In this episode, we welcome the industry insight of Paul Palmer. Paul covers his successful work in academia while juggling Guys Hospital, consultancy and private practice as well as explaining how he spots the potential in promising students.
Paul also covers the evolution of his experience from dealing with failed implants to selecting the right patients and what happens when routine cases spiral into court cases.
“At the end of the day, you’ve got to be able to be confident in your own ability and working within your own ability. That is what we try and instil in our students and the people we work with. Because once you lose that insight, life gets difficult and dangerous for all of us.” – Paul Palmer
In This Episode
01.15 – The Fur Trade Legacy
05.20 – Paul’s Introduction to Implants
12.26 – Dealing with Failure
19.17 – Spiralling Cases
26:44 – Advice for Young Implantologists
31:34 – Spotting Talent
37:24 – Efficacy in Procedures
49:36 – Balancing Workload
55:26 – Zygomatic Implants
57:31 – Legacy & Last Day on Earth
About Paul Palmer
Paul graduated with his BDS from the London Dental Hospital in 1986. From there, he gained his MSc in Periodontology at UMDS Guys Hospital and has since been working in part-time private periodontal practice.
He has a membership in Restorative Dentistry from the Royal College of Surgeons of England. He is an examiner for the Diploma in Implant Dentistry for the Royal College of Surgeons of Edinburgh and was on the Specialist Advisory Board for the Royal College of Surgeons of Edinburgh.
He currently provides implant treatment for complex cases and teaches implant dentistry to post-grad students. Having worked with various implant systems, he lectures nationally and internationally on the topic.
Paul has a particular interest in bone augmentation and non-invasive sinus grafting techniques.
Dental Leaders – Paul Palmer.mp3
[00:00:00] We always try and not treat patients to a budget. So if it means not treating a patient, I know it sounds mean, but we’d rather not treat a patient than try and treat them on the cheap.
[00:00:17] This is Dental Leaders, the podcast where you get to go one on one with emerging leaders in dentistry. Your hosts Paymen Langroudi and Prav Solanki, it gives me great pleasure to welcome Paul Palmer onto the podcast.
[00:00:40] Paul is a consultant periodontist from Guys Hospital, works in the West and has many papers and a book on employment policy and works in the South End practice. Pleasure to have you, Paul.
[00:00:58] Thank you very much. Nice to be on this podcast.
[00:01:01] It’s about kind of the person behind the persona. And we kind of we tend to start with the same question and end with the same question. So the first question always is, where were you born? How do you sort of grow up? What kind of childhood did you have?
[00:01:15] When did dentistry come onto your agenda? OK, so that’s what leads to her. You actually confused me with my brother in a setting up of the expected third year and one of a family of five boys, and our father was a furrier. Grandmother was in the fur trade as well. So a lot of my extended family were in the fur trade, which is obviously quite a high, highly technical manual job. Now, that’s partly where we go now, dexterity from so two my brothers, when it’s the fur trade we’re actually dying and they went on to other things. So one of them became a paramedic, another one which I went into a sale loft because we’re sort of major family sporting activity growing up with society. And then one, the middle one’s an accountant. And then so my eldest brother, Richard, who is a twin, he had the closest relationship and the five of us. So we were very close, all my three brothers, nine years between us. So he had a big influence on my choices, I suppose. So the classic story I tell is where my teacher at the age of nine asked me what I wanted to be and I was proud when I got home to tell my mother I’d had this conversation. And the answer I gave is all I want to be a gynaecologist. And she just basically just raised your eyebrows and just sort of took it as why would that be a surprise when he’s got four older brothers just influencing him.
[00:02:53] And so they had a massive influence. You know, when you got brothers who were that much older than you, they influence you. But then it’s always had a sort of medical balance, I suppose. But medicine saved a bit of a a far stretch. So rich nobody I who went to grammar school after eleven plus our middle brother joined us. So I went to grammar school on the same day he went to sixth form and I went into the first one. Did you grow up in Essex? Yeah. So we’re all born and bred in Essex by three of us live in our own lives and cultures. London, so by the time I was of deciding what to do, Richard was already just about to qualify as a dentist. And so then when I was at school, I nursed him a couple of times when you say periodontal surgery. So he started the practice we’re in now that started on Saturday mornings in our small surgery a mile away from me now. Well, what year did you start, though? So he started that a little bit, about nineteen seventy seven, something like that. Well, that’s that’s the one you just sold. Yeah. So that they evolved from. So that went from a Saturday morning to by the time I qualified and a year and a half in, in hospitals.
[00:04:21] So I thought that time I was about eighty nine and then joined Richard. So Richard basically phoned me up and said, do you want a job. But if you want a job you need to do a masters. So I joined him as his apprentice really went to work. So I said Friday night I got to work at Food Drive to Essex and then Friday evening I could work day surgery. So goddamn 10 o’clock at night people would come along and have it done. And then so that was he was doing Saturdays, as I was saying Friday evenings and now. It’s through surgery, nearly a five day a week practice, that’s those built on perio. And they very much built on implants because implants became a large part of perio activity and we were right at the beginning of that, but and that is a big thing.
[00:05:20] I started implants before he did. All right. So I was really fortunate. My second job was in Pecking, so I’d say more than anything. So we had fantastic consultants there and we had a brilliant senior registrar called Brian Littler, and he was putting in the implants for John Basford and the London. So we were taking pictures out of the London hospital and putting implanted in. And then John Basford was in the process. So that was we were really early on the activity that was in 1988. Well, so I go back along along with the prime system. And are you still using the wrong system now? So. So the thing to do, the things you learn as you go through life, at one point we were running five implant systems and partly that was because we were running a program at guys and we thought there were benefits to immersing people in a lot of systems. And what you learn from that is you actually confuse people a bit in some respects. It’s like, you know, you’re going to play golf, play with one set of clubs, don’t keep giving someone a different set of clubs every day as they were. Just just get confused. So we condensed it down, guys, and we also then condensed it down in our practice because we were running we’re running a mirror image so that we we were doing things in practice that we were then teaching in the hospital.
[00:06:57] And we’re familiar with all those systems. But then you have all the trials and tribulations of trying to run different kids, different spare’s different implants, and then as patients then come back to you for problems, which they always do, you’re trying to remember what went in or what the components were.
[00:07:17] Screwdrivers were what the top levels were just becomes a whole complete nightmare.
[00:07:23] So now actually we’ve basically use Astra and we use the Astra TX, so I’ve been resistant to changing that. So they evolved for the last five years, I suppose, introducing some of the research on the bone loss around Astraea implants.
[00:07:43] So we were very early on. We were very lucky that we were looking for people to run trials for the Astra ST. Once I remember the first I met Michael, nor have you interviewed him yet?
[00:07:55] No one to as a recommendation, say he’s a good raconteur and you know that he he sold the system incredibly well. So it was a very good system. It was very innovative and it’s in the way you could handle it. It’s quite user friendly.
[00:08:13] But then we were given the the early trial of the assay, which was the first Astra implants that had a.. Rotation indexing. So we did a small trial and they asked us to play and restoration, and that was with Brian Smith, who was the prosthodontics they got guys and what was it was to do up to that point?
[00:08:35] It was sort of standard thinking that you would always lose some bone up to the first thread.
[00:08:40] Yeah, that’s that’s a pretty. So we can literally print them out. And it has its good things and its bad things. But what we knew was that it would always lose power to the first strike and that’s part of the design of it. And it’s probably largely relates to it being a peripheral fit implant with an external fit. So where the implant meets you have a big biological insult coming through the stack of componentry. So it’s almost like a biological waste of that implant. And that’s why it goes to the first side is largely, I think, of, well, health there. And then so the Astra by almost by accident, was one of the early platforms, which is a platform switching implant with a really good seal. It’s called the conical. So it’s not it’s not a perfect seal, but it’s it just reduces that biological insult from the implant abutment junction. And so that really did hold the bone very well. And also the other component of that system at that point was the. So we’re using a single teeth. So that’s a sealed system. You’ve got a semantic crown. There’s not much leakage. And then their abutments were solid and they certainly are a lot of them still all. So the uniform is a solid column of titanium. So you don’t get a biological leak from the stack of componentry, so you don’t get a insole bone level. So it delivered on two levels. So it was platform switching and there wasn’t much in the way of biofilm within the stack of components. And that’s what made the big difference. So they always thought or promoted the concept of the micro threading and in the Corona portion of that implant, but that’s probably not the most important thing and it’s also one of the early surface traceroute implants. Yeah, it was. And that was really making a difference of.
[00:10:53] What’s changed in that period of time when it comes to implant dentistry? My involvement with dentists is primarily having conversations with them about the type of patients that are coming through the door, but also the interaction. And I’ll just give you my take on things. There’s this whole new and I know it’s not new people. There’s been this upsurge in the market of people promoting and offering immediate loaded S.A.T. solutions. And I’ve come across clinicians who are for or against that and various various arguments. And then there’s been, I would say, a growth of the interaction between the clinical dental technician and the implant dentist. And that how many of those two types of clinicians and I don’t know if you if you worked in that sort of collaboration before and if you got any thoughts on that, the answer would come to this as well.
[00:11:45] So the most important thing that the golden thing to remember in whatever you do, it’s all about case selection and in case selection, the first thing is patient selection. And the next thing is what are you going to do in that patient? So it’s the case selection within the patient selection. If you can stack up or you’ll get all your ducks in a row, then you’re going to have a quiet time. And I think our philosophy has always been to keep it simple. But obviously over decades of working, you inevitably have to take up certain new techniques and certain new philosophies.
[00:12:26] So as we spoke about earlier, there isn’t anything we haven’t done or tried in the past. And I always say with so logic, my philosophy, I suppose because I’m the one who is doing most of it, is you don’t push the envelope too far. So we don’t actively promote our business based on taking a day or immediate loading. But again, I’m not averse to it in the right situation. And the best example I could suggest is that immediate placement is that easy. If you got a small route and a big employer, an immediate load is that easy. If you’ve got a big problem and the occlusion is you just stack up all the right base to enable you to get to the end result. But our philosophy and that it’s not an uncommon one is that every time you lose an employer, it might be a small percentage of your activity, but it’s one hundred percent of the patient. And you’ve you’ve got to be very brave to actually put yourself in a position where you will either encouraging or allowing a patient to take your choice, where they’re taking out and then ultimately high risk for what effectively is a great gain in the scheme of things.
[00:13:50] If you can just delay things for a few months and be much nearer to one hundred percent, why would you make life so much more complicated for everyone and the added expense of it as well? So it’s always and obviously not always. So I always say always, but by and large, you add expense and complexity to the whole situation. And if you add expense and complexity and it fails, you failed on a higher level. Yeah, and that’s where you can really struggle with patients happy so that our overall philosophy really is that we still do immediate loading. We’ve done some really quite significant cases of patients walking in with periodontal involved, not particularly well kept teeth, but for their psychological well-being to actually give them a clearance and then give them full foot bridges in a day. Don’t don’t enjoy. I don’t I don’t feel any kudo’s doing it. I’ve done it to help the patient more than anything.
[00:15:10] So are there any, shall we say, sort of clinical biological benefits and in certain cases of giving, e.g. Lodin or if you were given choice and is the always patient driven in the sense that it’s more lifestyle? And if you would say, I don’t know, extrapolate out one year, two years, five years down the line, are there any benefits of immediate loading versus delayed loading apart from the inconvenience to the patient during the integration side?
[00:15:41] I think that most the evidence would suggest that other than the old millimeter of bone here or there, the differences aren’t great. So that it helps you argue it both ways, doesn’t it, that there’s no harm in doing it, but that the risks can be a little bit higher?
[00:15:59] Is there any any evidence pointing towards sort of failure rates and things like that with respect to immediate verses and then the whole argument that some people say, well, you only need four implants and some clinicians I speak to say, you know what, even if I’m immediately then I’m not going I’m not going to let it all hang on or I’ll put in five or six for the amount of time it takes me to stick in another one or two. It’s not worth the risk. But just on that front, is there any evidence that the risk of failure is higher with immediate loading?
[00:16:32] Yeah, there’s definitely slightly higher risk, but there’s there’s evidence to show it both ways. But overall, you have to accept there is a slightly higher risk. And again, because we grew up with Branum and we grew up with that in the back of our minds, that it was in the maxilla like a 15 percent failure rate over 10 years will be. When you look at all the stocks that you look at now, that’s that’s a completely different way of looking at implants. So we were we were in early and we had to accept that we were having to build a quite a high failure rate. And part of the reason the implants were so expensive from the get go wasn’t so much that it was expensive to actually start at the start up costs was significant. So the kids were really expensive. The drone attacks were expensive, but also in the background, the the fees were building in a degree of failure because we thought we were going to have to retreat more patients than we ever did. Not never got a refund. But that was it was a it was a philosophy and it was it was the right philosophy.
[00:17:40] And so we also had a protocol where we’ve never. Never say never, never say never, but we always try and not treat patients on to a budget. So if it means not treating a patient, I know it sounds mean, but we’d rather not treat a patient than try and treat them on the cheap and compromise what you do. So the other way looking that is when we when we had significant say about it that would accommodate three implants.
[00:18:17] You’d rather it’s in the early days, put three in and expect one of them to fail rather than put two in for the same things and then hope and pray that you didn’t lose one because then that’s catastrophic. So we fail. Team failure in lots and lots of our case is still part of our philosophy now that you should try and accommodate some degree of failure within within what you’re trying to do.
[00:18:47] We also know that we are really, really bad at predicting failure of a person’s dentition, whether it’s restorative. We operate on flavor. You know, anything. You’re probably a bit more certain we’ll treat you well by time period. But, you know, some of the bigger classes, you try and choose a path where you’ve got a parachute at some point down the line, but the truth will out and they never fight in the way you think.
[00:19:17] You remember any cases where either failure had a big impact on you clinically or just emotionally or perhaps the first time an implant failed. And how that felt and how you how you dealt with it obviously happens to everyone. And many implant surgeons I’ve spoken to, it’s you know, it’s like getting a letter from the GDC, not quite as bad as that is. That’s heart sinking feeling where they feel like, you know, what could have they done differently?
[00:19:47] And have there been any situations like that for you with patients know again, we’ve had it, there isn’t anything we are thinking we’ve not experienced. So with a failure to say so. We had a big legal case years ago where someone sued both Richard and I. Well, I filed a case back that went all the way. So we were ten days out of court. Wow, and that was stressing to the point where you would not believe. And so I think the end is very, you know, this this kind of stuff, it’s good to let people know that you share in the same experiences. And I was very lucky in that case in the rich and I were being so together. And he’s a man who is very driven and he’s classic. Is OneTouch a piece of paper once. So something comes in, lands on his desk. He comes out the next day.
[00:20:56] And I very much try and do that because if you want a quiet life to do so, that litigation was, I think, quite remarkable because what I had in the two of us was two people actually willing to take the fight and get stuff back super fast. So the other side never really had a chance to have anything over on us because every time they said something, it was back delivered robust defense and it was you know, we had more control of it because what did you learn from that process?
[00:21:41] You learn something that’s not the nicest places. The ones you get on best with can still bite you.
[00:21:48] And so you never assume that your relationship with a patient is always going to go the right way because we have a very good relationship with him and it just turned what was what do you think you must have reflected on?
[00:22:03] What was the pivotal moment when it turned? Why did it turn?
[00:22:09] You got a second opinion that probably wasn’t. Completely supportive of us. We didn’t expect it to be here. We had some kind of an implant that was that was the big problem that can be very, very difficult to manage. And so the management of him became someone else’s problem, and then that became our problem. And then when he decided to litigate, the expert was not impartial. So they forgot their duty to the call and they just felt I had a duty to the patient and they weren’t particularly careful.
[00:22:53] But so they had an axe to grind with at least one of us. And it wasn’t until very late in the day where our side said to the other side, if you got any idea who you’re trying to say, and I said, you don’t know what you mean, because the experts said that Richard and I were actually not trained fully what we provided. And then what? Well. He’s the first professor of implant industry in this country and I was a specialist associate, and so at that point they had to then go back to their expert and say, you know, why have you said? So he lost his credibility very, very quickly.
[00:23:44] Do you feel do you feel the weight of being at the leading edge?
[00:23:51] You know what I mean by that?
[00:23:53] I mean, I’ve talked to some dentists who say, you know, they’re well known lecturers or whatever. And when they’re doing the work, yes, they’re doing it for the patient. Yes, they’re doing it for their own self-respect and all of that. But the idea that at any point in the future, that patient could be seen by another dentist who then says, I was treated by Paul Palmer.
[00:24:12] And, you know, your reputation is is up there. So you can’t you feel the weight of that.
[00:24:18] I think we all feel the way I think I think that’s dentistry that, you know, I think my wife has always said that, you know, whenever you say a patient, a scene that someone else is going to say this.
[00:24:30] And I think that’s I suppose I suppose that a lot of your work has been by referral by for such a long time that that’s like just second nature to you.
[00:24:38] Yeah, I think that that’s implicit in a lot of our activity, that’s for sure. But I think it has I think that’s part of the stress of dentistry anyway, is that inevitably someone else will actually say your work is sort it’s almost a given and that should be your driving force to do your best, obviously. But it’s a good thing to remember that. And we’ve always tried to do our best by our patients. Sometimes it doesn’t you know, it’s not always going to go 100 percent, only if you’ve trained so many implant.
[00:25:16] So, I mean, you did you trained most of the people who went through that guy’s M.S. right now.
[00:25:21] And you’ve come at it yourself from the perio angle. But the plenty of people go go with implants from the restorative and then some come in from the oral surgery kind of angle for today. Now, I know that M.S. is not running anymore. Right.
[00:25:36] So we we them Clinton now. So that basically what happened was that in running a masters in implant industry, you get through a lot of clinical cases. So for four people on that course can just get through so much clinical activity on their own that it was not really allowing a good throughput into programs that were perio pros that were leading to a specialist certification. So it just made sense to come back from the the MSA and implants, which wasn’t it was delivering a very, very good degree and fantastic that they had an awful lot of clinical input on their clinical surgeries. But we had a lot of parents and students who were not benefiting so much. So it was better to drive a bigger and better implant.
[00:26:44] So those two degrees than if someone was thinking of if a young young dentist was thinking of going into implants now, what would be your advice as the best pathway to follow?
[00:27:00] Not not only from the educational perspective, but what to do, you know, get a mentor before I think that every now and again are some of the mentoring is good.
[00:27:13] But if, you know, all the programs will be driven by someone with more than one aspect or another. So getting a broad base I think can be difficult. But within an academic environment, I think you’re more likely to get a broader base. So, again, I think programs and certainly we’re very proud of because they get an input from and consultants or surgery and restorative. So they’re both broad based. So I think you’d still have to say that they are probably the gold standard. So an intern program. But the commitment that is is massive and you can’t deny that.
[00:28:02] How long does that take? How much does it cost? How hard is it to get onto these four years?
[00:28:07] The cost? Now there are about 20 grand a year. I think people would have to just check that. And the commitment is three days away. So it’s massive. And I feel really sorry for this. Last year has just been too painful for every one of our undergrads postgrads. It’s just been inconceivable. But is it hard to get on to that program? I think it’s really hard. It’s probably got a little bit easier. I think the numbers of the.
[00:28:43] Probably number of it might have gone down a bit, but I’ll pay you 20 grand and then you stay out of all the students you’ve told. Is it quite easy to spot talent I know Payman always talks about refers back to Dipesh and says when he first saw the passion to his work on the composite side of things, you could spot the talent straight away. And he was it was leagues ahead when you were teaching students. Can you pick the talent out pretty quickly? And if so, what are those what are those key indicators you look at and say, this guy’s going to be a good surgeon, he knows how to treatment plan, case selection, etc., etc. all of the skills of a good implant ologist because it’s not about drilling.
[00:29:33] The implant is not the key point now.
[00:29:36] So I thought we sort of drifted off a bit early because I was I was incredibly lucky that I had our training is undergraduate’s was very, very, very good. So we had a big surgical program. So we had probably at the London and the old surgery department that was actually amazing. So we took hundreds of teeth out. We could load the search crews out finals. You could end up doing an impacted wisdom, tooth surgical removal as part of your final exam rather than just doing something in concert. And then I did a house job and then a schedule, and that gave me a really good grounding in surgery. And then the NSA guys is obviously very surgically orientated. But I had a big restorative component to it. So we were it wasn’t just about perio. There was considerable process input. So that then gives you a really good basis to start your influence with an obviously, again, been exposed very early on to the Brenham protocol, which was so based on dictum that you can yeah, he’s a bit like playing golf.
[00:30:55] There’s a point where putting the implant in, as you say, is just the drilling the whole bit and when you can forget worrying about that.
[00:31:03] But that’s the point at which you raise your bit where you are trying to point where you’re going to be optimizing all the other bits, because all the stress for the students is, oh, God, I’ve got to drill this hole. But actually. It’s not quite that, but it’s the bit around it so is being restored to be driven and being able to think about all those facets rather than getting the implanted.
[00:31:34] So just going back to that question, when it comes to spotting talent, we’ve spoke to numerous educators, Payman himself, when he spotted Dipesh’s talent from a mile away. Do you spot that talent? I mean, is it obvious to you when you’ve got a cohort of students who’s going to be flying ahead? And if so, why?
[00:31:55] I think it’s you also have some that are academically very good and some are potentially very good with their hands. Yeah. And that’s obviously a bit like the most obviously is the practical side of things. So when you get someone who’s very confident in their soft tissue handling, that’s the point at which, you know, you’ve got someone who is probably going to excel. But there are plenty of times in the rough where you start and you think we’re going to have some problems here. But again, their exposure at that point just hasn’t been enough. And it’s part of the problem with undergraduates now and the reliance on what appears to be a lot in practice. Learning in practice is your exposure to enough surgery as an undergraduate and as a as a trainee that gets you to a point where you’re able to do that. So that’s how I was learning implants. The soft tissue handling and bone manipulation was sort of second nature. And that makes a big, big difference. But you can certainly take the good ones and you get most most students a very good standard.
[00:33:11] You must I mean, I said you must do you do charge more than an average guy for an implant?
[00:33:20] No, you do not know how much how much is a single unit restored in the back of the mouth if you’re in two thousand five hundred.
[00:33:30] For us, and that’s that would be standard. And that’s how you just got to. So things I remember about myself, my brother, is that we are quite good at what we do and we’re very efficient. So if you look to our hourly rate, it’s probably better by virtue of the fact that we are incredibly efficient at what we do.
[00:33:53] So how fast, how fast are you how how fast you can go and you are still the still actually mostly a few minutes.
[00:34:04] Well, he’s about 15 minutes. But that so it’s all the stuff around isn’t it. So it’s patient, a local analgesics also stuff.
[00:34:15] So I still largely book out an alpha for one between one and four implants will probably still be an hour. And if it’s a single then I’m going to finish well within the hour if it’s full and it’s going to be a little bit of time.
[00:34:32] But that that makes me, you know, I think a highly efficient individual. Whereas other people that’s a classic, you know, some of the most expensive things, they’re are being used to spend an entire afternoon putting one in on it now. Yeah, that’s fine. I don’t know how you do that.
[00:34:55] It reminds you that they’re not making any more money.
[00:34:59] That’s not something, isn’t it? It’s what charges it is. We want wanted to be comfortable with what we charge as well. So, you know, we hate proctoring. So we try and sort of apply a middle line in the West and we’re not wildly expensive either. We can always kept at a reasonable level.
[00:35:21] I was right here on the show and I was saying to him that every time he’s in the mouth, he’s probably doing something outside of the ordinary. And, you know, dentists know him as a sort of top restorative guy. But every time he meets a patient, he has to sort of justify himself to the patient because the patient doesn’t know who he is. And he said there’s an element of the referral then to sort of saying it.
[00:35:49] But do you find that problem? I mean, amongst dentists, you’re so highly regarded, but you have to keep telling yourself to patients every time you meet them and if you become good at that as well.
[00:35:59] No, don’t know if you even bother with that, you know, because I trust the dentist in all good faith and I think that is that’s the biggest thing that’s going to put you in the right place for the patient. So we’re quite straight talking.
[00:36:21] We don’t we don’t try to promote ourselves massively. We try to talk to patients on their level. So I think I hope we come over as trustworthy and we thrown back as many as we come through the door. There’s lots of places we won’t treat or don’t treat. Also to have something else we give them. We try to give them all the options they have.
[00:36:42] So I don’t I don’t sell implants. I don’t I don’t need to. And I often say to patients that I’m busy enough. I don’t need to trade you. So if I take it or leave it with us, I don’t mind patients. Some patients won’t like won’t like me. And that’s the way some patients will either gel with you or they won’t. I think we’re very lucky in Essex where you have a broad church of patients coming in, but you’re all on the same sort of level.
[00:37:20] Yeah, I like that. About a 16.
[00:37:24] Yeah, but they all live in the place that we have a very, very high tech, smart practice and it was purpose-built and we’re very proud of it and our staff are very proud of it. And they all they’re not driving it to create an income for their driving it. So you give patients the treatment and that comes over so we don’t have to sell anything. The site has been done. If someone sits in our chair, the chances of me not being you know, if I had the mind to do it, I could probably put an implant in just about every patient to walk through the door. But that’s not never been our philosophy. It’s always be that they need it to explode all the other possibilities.
[00:38:09] You know, is there something else that I could have done just just on that conversation of budget? Because if we look at implant, dentistry is probably one of the most expensive treatments that you can invest in, especially if you’re going for so full natural mouthfeel, need full mouth to sort of implant dentistry. And you mentioned earlier that one of your philosophies is you don’t let budget drive the treatment plan because that that could compromise your treatment plan, I guess. Do you ever speak to patients about the replacement of so how long this bridge is going to last, what the future cost of that could be? You know, when you when you get patients in clinics and a bridge is going to be several thousand pounds, and when we know it’s not going to last forever, is that a conversation that comes up or that you ask if we have with your patients?
[00:39:00] Yes. So I try and I try and impress on our students as well.
[00:39:05] So it’s quite good with being in practice and in the academic environment because you’re trying to teach people, but you’re also trying to teach them how to behave in practice and how best to look after their patients and how best to keep yourself out of court and out of the way of the GDC, and that he’s about giving them the information they need. So one of my go to things is looking at ten year data, which is the pool data. So it doesn’t have to be specific to your own activity necessarily. But if you pull data and tell them about ten year data that usually they can cope with that and get their heads around that.
[00:39:51] And what I often say to patients is if I didn’t think this would last ten years, I would be telling you not to have it done. It doesn’t mean it’s going to last ten years. But on balance and on average, I would expect this to be that in ten years time. And if I don’t believe that, then I shouldn’t do it. And I shouldn’t be encouraging you to have it done. And your patients, fortunately, do see ten years as a reasonable time frame and a good time frame for things to last. But that’s I think that’s the best way in the fairest way to do that as pool.
[00:40:30] How much of your work is classic perio work?
[00:40:35] How much is implant or none? But there’s not none. But it’s tiny so. But do we implant itis? Is that something you’re looking at? Someone’s accused of being a one trick pony. You had some while ago, which was stuck in my craw for a long time. So I’ve never given up perio and I’m happy to hear. But I’m surrounded by. Some very, very good periodontist in our practices, so unfortunate that they pick up that stuff, I’ll pick up on items, the take up on that is not quite so, so good. So I tend to do a reasonable amount. But again, I don’t dress it up in any great way.
[00:41:19] I don’t make it too technical. But overall, we have fairly good results with that, actually. So I’m very pleased that today they’re not they’re not great today. So it’s not it’s not a good place to start your relationship with a patient or in your relationship with a patient, because obviously things are going awry and we are looking at an avalanche of very important items that’s going to hit us.
[00:41:45] What’s your position like? What do you think is going to happen?
[00:41:48] I think we all agree that it is an inevitability, I’m afraid, fortunately out and we don’t have a huge amount of coming in that is of our doing. But obviously there is some I think we probably become a bit more cautious as well. So, again, in that case, selection. So where patients don’t have a great deal of attached Sokoya and stuff like that, again, you’re trying to do your best to not pay yourself to corner some point down the line. So I hope in our activities we’re reducing the chances of it happening, but we’re also more aggressive. And so when we identify it, we tend to be more aggressive early on.
[00:42:30] So it’s like a like a flat procedure.
[00:42:33] Yeah, definitely. So if you see it as an active, I’d say he’s only saying time to openly debride it. And I I’m one of the people who doesn’t I’m not concerned about using state instruments on implants, but I think they’re still the best. You’ve got contaminated surface. It’s a wrecked surface. There’s nothing you can do that’s going to preserve the surface. So you might as well get in debride aggressive way as you can. Again, your respective. So you’ll mostly effectively. Are you repositioning as much as you dare? Or you can give the aesthetic, though using adjectives like azithromycin seems to have an effect. But fortunately, overall, I think I get some good, good results. But they are the expensive, sometimes showing more metal, having more space on them. Is this going back to good old fashioned perio surgery? Unfortunately.
[00:43:36] Who are frustrated? I mean, I’m frustrated by how little perio has moved. Well, I don’t know if it’s partly partly periodontist or whatever the new thing comes along I’ll miss. So many fans have come and gone. The periodontist are so anti anything other than debridement.
[00:43:55] No, like is renaming everything from reclassifying it.
[00:44:02] I mean, every dentist must lie, lie back and try and try and invent the cure. It’s just amazing.
[00:44:10] Maybe it’s just I find it totally frustrating that a lot of people are out there.
[00:44:18] You’re just trying to muck around with it on an academic level where in some respects know for the most part the patients is actually a simple disease to treat.
[00:44:30] But it has complexities because you are evolving so often, so many take. And with Ruggie support, so, you know, that’s frustrating. They’re all places that do appear from nowhere, obviously, but I think one of the good things about her is that if you do actually deployed and so what is it now? Some changeable professional mechanical platform is the pmrp.
[00:45:07] Penalty is nearly palmitate fire, so it’s. That’s why they’re coming down and it’s just it’s good to realize that that is the number perio, but it’s also the biggest thing. And that is often the is the home care.
[00:45:25] So if you can’t drive very early on into the patient, but the bulk of periodontal treatment is home care, if you don’t get that message through early on, you’re probably onto a loser.
[00:45:40] I won’t be frustrated by that. I think some of the techniques are fantastic. And unfortunately, some of the most widely propagated and promoted techniques are actually all about recession that no one sees or cares about as far as I’m concerned, for the most part. And I find that frustrating. But, you know, that’s that’s the world we live in.
[00:45:59] So a couple of things when it comes to the peril that I see shopped around, one of the mizin repeated treatment with whatever laser it is for several thousand, if not tens of thousands of pounds marketed as the as the sort of cure. I’d like to get your take on that.
[00:46:19] And then and then the stuff you talking about propagates. And he talked about stuff like pinhole, surgical technique and stuff like that.
[00:46:25] Yes, I see techniques that recession and things like that. But for the most part of the country now he’s proper perio, but largely is is not required. Yeah. Cosmetic, which is truly cosmetic. And that’s a great thing. But yes, around four fives and sixes, that’s where I start to struggle. So I think again, after a little bit careful.
[00:46:52] But the last time I saw it shown in a lecture and shown as this is laser therapy, it was the closest thing to subdural Curatola and I mean curtilage, which is now with the new classification, an obsolete term because you shouldn’t do it unless it’s a periodontal lateral prophylaxis. It was the closest thing to that I have seen in 20 years being shown as this is laser therapy and it blatantly isn’t. So I think some of the people who try and promote it are not actually delivering it, as you would describe it. So if it was waving a laser down a pocket and it worked well, you know, who wouldn’t want that and who wouldn’t love that to be the case? And if it was that, why isn’t it really cheap? But they obviously isn’t.
[00:47:43] And it’s there’s no research or evidence that points to that being the trouble is there is there is supporting evidence.
[00:47:53] But the problem is then when you look at you’re not looking at like for like so if do laser treatment and you’ll know mechanically removing plaque, then you’re probably not going to get much of a result. But the minute you start to mechanically remove plaque professionally, then the level of what you do that is very much under the control of the operator. And it’s to set up a controlled study which is truly blind. And where you truly deliver an equivalent treatment can also be very difficult. What are your memories of the surgery and the data that came from that? The level of scaling root plating that the Swedes did in the good old days was phenomenal. Now, like over an hour on a one motivated to just heart such high end intervention that it doesn’t even compare to what you can deliver. And so if you introduce that into a study where you’re introducing a laser and you have the ability to manipulate the tissues outside of that, then there’s an opening to show more effect than maybe there is in the true world. But that’s the biggest problem.
[00:49:16] Would you do such a sort of variation of different things that you teach you research?
[00:49:25] And then you treat patients and and you know this on the patient side, this kind of mccolm on every side, and there’s the sort of treatment planning side and you write books and all that.
[00:49:36] What’s your favorite of those? Is it the mix? You like what you like the most? I mean, the university environment.
[00:49:44] So I have been blessed with with my career because once I started working in a practice that gave me another home outside of general practice and then very quickly became exclusively in perio practice, privately and in the academia. I’ve had a great mix of places I work. So for the last 20 years I worked in three practices and that guys. And that gives you a really nice it’s a complex world, but it’s also really nice because you’re in a different room every day. You have a different nurse. Most days often say, if I got into practice, I’ll probably be dead by now. I don’t think I could have coped with it. One room, one nurse. It wouldn’t have been good for me. So I had been really fortunate. So, you know, I think you can love and hate them equally, but a bad day in practice just, you know, can be really, really bad on be a good day. Practice, it’s very fulfilling, but having the mix and having a good group of colleagues and a network of friends are probably the reason I’m talking to you, was one of our students and he’s now my boss. And we have a great network of friends, colleagues who work for a lot of the time. We all like minded, but we all have different opinions and we have different ways of working, but we all bounce off each other as well. So when we get frustrated or we’re a bad case, we have a WhatsApp group and we share stuff online. So I think we’re lucky. And now it’s a different world, isn’t it? Twenty years ago, you could have been in practice and never you might never speak to another dentist, let alone a whole group of them.
[00:51:52] So are you on Instagram?
[00:51:54] No, I’m not. Tell us to go on Instagram. I’ll choose my hat or choose my hairdresser, my optician. My this is on the Instagram is a map top up on top of an idea on my way.
[00:52:16] And Paul’s outside would go so out of hand to us.
[00:52:20] The same question. Go for me. Yeah. So your favorite at eBay, you mentioned outside of work, what do you do for fun? So when you mentioned comparing golf clubs to implement tools, it’s I’m guessing not that features somewhere and.
[00:52:36] But tell us what tell us what you do outside of academia and practice to relax.
[00:52:44] If you Times is watching this game, you play golf and it’s not pretty. Basically once a year and it’s usually a charity thing or something gets me to dust the clubs off. So but I appreciate the technicalities of that and how difficult that is and more by the time you need to play such a key hole that they should go for it.
[00:53:08] That’s a use as an analogy. I love my rugby, but so I’m a bit sad today. And so I’ve used that sometimes in my teaching where you’re trying to get people to look at a perspective and you can say is sometimes like, you know, Jonny Wilkinson is lining up a kick. You’ve got to look at it in such a way. You’ve you’ve got to visualize it and you’ve got to put it in plain view as you can and break it down to that point. So it’s the machinations of those things. So, yeah, I’m not quite a sport, but my biggest activity was exciting stuff, saying if you had a week to sell, what would you be doing outside of work?
[00:53:56] So we recycle a lot. So we’re going down the coast to coast in May. We just we snuck in before Boris’s announcement. So we we booked a welcome to Bridlington cycle. Right. Actually, my brother Richard and his wife, my wife and our daughter. So we’re doing that. So that sort of thing. If we got a holiday, it’s an active one. We I can’t I cannot sit on the beach. I mean, look at the look at the colour of my guys. So I’m pale and pasty. I still have the sun off on the beach, the most uncomfortable place on Earth. So I’ll have to sit in the warm shade and read a book or cycle sail to all that stuff.
[00:54:43] It’s been a great honor to meet you. But having heard so many stories about you from a lot of your students, and and we got some great laughs over the years of that lately.
[00:54:58] Yeah. My good friend to all of them worked under Paul and his brother and Pete friend, who I’ve known for years and years and years, always used to tell me about it. So it’s been lovely to meet you, but always ends it on the same question.
[00:55:14] I do. I do. I’ve got I’ve actually got one more question if that’s OK. Know, we’ll kick off with that. And it’s just because it comes up a lot with people I speak to and that’s zygomatic implant’s.
[00:55:26] And you’ll I just want I just want your thoughts on it, because you know what? I’ve come across some dentists who jump on a weekend course to learn zygomatic implants.
[00:55:35] I personally think that’s bonkers.
[00:55:37] And then whatever your philosophy is on it, what sort of training and qualifications do you think somebody should have to be doing that, that level of surgery?
[00:55:49] That’s always a tricky one. I’m not staying at the door letting people in and excluding people. So I think it’s dangerous to even stranger than the line of who who should or shouldn’t, because at the end of the day, the person holding the drill is the one who has to answer so self and the gdc. So it not how much training you’ve had and what courses you’ve done. At the end of the day, you’ve got to be able to be confident in your own ability and working within your own ability. That again, is what we try and instill in our students and our the people we work with. Because once you lose that insight, life gets difficult and dangerous for all of us. But it’s automatic imprisonment. So you have a good enough record and in the right hands they certainly have a place. But what they actually can deliver again is another one. It’s a common philosophy, isn’t it? And one used by by Boris of Light, which is under promise and over deliver. And I think once you’re at the level where you’re starting zygomatic in your stance across the lines where delivery could prove very problematic. So just proceed with caution would be my word with it. It’s not something again, we know well our level of expertise. And when it comes to that, we’ll we’d found that out if we felt it appropriate to have anyone within our practices to actually provide some interest.
[00:57:31] And so on to my final question, Paul. So much in it’s your last day on the planet.
[00:57:40] You’ve got all your loved ones around you, and you need to leave them with three pieces of wisdom, obstructer of advice.
[00:57:49] If I did this one, three, I think you know that. Don’t don’t forget overpromise under promise and over deliver a good one, but you choose yourself and always try and work within your own capabilities because otherwise life is going to be difficult. Now I look after each other really nothing, nothing, nothing groundbreaking there is that it comes down to what your values are really.
[00:58:20] And you have to ride it out. Don’t what you’re also like broken glass.
[00:58:23] But let’s leave.
[00:58:26] I may you might save some people’s backsides. They’re finally available. And how would you like to be remembered, Paul, if if that upset, then this sense and it was Paul loss, how would you like to be remembered for good company?
[00:58:49] I like making people laugh and I think, OK, most most I can do that without causing offence. I hope people think that I do bring about humor into their lives more than anything I do. And I’ve spent my whole life pissing about expense out of classrooms and detention. And I’ve read one of my reports the other day which was post preoccupied with, you know, amusing the rest of the class. Everyone’s expense, not just his own, but erm I suppose is one of my traits. I’m disruptive, I’m a disruptor I think. But no, I don’t do it maliciously, but I can’t, I can’t resist the old gag and luckily actually you know today of not being pulled out of a. Professionally, it must have been close a few times, and I know that Richard would have would have been close a few times as well when one of your students told me he was one of the lads, always one of the lads.
[00:59:58] And that could be that could be your undoing as well. So, yeah, we really like to be a part of that.
[01:00:05] It’s good to have a good relationship. You know, I think the best of the British society, period, period, ontologies always had a good image of being in a place where you can go and learn a bit, but also have some fun, have some fun and hopefully we’ll get some of that sometime soon.
[01:00:28] And the last question for you, about a month left.
[01:00:32] What do you do in that month?
[01:00:34] Isn’t that what amazes me is that people who go back to work, I seriously, I.
[01:00:45] But yeah, I would not be doing that, that’s for sure. What do you think? I didn’t go particularly mad. A party which is spending time, you know, very, very nice life. No. Where we walk away so I can only do stuff. Let’s spend it with our our children are everything to us and we want to spend it with them.
[01:01:11] Are they going to need some nice stuff. How old are your kids? Twenty nine. Twenty six. I loved talking to you made it actually it was terrifying, as I expected it to be, just to chat down the people, you know.
[01:01:34] Yeah. Yeah, I know. Thank you so much for doing it.
[01:01:38] You know, welcome. This is Dental Leaders. The podcast where you get to go one on one with emerging leaders in dentistry.
[01:01:52] Your hosts Paymen Langroudi and Prav Solanki. Thanks for listening, guys. If you got this far, 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.
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