I’ll be honest, sometimes I think people are focussed on the technology and they’re not focussed with the basics. So I see people using guided and digital and you know, they haven’t got their basics of restorative there. They haven’t got their understanding of how to fabricate the bridge on what’s important in the fabrication of the bridge. They haven’t got their basics of surgery and what you’re trying to achieve correctly. So, you know, there’s a lot of people out there who are focussed on digital and guided and there’s nothing wrong with that. But I do feel that the focus so much into that and they’ve kind of missed out on the basic parts of the surgery and restoration.

This is Dental Leaders, the podcast where you get to go one on one with emerging leaders in dentistry. Your hosts, Payman, Langroudi and Prav Solanki.

It’s my great pleasure to welcome Pinata George onto the podcast. George I’m going to call it from now on. He’s one of the handful of implant surgeons who are known for full mouth. Known for this eye. Gomer Work. Terri void work transfer of sinus work so that the very high level restorative implant work is a great pleasure to have you. But I want to get to your backstory first because someone like you, you know, people look at someone like you and I was scrolling through your Instagram today and it’s just like it’s a different world to the dentistry that I know. And you sometimes forget that, you know, that person started out as a dental student just like the rest of us. And, you know, you built into that into that world. But do you remember the first time that you considered dentistry as an option?

Well, actually, it wasn’t. I had actually started off as medicine, and in my first year I swapped to dentistry. My dad say, Yeah, my dad’s a cancer surgeon, a plastic breast surgeon. And he he kind of pushed me towards medicine. So I actually started off doing medicine and then I had a little bit of a moment of truth where, you know, I was kind of doing the degree for my dad’s sake. I actually wanted to be a priest, to be honest. I didn’t I didn’t want a priest or an artist. I didn’t want to do anything. And it was my mom who convinced me. Priest Yeah. Priest Yeah, I was quite I was quite a deep Christian, Orthodox. Christian Yeah, yeah. So I was quite deep in my thoughts as a youngster. Yeah. Yeah. So that kind of went to the side and then started off in medicine. And then I kind of had a moment of truth where we didn’t, me and my, my brother and I didn’t really see much of my dad growing up and he was working long hours. It was quite a hierarchical kind of system that he was in. There was a lot of work for very little reward, So I decided I didn’t really want that lifestyle, especially if I had kids myself. So I kind of moved on to dentistry. It was quite a kind of a similar profession. A lot of reward for the hard work. Yeah, and I started off as a dental student like us all, really.

So did you have to reset even year one?

No, no, no. So I got into a couple of places in medicine. I got into Liverpool in medicine, and I was able to transfer to dentistry without a problem. Back then, the first two or three years were literally exactly the same for medicine and dentistry. We shared a lot of the lectures together and there wasn’t much difference. And there was, I think there was a number of people who swapped over either from dentistry to medicine and vice versa. So it’s quite a fairly.

Was it a difficult decision?

No, no, no, no. And even now, I mean, I was in a party over the weekend. Yeah, even even now I look back thinking what a mistake that would have been if I had done medicine. I mean, I look at my friends and I see the slog that they have to do as medics and the amount of hard work that they have to do. Don’t get me wrong, I think the degree dentistry as a degree is a harder degree than medicine. I’m talking about undergraduate degrees. Yeah, but actually, once you’ve done your undergraduate degree as a dentist, you’re kind of free and open to do what you want, obviously within within limits. But for medics, that’s where their life starts. Once they’re finished, their their undergraduate degree, they are literally starting their medical career at that point. And it’s another, what, eight years minimum or ten years, you know, maybe longer if you’re if you’re Max Fox. And yeah, that’s not what I wanted.

But I can understand now you saying that. But at the time, did you not feel like you were letting your dad down or, you know, this pressure to go into it in the first place. Yeah. And then getting out of it so quickly should not feel like you were. Did you get a backlash from your parents or.

No, No, no, no, no, not at all. I think my dad still regrets I didn’t do medicine. I think he kind of hoped that I’d go into Max FACS, But then I think you get to a certain age. My dad got to that age where he looks back at his career and he thinks in terms of benefits and costs and advantages and disadvantages, what he’s achieved, I mean, he’s achieved he’s achieved a hell of a lot in this career, especially as we were from India. He’s not from India. He came over not knowing the English language. He had to learn the language when he came over to do the what was called the lab exam back then, and then start off as a junior doctor in quite a middle age kind of. Rare for him. He was already middle aged. Sorry, and start from the bottom again and I think he may have some regrets about that. I don’t know. I’ve never really spoken to him about it, but I had no regrets. And I don’t think at this point now, my my father feels that I’ve have made the wrong decision. I think he he knows I made the right decision. So I’m quite happy with that.

Well, you are now now looking now looking at your career, of course. Did you guys come from Goa?

No, we came from Kerala.

Kerala? Oh, nice.

Yeah. Yeah. So I actually came over when I was about, I think maybe about seven or something. Six, seven. And then we stayed here for a few years. I couldn’t obviously I didn’t know English. Yeah. And then we had to go back to India for boarding school. That didn’t work out. And then we came back again and started off in, I think, the final year primary. So yeah, came over.

You moved to London at the time?

No. So when we came over, we first started off in Ireland, then Scotland, then the Northeast, and then travelled around a bit and then we settled in London in Southall.

Life of a doctor’s family, isn’t it, back then.

Exactly.

Lots of moving around. Yeah. So. So you grew up mainly in Southall?

Yeah, exactly. I mean, and when we did settle, it was in Southall, which you know, was Little India at the time. It’s kind of still is, but I think a lot of Indians have kind of got out as they’ve achieved a higher wealth status or social status, they’ve kind of and then each successive immigrant populations kind of moves into Southall. I think even when we were there, we had, you know, the Somalians move in, Sudanese move in, and now I think it’s Eastern Europeans who moved in. Yeah, although I’ve not been south for a long time. I’d like to go, but I’ve not been in a long time.

So do you think that the fact that you’ve gone into surgery has something to do with the fact that you left medicine and your dad’s a surgeon?

No, definitely, definitely not. It was just coincidental. So I kind of I was in I was actually into restorative dentistry. So I was working in restorative dentistry. I was teaching restorative dentistry. I did an MSC in restorative dentistry at the Eastman. And then I went back to Liverpool to teach undergraduates and some postgraduate trainees. And then I started off in a general hospital, district hospital, doing restorative dentistry for oncology patients. And I was in this kind of funny scenario where I was doing pre prosthetic surgery for implants, but I was the one in the room doing the surgery and I was showing the restorative consultants the surgery and I was showing the Max FACS can consultants do surgery in the operating room. But then I wasn’t classed as a consultant, which I found quite frustrating. So if I wanted to do something, they would the nurses would then look towards the consultants. So I thought I’d go back and do surgery, oral surgery. So I went off and I went off and did oral surgery and that kind of it kind of grounded my implant work, to be honest, because it implants. Implant ology really is a mixture of restorative dentistry and oral surgery. So I kind of ticked that in my view, I kind of ticked those boxes. So, you know, I’ve done the Amnesty and restorative and did some training restorative. I did a doctorate in oral surgery and did specialist training at all surgery. And I had this like MSC in implants in the middle of it all. So that for me, kind of that was enough for me professionally. I had I had kind of I’m satisfied with that now.

So back back then, those that was kind of the people were going with training because there wasn’t much else. Right? There weren’t these courses like the courses you are now. But what would you tell someone who wants to get into it now? Would you tell them to do the kind of things that you did, or would you tell them to sort of find a mentor or do courses? Weekend courses? Yeah, courses. Which way? Which way would you or would you say both?

You know, I think because I get asked that question like a lot, like maybe every week at least if not. Yeah, if not a couple of times a week, I get asked that same question and it really, it’s really dependent on what you want. So for me, you know, I did a doctorate and training in oral surgery, not just because of the implant ology thing. I had other reasons why I was doing it. I had quite a significant neck injury and because of that neck injury, I was told, you know, I shouldn’t be working to the same levels and rates as I was working before the neck injury. So to take time out and I thought, you know, I could take time out and do a research degree and do some training with it at the same time. But if you want those letters, if you want, you know, letters after your name, if you want formal training, the. You’ve got to go and do formal training. But if you want to be a generalist and you know, I look, I look up to my colleagues who are, you know, really more or less the specialist generalists, and you don’t want to commit to doing three years full time training or, you know, research degree at a doctorate level, then don’t do it.

You don’t need it for, you know, high level implant ology work. You don’t need to do all of that to be able to do advanced and complex procedures. It’s not it’s not required. But if you do want to get trained to that higher level, you do what letters then yeah, of course you’ve got to go off and do the course. You’ve got to go off and do full time training, but it’s certainly not necessary for complex implant ology. There are other ways and actually I’d probably say the same thing for all specialities out there, with the exception of maybe max vacs, you know, even within oral surgery or restorative dentistry or orthodontics or periodontist or ended ontex, you know, to become a specialist. Yes, of course you do a number of years full time and you get some letters. But that doesn’t mean it’s the only way of attaining that specialist level kind of work. Yes, you may not be classed as a specialist, but you’ll certainly get training to a specialist level because, yeah, it’s a difficult question.

I think, you know, we put specialists on a pedestal, we put we put letters after your name on a pedestal. But you know as well as I do that not all master’s programs are equally.

Yeah.

And you know, I’ve spoken to people who’ve been on master’s programs in all sorts of different disciplines who said that it was very disappointing the level of education and the level of experience they got out of them. And then I’ve heard the opposite as well. You know, I’ve heard people say that their career would never have been where it’s gotten to without the master’s program. And sometimes, I mean, I was talking to heart him, you know, Heart Graffy the periodontist.

Yeah, I know. How so. Yeah, he’s a lovely guy. Yeah.

And and, you know, he was he was going through what his course is period courses about. And, you know, if someone, someone who’s really on it, let’s say you want to get into perio and let’s say you go on a course like his, I’m sure there are others as well, but you go on a course like his, it’s someone who’s who’s putting down the very most important. I’m sure it’s a similar thing with your implant courses. You’ve got the very most important bits of knowledge and thinking and treatment planning in that course. You might think that in that sort of very practical, more practical orientated course, you could get more out of it than from an average MSC that you go to.

I think I think it’s difficult for me. I did the courses, the MSC and Doctorates, where it did ground me, and I was taught by very good people. And without those people, I wouldn’t be where I am and I’m eternally grateful to those people. But you’re right, there are other courses out there that may not fulfil what you would expect, but it’s not just also down to the teachers of the course, it’s also down to the students as well. There were people on the same course as me and you get what you put in. Absolutely, you really do. So there’s that aspect as well in terms of the courses that had him and, you know, myself and other people put out there, you know, those courses. I mean, I’ll put out there because we feel we’re educating colleagues to certain aspects that maybe we weren’t taught or think certain things aren’t taught in a certain structured way, or you will only get taught it if you’re doing a formal structured course. And that may be may not be what your average colleague wants. You know what? Even with my own courses, my own course, sorry, even my own courses, I wouldn’t say they’re the only course out there.

And I did a social media post about it recently. I don’t feel my course is the only course out there. I think if you’re going to study a subject, you know, whether it’s Periodontist and the Don techs, whether that’s on specialist training or not, you know, it’s a lifelong learning. You know, I’m constantly learning. I know a number of colleagues of mine who are specialists in prose or endo perio. You know, their specialist training was literally their beginning. And after their trainings where they learnt more, they refined their knowledge more. And I don’t think there is any one course out there or one qualification or one specialist training programme out there that will fulfil everything. It really is down to what you put in and going on a number of courses and I think there are some courses that should be avoided. There are definitely some courses that should be avoided. That goes without saying. And funny enough, I put a social media post about that as well recently. And I think I think people thought I had this agenda. With regards to that, I put a post that way.

I read that.

But that’s when you if you’re.

Learning different people.

Yeah, different people from different you know, they’re from different backgrounds, they’re being sponsored by different implant companies to, you know, from the guys that I get sponsored by, I get sponsored by Strawman and, and, and by Horizons. And I think people. People question was there their agenda and there wasn’t you know, people said, well, how can you recommend these? I can’t remember how many people are recommended. How can you recommend these guys and not anybody else out there? And, you know, the question was, don’t you have to go on every single course before you can recommend? And my point was, well, you know, if if you’re going to a restaurant or a hotel, you know, you’re not going to go to every single hotel before you make a recommendation. You make a recommendation because you’ve experienced that particular hotel restaurant, course, you know, whatever it is, because you’ve experienced it. And and those guys that I’ve mentioned, I know their courses, I know the content of their courses, I know their knowledge, I know their background, and I know their ethics, their principles. I know a hell of a lot about them. And, you know, there wasn’t anything else other than that. But I think as a profession, we always like to think there’s there’s another ulterior kind of agenda here or motive here or, you know, I think you can’t go on one course. You have to go on multiple courses. And yes, I may not have named every single course provider out there, but that’s not to say I don’t recommend them. It’s just that I know these guys and these are the guys that I recommend. And it was literally off off my head. There wasn’t anything else. I’m sure there are people that I may have missed out on that list as well, and I hope they don’t take offence to it. It was just I think we get very sensitive these days when it comes to social media. I think that’s the problem. Sometimes I feel like I should just shut up and not speak.

But look, I think.

I kind of like the controversy a.

Little bit. You actually said in the Post, you actually said off the top of my head, you said those those words off the top of my head. Did I? You did.

I can’t even remember.

And and, you know, people get sensitive, don’t they? I mean, I don’t know if the guy said to you, do you have an agenda? Did he have his own course? And he felt his course was better than, you know, these things happen. I wouldn’t I wouldn’t worry too much about about it. But what you said about doing more than one course, it’s so true. Even in in our area with just composite dentistry, I always, you know, routinely tell people to go on to as many course as possible because, you know, we do we do a course. But but that’s one opinion and one way of looking at it, one type of material. So in your world, it would be one type of implant or whatever. Yeah. If you’re going to do something every day like dentists with composite, every single patient every single day, it makes sense to go on 12 courses if you want to really know what’s going on. So I do I do understand what you say. Yeah. I’m interested in what you said before, that the reason for that comment was that you’d come across something bad in. Of course, I don’t want you to tell me which course it was, obviously. But what would you come across?

Oh, to be honest, I mean, like, I can’t. There are so many courses out there that I’ve seen snippets of not the actual course, but the course provider. And I see their cases on social media. And sometimes if I’m in the mood, I’ll question the clinical aspect of it and other times I don’t. In the past, maybe about seven, eight years ago, I used to come in all guns blazing and start critiquing cases online, which you know what? That was just that was not the right thing to do, to be honest. It was just me being very cocky. But these days, you know, there’s so many aspects out there. You know, it’s even today I saw a course provider, someone who teaches for lunch, and he’s put out a case on social media. And you can see the transition line of this flat. So when the patient smiling, I can see where the where the bridge finishes and whether the real gums meet the bridge while the patient is smiling. Not to me. That’s that’s not the best case to highlight. And obviously, you’re really, really going to highlight your best cases on social media unless you’re pointing out the mistakes that you’ve made.

So there’s there’s loads of aspects on full arch and implant ology out there. And, you know, there’s no point me kind of pointing to one course or, you know, what kind of problems I’ve seen. I think the other aspect is a lot of colleagues will attend courses without actually knowing the background of the speaker and their knowledge base. So it then becomes, you know, a kind. Of a watered down course because that person would have learnt from someone. He’s learnt it for a number of years. He’s now teaching on a course. You know how I would question the one not just competency, but I’d question the insight and reflection of that speaker because how many complications has he seen? How does he know what he’s teaching is going to work long term? I think there’s a responsibility from the Speaker, but also from the participant of these courses to kind of research the speaker of their course and how experienced they are. But in what Hayhoe is what it is, I can’t change much about it.

The thing is, you can’t get experience without making mistakes, right? I think it’s one of those things that absolutely. And we all start somewhere, even as teachers, as educators. Yeah, we all start somewhere. So it’s a difficult one. I grant you, in an area like yours, though, I do see why you’d be more concerned about that than in an area like mine, for instance. You know, you’ve got potentially you could have, you know, you could blind someone, could you, with one of those good one of those long implants you stick in the in. Yeah. So all right, let’s, let’s move on. Let’s move on to your actual day to day because you work in lots of different practices. You kind of visit them. Is that right?

Payman, You’ve done your research well, haven’t you? Like like before we came on, you knew where I qualified from and you know a little bit about my background. That’s quite surprising, seeing as we’ve not really crossed paths and you’re not really in a kind of a similar field to me. So But yeah, you’re right. I kind of What’s the, what’s the proper term?

Peripatetic.

Yeah, peripatetic. I’m sure some people just say pathetic, but yeah, peripatetic, which means I tend to travel around. Although in saying that although I travel around, I do own my own practice. Oh, so I have my own practice in North Wales. A lot of people don’t know that. I only work there half a day a week and the only other practice I tend to work regularly every week is dental excellence with Robbie. Robbie, he’s. Yeah, I think you guys know Robbie Hughes.

Yeah, I had Robbie on the show.

Oh, did you? I didn’t realise that. So he, he came before me, got damage.

He was episode number six or something, 16 or so. It’s one of the biggest listened to episodes that we’ve ever done.

Well, to be fair, I can imagine that Robbie is a very charismatic guy. He’s a he’s a he’s a lovely guy and he’s well experienced clinician. And, you know, we went to university together. I think it was a couple of years below me. But so those are the two kind of practices that I kind of regularly attend to every week. And otherwise I’m here. They’re in everywhere. So Ireland, Scotland, England, Wales, I kind of travel around, but but my my work is only limited.

But how does it work as far as consultation?

So it’s so it’s interesting. I only work with either what I call what I define. And I know everyone has their own opinion on this. I’m sure this will cause a little bit of controversy, but I will only work with what I would classed as a proper implant ologist. And you can ask me what that means in a sack or a specialist. So either a specialist in prose perio or oral surgery or something. Yeah, some sort of specialist. So I’ll only work with those two types of clinicians or colleagues. So because I’m only working with those two types of colleagues, I’m more than happy for them to do the consultation because they will be more than experienced enough to handle the consultation, liaise with me if there’s any medical issues or or other issues or factors that may complicate the treatment, and then I’ll come and do the surgery with them and then leave.

Okay. But who makes the plan? Both of you or them?

Yeah, yeah, yeah. So we both make the plan generally. It’s generally me defining that plan because they’re going through a mentoring process. So that mentoring process means that, you know, I’ve got to allow them to, to learn from the plan and for me to point out any mistakes and, and how to rectify those mistakes or give them feedback, and then we’ll come to an agreement of of the plan. And they need to understand why that plan is that way. But yeah, it’s both of us making the plan.

So what you said you sit with CT scans and photos and x rays and and talk about the consultation the guy just did.

So essentially the way it works is even before seeing a CT scan, I want to see the patient’s psych assessment or what we call psych assessment. Which is a kind of a, um, like a, I don’t know how many pages it is, but it’s, it’s a number of questions. It’s a number of questions that the patients would have to go through. And I want to see the results of that before the medical history, before the social history, before the scan, CT scans, photos. I don’t want to waste my time on going through a hell of a lot of information. If I know from the beginning that this patient is, you know, expectations aren’t realistic or, you know, they’ve got some sort of issue with anxiety or something like that. So I want to see that score first before I even consider them as a patient.

So you think that you’ve got this five page thing that can actually give you a map psychologically of whether that were whether or not the patient is suitable?

Yeah.

So what kind of questions does it.

Oh, exactly. You know, it’s it’s they’re quite simple, straightforward questions. So does, um does Slate’s or health kind of questionnaire there there’s the modified dental anxiety score questionnaire which is quite straightforward. There’s a questionnaire from general practice, general medical practice, which is to do with anxieties and stresses and other things like that. And then there’s a dental questionnaire, which I’m more concerned with, which is more to do with expectations. So, for example, do you think implants lasts forever? You know, and you’ll be surprised how many patients think implants lasts forever. Yeah. Or for example, do you think implants are indestructible, You know, and there’ll be patients out there that will think implants are indestructible. And, you know, a lot of these patients will answer yes, and that’s fine. There’s nothing wrong with that. But then it’s highlighted, you know, their level of, I suppose, knowledge of what they think implants do. And then that needs to be clarified. And if they don’t accept the fact that implants on average may last 10 to 15 years or, you know, they certainly don’t always last forever or they’re not indestructible, things will break, you know, things like that if or for example, you know, they’re able to come to appointments, they’re flexible to attend for appointments. You know, if they’re if they’re accepting with all of this stuff, then fine. But if after the questionnaire they’ve ticked, yes, implants last forever, then the colleague or clinician says implants don’t last forever. Are you okay with that? And they say, no, I’m not okay with it. Well, then they’re not suitable.

Fair enough. Yeah, I get it.

You know, or or they’re not accepting of the fact that implants are not indestructible. They can break, they can ship, they can get loose. If they’re accepting of it, then great. If they’re not accepting of it, then they’re not a patient for me.

And what about just the anxious patient? Are you saying that you won’t treat someone who’s anxious about.

It’s not that I won’t treat them so. On the modified dental anxiety score. Sometimes patients, depending on what we’re doing, may actually need a general anaesthetic. They may not be suitable for single drug midazolam or, you know, and I also offer multi drug sedation. And they may not be suitable for multi drug sedation either, in which case they do need general anaesthetic. So then we have access to general anaesthetic, but that is a completely different fee associated if we’re going to do things on the. And it also means if they’re that anxious and they get a complication, you know, are we going to take them back to G? No. So it becomes quite difficult. Recently I had a, I had a young girl referred from a very, very prominent implant dentist, you know, very capable. He he’s very competent in all types of implant ology, very skilled. He referred a young girl to me and as soon as she came in, my colleague who was seeing her for the console because he works in Manchester, gave me some red flags. So I said, okay, that’s fine. Thanks for giving me the heads up. I then did my own consultation with her. This girl’s 18, her mum’s a nurse and her mum wanted to be in a Zoom consultation with me and I said no. So I ended up having a chat with this girl and I asked her would she be okay because of her anxiety that we may end up aborting because I’ve never treated her before. And you know, it was a bit questionable. So that was red flags for me. She wasn’t accepting of the fact that her anxiety may not be suitable for just single drug midazolam. And if she went, you know, a little bit off wire with the single drug midazolam, I’ll I’ll end up having to abort the surgery. I’ve never had to abort. But she needs to know that that’s always a possibility. And that was an accepting for her. So it was as simple as, Nope, I can’t treat you. Unfortunately.

I get it.

So, you know, things come about and it’s not it’s not me trying to be horrible. I’m here to help patients out, but I’m also here to do things properly and safely. And, you know, the more experience you get, you become less forgiving with. Well, you become less flexible, there’s less compromise. You do things by the book and, you know, that’s how you get more success because you’re doing things by the book.

So you’re sitting you’re sitting with the other dentist, the implantable digital specialist. The psych assessments come in positive. Now you’re sharing CT scans, X-rays, examinations, photos. And how how is that process take you? Is it like a quick discussion? Is it an hour? How long does it take to go from you’ve never met this, you’ve never even seen a single thing about this patient to you’ve got a treatment plan that you’re happy to then go in and treat.

So I suppose it depends on the experience level of the.

Depends on the situation, right? Well, actually.

Not always, to be honest. Payman it it really depends on the experience level of the mentee and how where they are at their stage. So I’ve got some mentees who are, you know, they’re good to go. I don’t really need to do much. Even when I come to mentor them, they they are really using me there as sometimes I question why I’m there. I’m literally sitting in the corner, actually, to be honest, Payman for some mentees, I’m not even in the room. I’m in the building. That’s how confident I am with their ability. But they want me in the in the building somewhere, just in case, I think for their own comfort until they build things up to a certain level. And then for other mentees, I am literally holding their hands, not even holding their hands, holding their fingers while they’re doing the work. Now you have to remember it’s very unlikely for that to happen to that level because generally the people that I’m working with already at a certain level of experience, so I’m not having to really handhold, I’m kind of really showing them finer details at that point of, of how I would approach a case. Yeah, but the planning, the planning for all of these guys will take more than 40 minutes, half an hour. They’re all at a certain level and I think that’s the difference with me. So I, I have a mentee requirement and it’s all my mentees, like I said, have to be either a proper implant ologist or a specialist.

Yeah.

So, you know, if they’ve met that kind of level, I’m doing very little schooling. In some ways. There’s already a certain level of understanding.

But it’s still it’s still it’s still making my palms sweaty, though. Yeah. That you’ll come in and do such a massive operation on a patient you’ve never met. And I get it. I get it. You’ve done this for long enough. That you know that the mentees and your process is there to to take care of all the different bits. But do you not worry that sometimes someone’s missed something and you’re you’re going to be the one who pays the price for that?

You know, that’s a really good point. But payment. The other thing is you’re absolutely right. So for me to come in, never having met this patient and do some pretty invasive surgery, what what do you think that tells you about my success rate and complication rate?

Yeah, the process is kind of, well, well trodden. It’s a well, well thought out process. Yeah.

Yeah. So I get very little. I shouldn’t really say this word right now. I get very little complication rates and very little failures. So in so I’ve only had, for example, with psychometrics, I’ve only had one case fail. That’s it. And I do a good number every month. I’m not just doing one, I do a good number every month. And I’ve only had one fail since I’ve been doing psychometrics and that that was the case for maybe four years ago. And that was a very complex case with complex medical history and I would do things very differently. So I’ve learnt from that. But other than that, I’ve had very little complications and I’ve not had a case fail. Very little problems post-op and years later. So as long as things are met and there’s very little flexibility with me, I’ve not really had a problem. The other thing is that I choose my patients very well. So it’s not just a psych assessment. You know, the medical history needs to be a certain level. Their social history needs to be at some level. You know, I don’t treat smokers, for example, which is I know it’s a big thing for people out there, but hey, ho, that’s that’s my kind of requirement. If somebody else wants to treat them, that’s up to them. There’s no certainly no criticism from me.

I think smokers are often the ones who need this treatment, isn’t it?

You know what? You say that if that was true, then I would be treating smokers because I wouldn’t have any work. I think in certain areas colleagues are pushed to treat smokers because otherwise there may not be enough work out there. But certainly the cases that I do, if a patient smokes, they have to quit smoking. They have to choose between their teeth and function and all of that, or the fags one or the two. There’s no compromise with me when it comes to that, because, you know, when you’re doing these kind of complex treatments, you can’t have you can’t afford to have any complications. You know, the complications can be significant. So the patients have to be on board. If they’re not on board, then I don’t treat them. It’s as simple as that. I probably say no to God knows how many patients a year.

But how long, how long before surgery you have? Do they have to give up? Is it a long time or is it not?

Yes. They have to give up a minimum of three months minimum, and they have to permanently give up. It’s not just quit for three months after the surgery, a few months later, and then they can start smoking again. They have to permanently quit now if they lie to me. I can’t do much about that.

What about other other sort of health complications, systemic complications? I don’t know. Is it diabetes? That sort of thing must affect it.

Yeah, absolutely. So again, for diabetics. So so again, it’s not just smoking. There’s diabetics, people with autoimmune diseases, you know, a whole bunch of things. So, you know, patients on anticoagulants or antiplatelets, there’s a there’s a whole bunch of medical problems for all of.

Them, and they.

All have to be stable before I treat them, all of them without fail. So, for example, diabetics, they I have to see their HBA one C score before I’ll treat them. And then that score has to be within a good level, not an okay level. It has to be at a good level. And if it’s not at a good level, I won’t treat them. I need to see evidence that they have a good HBA one C score. And then also I do my own blood payment, so I’ll do a full range of bloods and my blood tests are not like the NHS, GP blood tests, they are full range and I’m talking about everything. So I’m talking about, you know, testosterone, I’m talking about vitamin D, I’m talking about, you know, various different types of hormones. So it’s not just the faeces under liver function, kidney function, it’s not just those standard tests, but it’s literally everything you can test for. So I’ll do my checks if I’m not sure about a patient.

Amazing. But the work itself, but it’s sort of hairy work here for the likes of us. I don’t even like blood, but I wasn’t. I wasn’t even the type of dentist you used to take out. Difficult wisdom teeth or even easy wisdom teeth. You’re looking at the work and you see it. You see the sort of, you do think guided sinus lifts and you’re so nice sometimes you correct me if I’m wrong, you bring an implant through the sinus. Yeah, right.

So you really have done some research on me, haven’t you? Like guided sinus grafts and things like that?

Yeah, it’s mind blowing for someone like me too.

So you know what, though, To be honest, Payman like you say that, But actually, any anything you do for the first time is difficult, you know? And I see, you know, you talk about the stuff you’re involved with, composites. I actually think that’s a harder job than sometimes the stuff I do. You know, I look at the work Robbie does and the guys in the practice, you know, Craig does. So I’m having dental treatment right now by Craig, who also works in in dental excellence. And it’s not just Robbie. I look at the stuff Kailash does because I know Kailash really well and he does things slightly different, but similar level and all these guys doing composites out there and I’m like, I couldn’t cope with that, you know? And because it’s because anything you do for the first time is going to be difficult. And I think that type of work is just as difficult, just as complicated. And often it’s management of the patient, not actually the work. The dentistry is the dentistry. You know, it’s actually managing the patient and their personality and their expectations and their wants and desires and telling them what can be achieved and what can’t be achieved. That’s actually the harder bit. True, The actual surgery itself, you know, I personally don’t think is that difficult, to be honest. And that’s, you know, sinus graft, psychometric steroids for larch, single implants, soft tissue grafting, bone grafting, all of it. You know, if you follow the structure, you follow the plan. It’s actually pretty predictable stuff. So I don’t think the dentistry is hard. I think it’s everything else that that makes it difficult.

So do you visit all these different practices? You must see best practice. And I guess sometimes you see worse practice.

And I don’t Payman I don’t see worse practices because the guys I work with are all really slick guys and their practice.

I get.

It. I really I get it practices. But in the past, yeah.

You learn one thing from Robbie and then you learn a different thing from the next guy. I mean, not everyone’s got Robbie set up, right? And it must, it must be, it must be a real education, getting all these different sort of points of view. But the question of the nurse, do you take your nurse with you.

Yeah. I take I sometimes I do because I get a free ride with my nurse so she’ll drive the car, take me to the practice so I can get to snooze in the car. But these days, no, not really. Because, you know, I’m so busy doing so generally after work, I’ll go out for food somewhere. I love eating. I just. I could eat all day, honestly. Yeah. So I tend to work just so I can eat. So I don’t tend to take my nurse with me. I’ll go out there, do the job, and then go somewhere to eat or meet up with mates afterwards. Dentistry for me right now, payment in my level. At my stage of my career, I kind of do it because I. I really enjoy working here, not enjoy working. I enjoy the work. It’s it’s really enjoyable.

Doesn’t it piss you off having to use different nurses who don’t know the way that you do your stuff?

I love I love the nurses. And you know what? The the work that I do, the nurses love it. They honestly, you know, because most of these nurses are implant nurses.

Uh huh.

But as in, do I get annoyed because they may not know what to do and stuff?

Yeah.

To be honest, no. If anything, I’m happier than nurses are nursing than than the guy or girl that I’m mentoring. Because generally the mentees are crap at nursing. And because they’re not nurses, the nurses are generally on the ball. You know, I don’t think I’ve ever again, I’m not working with junior nurses or trainee nurses. They’re they’re often quite experienced nurses, if not, the most experienced nurse in the team is the implant nurse and they’re generally on the board. Generally, you know, I work with an amazing nurse called Leanne in Dental Excellence, and she was so she was doing full arch implants before me. So I started well, I was doing full arch implants with a guy called Eva Dental. I don’t know if you’ve heard of. I’m sure you would have heard of you very dental. And so this was in 2000, I think it was 2012. So this is ten years ago now. And Leanne was a nurse then as well as I’d been working with Leanne ten years ago. She’s now at Robby’s place and she was trained by Veejay. And if anyone knows Veejay, you know, you’ve got to like the nurses needed to have really thick skin to put up with V.J. So I work with her in dental excellent. My, my own nurses in my practice also, they’re amazing nurses because they’ve got to put up with my nonsense and the nurses in all these other practices elsewhere. If anything, I really feel for them because they’re quite nervous when I come along and I can see the nerves in them and they’re really good nurses, like amazing nurses. So I’m generally really happy with with the nursing support.

So tell me this, but the technology is moving forwards all the time. Yeah. So I imagine what you’re doing today is very different to what someone would have done ten years ago. As far as you know, Digital’s really taken a how do you keep abreast of what’s going on? Best practice. And you know, when you’re that at the tip of the spear, I guess internationally there are people who you look up to or whatever. But how do you how do you or are you constantly improving your own process? And where do you see that line between the sort of the risk of trying something new yourself and the medicolegal nightmare that we’re all in?

Yeah, that’s that’s really interesting that you say that, because sometimes I wonder what I’m doing myself to try and keep keep ahead. And it’s really difficult, isn’t it? Technology is moving, but sometimes I’ll be honest, sometimes I think people are focussed on the technology and they’re not focussed with the basics. So I see people using guided and digital and you know, they haven’t got their basics of restorative there, they haven’t got their understanding of how to fabricate the bridge on what’s important in the fabrication of the bridge. They haven’t got their basics of surgery and what you’re trying to achieve correctly. So, you know, there’s a lot of people out there who are focussed on digital and guided and there’s nothing wrong with that. But I do feel that the focus so much into that and they’ve kind of missed out on the basic parts of the surgery and restoration. But yeah, I mean it’s difficult isn’t it? I mean I was doing guided and digital planning, you know, way back before it became quite popular and I was using cadre in America and their labs and shipping it over after sending them the DICOM and CBC because no one was doing it in the UK at that point. But now you know, everyone’s doing it.

Digital is great, but it’s good. You know, in certain scenarios we know that. We don’t know if it’s 100% in every scenario, and that’s mainly when it comes to full artwork, especially the psychometrics and terror grade stuff where there’s much higher risk. And I also think it’s certainly not there for bone grafting and gum grafting, that’s for sure. Although bone grafting, it’s kind of, you know, getting certain aspects are there’s some certain benefits with digital, with with bone grafting, but with full arch stuff where the risks are a bit higher. You know, I’m still dabbling myself. So the guys in Chrome Chrome guided. We had set off to do our first guided psychometrics, but I suppose that’s a little bit under wraps right now. So I can’t talk too much about that. So it’s still kind of up in the air. But up until at this current point, the likes of Zynga, Matic’s and Terra needs to be honest and try and sign us, to be fair. And I won’t be advocating fully guided. Not as of yet. Not until I’ve tried it out myself and worked it out. And and I don’t think there’s anyone out there who’s done fully guided psychometrics anyway to give an opinion. Navigation is different.

Would you do actually print prints the maxilla?

Yeah. Well.

And then build something around.

Well, you wouldn’t necessarily print the maxilla. You could kind of set the guides according to your scan and DICOM. From what you have, it’s a little bit complicated because it also depends on the, the technique your, your you’re going to use for psychometrics. And, you know, we talk about technology coming in. You know, actually the biggest thing when it comes to full arch and psychometrics and terror guides and trance sinus and all of this kind of stuff is actually the surgical technique has changed vastly over the years. And that’s what’s made the difference. It’s not the the guided stuff or digital stuff. The actual surgery has changed.

In what.

Way? And the risks of surgery has changed. So, for example, just as an example triggered, implants in the past were placed almost to the base of your skull. That’s how long they were. So they would use psychometric implants in the Terra region because there were no Terra guide implants back then. And that’s a very, very high risk kind of procedure. But now thyroid implants, you know, they’re specially designed. We’re aiming for just the terra bone and not the terra gold and spheroid bone. So it’s much safer. Yes, there are still risks, but it’s much safer because we’re not drilling right up to the base of the skull. Psychopathic, same thing. You know, there’s always that risk of hitting the eye that you joked about when we first spoke. But actually, if you follow the technique and you can see exactly where you’re going and you reflected a flap, a nice clean flap, and you can see exactly where you’re drilling into, you’re not going to do that damage. Yes, complications can happen, but you’re not going to do that damage. You know, the implants are much better now, so they’re smaller and narrower, so there’s less drilling. And because there’s less drilling, there’s less surgery times, the less complications. We’re avoiding the sinus now altogether. So we’re not getting problems with sinusitis, restorative. They were really quite palatal and now they’re not palatal. So from a restoration point of view, they’re much better. So there’s a whole heap of changes to the implant itself, the technique itself and things are constantly progressing. I am interested in the guided stuff. It’s not that I’m not interested, I just want to try it out first before I can give an opinion on it.

I noticed you’ve got Ricardo Kern teaching for you or with you, is it? And you know, the whole soft tissue side of it.

Yeah.

Yeah. I didn’t really appreciate how important soft tissue is to implant ology until I’ve spoken to a few implant ologists on this on, on here. And it’s so interesting that you’re I always used to think of it as the implant bone issue is what the implant is is interested in. But the soft tissue is always the most unpredictable part of it, right.

Um. I don’t know, actually. I mean, soft tissue is a big, big issue. Don’t get me wrong. But actually, it’s certainly more predictable than bone grafting. Really soft tissue grafting is a lot more Yeah, it’s a lot more predictable and successful than than bone grafting, that’s for sure. I think it’s just that it’s only in the past few years that implant dentists have really been looking at soft tissue grafting. You know, they’ve done all the other stuff out there. They’ve done the full arch courses that done the bone grafting courses, they’ve done the sinus grafting courses, and they want to see what else there is out there to refine their technique. And soft tissue is exactly that. It’s that little last bit of refining their technique. And, you know, most implant dentists are not used to using micro surgical instruments and six sutures and 700 sutures. You know, that’s a new challenge for them or maybe a new tool for them to do so. There’s a hell of a lot of popularity when it comes to soft tissue. But I think that’s because it’s a progression thing. So, you know, implants, when you start doing implants, you do the single implants, you do, you know, a couple of implants for small span bridge. You then move on to over dentures.

You then move on to full arch bridges, you know, maybe PHP one type bridges, then bigger implants like Zeiger matic, Terra Guedes type stuff. You know, you’re looking at sinus grafts, block grafts and that soft tissue. The soft tissue work is the bit right at the end, you know. So I think and I think that’s really, really come about now, especially because we’ve got the likes of, you know, you mentioned Kern, who’s great at soft tissue. You know, you’ve got Giovanni Kelly, who I’m a big fan of, and also the likes of Amit Patel in the U.K. You know, it was actually Abbott Patel who taught me soft tissue work. So I was taught soft tissue work the old school way, you know, doing free gingival grafts and, you know, VIP grafts and quite, quite old school techniques. But it’s actually Emett Patel who who kind of got me to open my eyes a little bit into the into the, I suppose, newer techniques with the Kelly style, maybe Ricardo Kern style. And those techniques are a hell of a lot more predictable and easier to do once you’ve got your head around it. It’s, you know, it’s really quite doable. So you get some amazing results with those techniques.

We’ve had Patel on, on, on the podcast. Tell me, tell me this, but where’s the follow up as far as I’m not talking about of course you have to follow up these patients. Yeah, but my, my point is this. That long term follow up often shows you the results of your decisions that you made in the surgery or in the planning or whatever. Do you get to see that? Do you get to see patients that you treated years ago?

Yeah.

And you learn a lot from that.

Absolutely. Yeah, massively. I think that that is where you learn and it goes back to, you know, me making that statement about course providers and how long have they been doing it for? Because if you’ve not been doing it for more than five years, how do you know what you’re doing works? How can you be confident to teach someone what you’re doing works? Because in my opinion, you can’t. And until you see long term results of your work and how you you could have improved based on the work that you’ve done in the past, I don’t think you can. So one of the one good things of being of owning my own practices, I’ve had that practice since 2007. I’ve had that practice, so I’ve seen all my work in that practice for the past, what, 15 years now? So I know what works when it comes to bone grafting. You know, I see what works when it comes to soft tissue grafts. I’ve got my long term kind of results when it comes to full arch, when it comes to psychometrics, when it comes to terra guedes, the prosthetic kind of work that over denture work, soft tissue work, I see all of that regularly, you know, and the patients that come in, we even laugh about it. Now. The old school techniques that I used to do here, where I’m using austere tomes and banging instruments into people’s jaws and cutting out people’s mandibles and chins and, you know, and all this other stuff with old school drills as opposed to pesos and, you know, various things that I used to do to do full arch. Things have changed. And, you know, I’m so grateful in owning that practice because that is where I learn a lot of it’s where I’ve learned from my mistakes in being in that same practice for the past 15 years.

Let’s get. Let’s get to darker moments. Oh, here we go. Not only against them a bit earlier on this podcast, but someone was telling me, I’ve met somebody that weekend. He said, You really enjoy that bit with the darker moments. Yeah. And I kind of do if I’m got you.

Have you paid when you got a really dark side?

For sure. For sure. Tell me. I mean, it’s important we talk about them, right? We learn, we learn from them and we don’t talk about them enough in medicine or dentistry mistakes. Tell me about mistakes you’ve made. It could be an oh, shit moment. It could be a treatment planning mistake. It could be a patient who lost their confidence. And you know that that sort of patient management mistake. Tell me something about mistakes. You must have had your fair share doing the kind of work you’re doing.

This is Dental Leaders, the podcast, where you get to go one on one with emerging leaders in dentistry. Your hosts. Payman, Langroudi and Prav. Solanki.

Thanks for listening, guys. If you got this file, you must have listened to the whole thing. And just a huge thank you both from me and pay for actually sticking through and listening to what we had to say and what our guest has had to say, because I’m assuming you got some value out of it. If you did get some value out of it, think about subscribing and if you would share this with a friend who you think might get some value out of it too. Thank you so, so, so much for listening. Thanks. Don’t forget our six star rating.