating.
It's the hardest thing to do is to break people's habits.
You know, a lot of it.
So the whole on four is interesting and not to digress on this.
I'm bad.
So all on four, I don't do hybrid anymore.
I don't do acrylic.
I do mostly zirconia or PFN.
And the reason why is because everything sticks to zirconia, to acrylic.
Okay.
Everything sticks to it.
It gets nasty looking.
It gets melty.
It just gets like, you know, it's just not, it's so zirconia, especially everything
just falls away from zirconia.
Things don't stick to zirconia.
They don't stick to it.
So you'll see that, you know, zirconia is easier to clean.
Like there's not as much sticking to it, there's no staining that you see with the acrylic.
Okay.
If you have a smoke and you do an acrylic hybrid, it's stained within a year.
It's stained and looks gross.
You don't deal with as many broken teeth, broken appliances, but where's the weak link?
This is something that we all talk about.
So a lot of the docs that do full arch like myself, one of our big discussions that we
have is a lot of times I go with zirconia or PFM, but here's the thing with all on four
or full arch.
I don't really consider all on four.
I consider it all on whatever it takes.
But the zirconia is strong, very strong.
So especially monolithic zirconia, right?
So we're not doing porcelain, fuses, zirconia or something like that.
So where's the weak link?
What's great about acrylic is they implant, 10 won't get overloaded, 10 not to get overloaded
because the acrylic will break or the acrylic.
So we always, so these long, these cases I'm interested to see long term what's going to
happen.
So where is the weak link?
It could be a prosthetic screw.
It could be an abutment screw.
It could be, God forbid, the implant loses bone around or certain implant loses bone around
it.
So there's always going to be a weak link somewhere.
And that's the biggest thing that with these all on four cases or these full arch cases
is occlusion.
I say this all the time and passive fit of the prosthetic.
That's it.
Passive fit.
I'm still worrying about that.
What do you mean by passive fit?
So when you're doing a, so I mean I can get on to this is prosthetics like big time prosthetics
that we're talking about.
So passive fit is so when you have implants splinted together, the appliance fits on them
and fully fits on it passively.
You should be able to just drop it on it as it seats.
Oh, okay.
You could go rock.
There's no kind of the screws aren't tight going in.
So like right, so you got forces from occlusion.
But if you have an appliance that you squeezed on, you're putting pressure on those implants
internally.
That's right.
So what happens?
So like I like to say, what happens in ortho like when you put pressure on a tooth, bone
source to remodel, right?
And then the penis moves.
Well implants don't want to move, right?
So if you get bone remodeling around an implant or like if you have constant pressure in that
area that that in around an implant, it's going to lose bone around.
That's sort of the solution.
Yeah.
So I mean that's that's so you want passive fit appliances and it's hard sometimes.
The more implants that you're trying to connect together, the harder it is.
So do you do like our office we do temporary acrylics and then you actually go to the finals
out kind of what you do?
Yes.
And then even when I'm making the finals, your calling in case I go to a prototype PMMA
that I let the patient wear for a couple of weeks before I copy Miller and you should
call me and stuff like that.
So I mean, it's great because you get they get to test drive it, right?
And then you've got any chance changes you want to make you want to make in the PMMA
provision, right?
And then what happens is you take that temporary away from the patient, usually have the other
temporary that you put them back in and then you put that on the master model and then
they copy Miller at the lab in Zirconia.
Right.
Do you want to sit with the Zirconia final like trimming it away and putting the bi-paper
and trying to figure in that like.
Even when they copy Miller, you always go back to occlusion and occlusion still always has
to be modified a little bit 100%, but it's so hard to draw a Zirconia strung.
You want to touch the final product as little as possible.
You know, I mean 100%.
And so I mean, that's how it is.
But I mean, we talk TMJ, you could talk about passive fitter down implants for like, I mean,
we can talk about it for hours.
You know, it's a lot.
It's a lot.
Actually, that talk about.
You talk about verified impressions, you got to get a verified impression.
You know, so like people are a lot people who don't get a verified impression.
It's like, so I mean, there's certain things that go into it.
I'm interested where how CADCAM is coming along with it, like, you know, with, you know,
digital dentistry and stuff like that, you know, with the accuracy and everything like
that.
So, you know, dentistry is changing and systems are getting quicker, which is great.
But you know, you still have to, I think still have to fit.
You know, they have to fit.
You know, I'm at the VA right now where it's very heavy for implants because, you know,
the VA covers a lot of that.
And what I like most about the VA is not only that, which is great training.
We have a new attending over there that's fantastic.
We do all on X cases.
We don't bore now all on fives.
And one of them was two of that.
One of them was guided.
It was great.
What's great is that in the clinic at the dental clinic at the VA, we're in the oral
surgery, but then down the whole process.
So we just go walk down the hall and talk with Prost and EPR down the hall the other
way, perio, endo.
It's not something I have at any other facility.
And that's what we, exactly how we could talk about.
And so what you say is everything comes down to occlusion.
I could actually learn from the Prostadontis because what I'm trying to learn that I don't
get when I'm at other facilities is I work for you, the Prostadontis, right?
Not you work for me.
You send me where I do some implants.
No, no, no, I need to know how to put implants in according to how you're going to make the
occlusion, the restoration, the MIO.
That's I wish I had more time there.
So implants should not be, so everybody used to use the word prosthetically driven implants
should be placed prosthetically driven.
It's not really accurate.
It's prosthetically referenced.
Okay.
Because you can't put implants, you can't put implants where the bone isn't, right?
So you guys are, your hands are tied to a certain extent, especially in a maxillary
anterior.
And sometimes you have to build the bone just to put it, you know, close to the right spot.
You know, it's, so it's always prosthetically referenced.
It should be, especially these, especially it's going to be an all white case.
Okay.
All right.
Here we go, I'm going to get on my soapbox for a second.
So we have these all on X cases and they're great and everything like that.
I really think that we should get away from lacking so much bone away.
Really?
You think so?
Cause I'm just learning about the bone reduction, especially in the mannable.
You need the bone right.
So the whole thing is I have problems with that.
So when you do, when you lack the bone away and you're, you're taking a patient that's
an FP1 where they have, you know, an FP1, have you heard FP1?
So FP1 is where their teeth are of normal size, right?
FP2, the teeth look a little longer.
And now FP3 is where there's pink.
You need both pink and teeth, right?
Yes.
Okay.
So taking an FP1 patient and turning them into an FP3 patient, is that really doing
a lot of service for the patient?
Right.
So with those implants fail, what do we got?
We got nothing left.
Right.
We got to talk about zygomas, what are we talking about?
We have to do zygoma implants.
And so you can do a good restoration and keep an FP1, but your implants have to be critically
placed.
They have to be where the tooth is supposed to be.
It means you'll just leave buckling or.
Right.
Cause you can't put a multi unit on it because you don't have the space for the multi unit.
Right?
Cause the reason why you're whacking on our bone is to create space for the appliance.
Right?
Right.
Minimum of 15 millimeters that you need.
Right?
Basically what you guys learned.
But we can talk about this forever.
It'll have to be a different topic.
Cause like.
Actually, I was going to say that, Siraj, this is actually an excellent introduction into
the next topic.
Dr. Kashel, maybe we could even bring on the, I would say, who would you, who do you do
all on X cases with like predominantly?
So I do probably with Dr. Kebluanam, but I do do them with Dr. Gish and stuff like that.
And stuff like that.
Those are the two surgeons that I do most of my own X, you know, on.
Yeah.
We could talk about like cases and stuff one day if you want, like, you know, if you have
pictures and stuff or, you know.
Yeah.
And so I mean, it's a great, it's, you know, this, this is the hot topic, right?
I mean, this is whether you, you know, this, you, you see all the commercials.
This is the, the, the hot thing.
But so I had a pros and dollars who taught me and he said, it makes no sense whacking
me all this bone and understand.
So a patient loses a tooth.
What do you do?
You take the tooth out, you put an implant in, you didn't whack away any ball, right?
Now they lose the tooth next to it.
What do we do?
We take out the tooth, we put the implant in, we didn't whack away any ball.
We're keeping the architecture of the patient, right?
Right.
I keep me rethink.
You just take a 40 year old patient and you whack away all this bone and they'll give
you a role.
I've done it.
I'm guilty of it.
I did like, I'm not saying I'm not, I'm not, you know, I, but I'm, as I'm looking back,
I'm saying, are we creating dental triples in the future?
Because if the case fails in 20 years, what do we have left?
And now the patient's only 65, 66 years old.
Got to be dentures, right?
At that point.
Yeah.
And that's still, and that, and what's the, what's the morbidity on that?
Right?
So that's, you know, it's not like that.
So I mean, but you know, zygomas, you could talk zygomas, you could talk like, you know,
there's still other things to do, but it's very invasive.
It's, you know, it's interesting.
That's a very interesting thought.
Cause I'm just learning about, and don't get me wrong.
I'm not bashing.
I've done it.
Like this is what I'm saying.
So this is the things that we talk about, you know, yeah, constantly learning.
I follow, I follow or constantly learning.
We got it.
We got to do this.
Maybe I know Dr. Gish likes to lecture.
Would you guys maybe come on together and we have a session where we kind of go through
the stepwise process, cause I know there are multiple processes that need to be made before
we even get to talking about implants and whatnot.
The body level.
So yeah, Dr. Gish, I'm sure would, would love to talk.
I'll talk to him.
I mean, Dr. Gish is a great teacher.
He really is.
I mean, he's good at, good at explaining.
He's one of the good, you know, and that's kind of the same way.
They both know occlusion.
They both know prosthetics and they have to, they know up to where they need to know.
Like you know what I'm saying?
And stuff like that.
Like where, because they do these cases and you have to know and just think about it.
When you do ortho-anathetic surgery, you have to know occlusion.
You have to know, like you have to know this stuff, right?
Right.
Brian's stuff like that.
So I mean, it's, it's, but it's a topic we can talk about all, you know, you know, all
the time.
I think that, that would be really good.
Say when patients know about it, it's on TV.
I mean, you get them all the time.
I get it all the time.
Yeah.
And then with the residents, I see the patients just like, I want to all on the case, you
know, you know, and, you know, and where it's, where it happens.
So let's do it.
Let's make that the next talk.
That's all I can reach out to Dr. Gashim and, and see if, you know, I'm sure he'd like,
would, he's very, you know, like, you know, just keep fighting the time to get us both
together.
That would be fun.
You know, I'm sorry.
It'll be great.
Let's work around your schedules best weekend.
So Raj will set up, we'll try and eat for a Wednesday.
Let's plant it for, let's plant it for April though.
Let's give it some time.
Yeah.
You know, some time.
Yeah.
I'm sure.
Let's do it.
That'll be great.
That'll be awesome.
So as a dental, you know, as a, as a pre dental student, right?
Yeah.
So you're obviously working in private practice.
Like so you're volunteering.
No.
So I've been working as his twight for two years almost now.
You know, pre-deadsel?
Yeah.
I work over there.
Okay.
Yeah.
Do you know Dr. Pradensi?
He's also across Dallas.
He's also, he went to Sunday.
I've heard of him.
Yeah.
He works there.
There's Dr. Vibert, Dr. Benoy, Dr. Herron.
Dr. Benoy, I trained.
Yeah.
He probably knows you too.
Yeah.
Great guy.
He's like my main mentor.
He's the one who got me working there.
It's been really amazing to see a bunch of different things.
All in four cases.
We built a new office just for this, just for all in X cases, I guess you can call him.
You know, see a lot of root canals and plants, crowns.
I see everything over there.
So it's great.
Because it does help to see it.
It helps.
I always tell, you know, pre-Dallas students, just by watching, you learn things and you
made that, not until you get into clinic, but all of a sudden you're in clinic.
Like I know how to do this, or pre-clinic.
I know, I've seen this so many times I could do this.
Like you don't say, even though it's a lot harder holding the drill, right?
When you see somebody doing it, it's like, I can do that.
And then you do it.
You're like, oh my God.
It's more than harder than I thought it was.
Well, something that's probably like a mic or a make a temporary for a patient for a
prep.
But even that, it's like, damn, okay, I really get into it.
I've always wanted to, you know, shadowing is one thing, but I feel like getting into
the chair and holding a suction, like get past them instruments is like another level.
And then obviously being a dental student and then, you know, where you guys are at.
So, well, that's kind of my thought process.
Well, when I was a dental student, I remember telling my dad that I only wanted to work
on lower teeth because I couldn't use the mirror.
That's true.
And then he said a great thing to me.
He goes, well, do you comb your hair in the mirror?
I go, yeah.
And he goes, do you think about it?
I go, no, he goes, and that's what will happen.
You want to do this?
Exactly.
That's pretty good.
Yeah.
So, I mean, so, yeah.
So, and everything.
But I, you know, so private practice.
Yeah.
So, I mean, just like, private practice is great.
And private practice is, you know, I really do, I like, you know, I have enjoyed it.
You know, I have enjoyed my ride and continue to enjoy it, like, you know, and stuff like
that.
It's a great profession.
So, the profession you guys are going into is an unbelievable profession.
And when you, the days are, the stressful days come, just remember it's because you are
in a great profession.
And if it was easy, everybody would do it.
That's right.
Basically, what if I'm sad to, you know, you know, I know I talked to you when you were
having your tough days and I'm like, just, just take it on the chin and move on.
That's it.
That's all you can do.
My chin's pretty broken right now.
Yeah.
So.
Oh, it's, it's, it's rough.
I mean, today was another 13 hour day, but you know, oh, it's good stuff.
But yeah, let's, so that's cool.
We got, we got another one coming up.
We'll do that in a month or a month and a half.
And, and yeah, because I got to start, I got to go eat dinner still.
But that's it, man.
Now, congratulations.
Thanks for having me.
I appreciate it.
You're ready after you.
I'm not on.
Well, thank you.
All right.
So you guys, good luck with everything that you're doing and we'll talk soon.
Absolutely.
I'll see you Friday, Dr. Cash.
I'll see you Friday.
I'll see you Friday too.
All right.
And Siraj, congrats, man.
Yeah, congrats on the D.A.T.
That's great.
Big thing over now.
Just got to apply and then that's it.
Yeah.
You got to have a drink now.
You weren't a drink.
I think I saw my mom earlier.
We did, we did have a little drink with my mom.
So there we go.
Oh, that's special.
It's seven metal.
It's just, just drink.
So it's pretty fun.
That's a big night.
I tell you, you know, she's proud of me.
So you know, she's passed out.
Yeah, it's because she never drank and you gave her a drink and that's.
That's not, she's next.
Oh, this one.
I was shaking like the last 40 an hour.
Yeah.
I got a J.U. feel like the D.A.T.s was, I remember it.
And the only reason why I remember it is it allowed me to be like somber on this, but
my sister had passed away in a car.
It's a month before.
And so I kind of went into the D.A.T.s and I wasn't in a good state of mind.
Like I was still upset and you know, and everything like that.
And I think it made me do better because I was just very relaxed.
Like I wasn't, I didn't care.
I was just like, in my own like, like my thing.
And I can remember like, I remember, I don't remember the test.
I remember taking it.
I just don't remember like, you know, because I was interested in a different place at that point.
But it's, for sure, it's a stressful day.
I think the clinical board exam is probably the most stressful day that we have.
You have the dentistry.
I would think.
Where you do the clinicals like, you know, for your licensing.
So it was the Northeast Regional Board when we took it.
You know, that's what it was.
You know, it seemed the D.A.T. is not the most stressful day of your dental career.
But you know, it's what it's like first.
One of the factors.
But like, because you put so much weight on it, right?
You know, I mean, you're pretty good at doing stuff like that.
You'll look back on it and be like, I can't believe I was in worried or like, you know, and so it's like like college, right?
So it's like college, you, when you're in college, you've got a dentistry.
You was like, oh my God, whatever.
You get through it.
There's always another stressful exam, another stressful day.
It's learning how to manage it.