In the final episode of our two-part show with Ian Buckle, he talks about procedural and design-driven approaches to treatment and what it takes to become a complete GDP.
Ian reveals not just one but two memorable black-box moments and talks about replacement events, managing expectations, teeth from Turkey and much more.
“If your patient doesn’t clean their teeth or doesn’t come regularly…you are cruising for a bruising.” – Dr Ian Buckle
In This Episode
01.31 – Being a patient
04.42 – Procedure and design
10.42 – Replacement events
17.10 – Blackbox thinking
21.46 – Guarantees, expectations, limitations
36.39 – Teeth from Turkey
48.18 – Last days and legacy
About Ian Buckle
Ian qualified from Liverpool University in 1985 and spent time in NHS practice before setting up Buckle Advanced Dental Care in the Wirral.
He is a prolific educator who has run courses with The Dawson Academy and IAS Academy, who has also designed practical training on the core curriculum.
He is also a prolific international speaker who hosts regular study clubs and seminars.
Ian has committed to spending one-third of his time teaching and the remaining time in clinical practice.
He is a member of the American Academy of Cosmetic Dentistry (AACD), the British Academy of Cosmetic Dentistry (BACD), The British Dental Association (BDA) and the Association of Dental Implantology (ADI).
Ian Buckle: If you ask me what’s the most important thing that we all do every day is managing expectations.
Prav Solanki: Yeah.
Ian Buckle: Full stop. All right? And there’s all sorts of potholes to fall into, et cetera. But managing expectations is the most important thing. If we look at difference between a bit of whitening and bonding and maybe the most beautiful veneer, I do get patients who are looking at moving a tooth and sticking a bit of filling on but they expect it to look like the best looking veneer. And there’s a gap in there. And I got to try and make sure that I don’t fall into that gap with them.
Speaker 2: This is Dental Leaders, the podcast where you get to go one-on-one with emerging leaders in dentistry. Your hosts Payman Langroud and Prav Solanki.
Payman Langroud: Hi guys. Welcome to part two of Ian Buckle’s two and a half hour epic conversation with Prav. If you haven’t listened to the last part, it would probably make sense to listen to that part first. But in the last part he went into his early life, why he got into dentistry in the beginning of that treatment planning piece. In this part he goes much more into how to go from being a single tooth or single quadrant dentist into a full mouth treatment planner. One of the more educational ones on the ones that we’ve done. Enjoy it. Bye.
Prav Solanki: So Ian, take me through. Curious to learn about what it’s like being a patient of yours. So, my mouth is knackered, yeah?
Ian Buckle: Yeah.
Prav Solanki: I walk in and I meet you for the first time. What happens next?
Ian Buckle: What happens next? Well, one of the things that’s absolutely pivotal to what we do is the complete examination, which is why it’s the first part of the course. And one of the … Pete always used to talk about patients … you talk about trying to set yourself aside. One of the things that will set you aside is if you examine people properly, they’ll say, “No one has ever examined me like that.” And it’s not because it’s [inaudible] Tuesday or whatever it might be but because it’s a thorough examination and it’s what we call a codiagnostic examination. And these days as well it starts even before they’ve entered the practise because how we ask people about what it is they’re looking for, again, we could go on for a lot of time with this stuff. But we have to remember that the patient’s experience is usually dictated by the experience that they’ve had with other dentists. And so they don’t know what to expect from someone like us who we think because I think I’m different.
Ian Buckle: So, we have to let them know that we’re different. But the problem arises when the experience they receive does not match their expectation. And so we don’t want to put people off because I’m a firm believer that hopefully if they come here and they see what we do, they’ll start to get interested. And again, this is not about getting someone in the practise and doing stuff to them. This is about being on their side and it’s a lifetime experience. Again, another reason why Tif and I get on. It’s about being there when the teacher is ready, when the student is ready the teacher appears. I always think that when the patient is ready the dentist appears.
Prav Solanki: Right.
Ian Buckle: And so there may be some patients who are more what we call biologically driven, that they’re mainly, oh, I just want to get a couple of fillings done. Whatever else. Okay. That’s no problem. We’ll get you in. This is what we’ll do for you. This is how we handle it, okay? And then we also get the other ones who are driven by different things and we want to find that out before they come in. However the complete examination is pivotal to what I do because we want to find out what the patient wants and what they expect from us but we also want to find out what they need. That’s my professional duty, I think. And we find out what they want by asking them.
Ian Buckle: And then we find out what they need by examining them properly. And again, a lot of the time, I mean you go to an endodontist, you get a root filling, you go to an implant guy you get an implant. What we’re looking at is what does the patient want? What do I think they need? How can we bring this all together to create a lifetime treatment plan that’s going to keep this patient healthy and well and looking great for the rest of their life?
Prav Solanki: Quest question for you, Ian, right? If you’re a GDP and you don’t have experience in implants or ortho and all of this stuff, how can you possibly give that patient a complete approach? So I understand you’re saying, “Look, if you send them to an ortho,” they’re just going to look through tunnel vision and say, “I need to move your teeth from here to here.” And if you send them to an implant guy he’s going to say, “Right. I need to stick an implant in here and fill that gap.” I guess what you’re telling me is, actually I’m the guy who sort of brings it all together and it’s sort of like the football manager, so to speak. And how do you get all of that knowledge with a level of confidence to be able to do that? Because [inaudible] and I’ll save that question for later, but how would you do that piece?
Ian Buckle: So, let’s just think a little bit differently about this because what you’ve just said is you sound very much like a dentist, Prav. You’re obviously spending too much time with them.
Prav Solanki: [crosstalk].
Ian Buckle: [crosstalk]. So everything tends to be driven by procedure. So what I’m thinking is and I’m a little bit more driven by design, and think about where do I need to get these teeth to make them healthy, work well and look great?
Prav Solanki: Yeah.
Ian Buckle: And then how we do that depends on what the patient wants, what you can do, whatever else. So you might not know how to place the implants as such but if there’s a space there one of the potential options is to provide an implant. So if we understand where that tooth goes and there’s a space, these are the options that we could provide for you whether you work with someone to do that or whether you do it yourself. If you can understand, let’s say the teeth are crooked and we realise that it’s going to be better to get them aligned and we can understand that, we can work out where those teeth need to go, all we’ve got to understand is where the teeth need to go. Not actually how to do it. And then we can either learn how to do it ourselves or we can work with someone else who likes to do that stuff.
Ian Buckle: But it’s all within the framework. So I see my main part of this as a diagnostician to work out what’s needed and then a treatment planner to design where everything needs to be and then we choose the most appropriate treatment options based on what the patient would like and their budget and all those different things. So, it’s also a very valid question what you ask because particularly from less experienced perspective it’s thinking, it’s too much, where do I start with all this? You have to start somewhere. And one of the things that Tif’s been big on and again I’m big on is to be there as a mentor for you and if you [inaudible] off and you’re thinking, “I know what to do but I don’t know what to do with it after that,” we’re here to help you.
Ian Buckle: And that again has always been one of my big things because I come across a lot of people where it’s like, okay, this is what to do and then you ask the question and no one helps you. So I think it’s super, super important that we have this mentoring and support network which I know [IES] do very well so that we can help with that. And it’s a tremendous way of learning as well.
Prav Solanki: So I’m a big believer in like I think the easiest analogy for me is you take driving lessons and you learn how to drive. When you get on the road by yourself, you learn how to drive. That’s when you really learn how to drive. And so I turned up to a one day course, a two day course or whatever, and go back into my clinic. I pull a patient in. Totally different scenario to the X number of cases you showed me in the course and it’s that one-to-one mentoring where I can take that patient’s records, send them to Ian on the platform, and Ian can say to me, “With all my years of experience, this is how you should do it, kid.” I just think that that’s when the learning really starts.
Ian Buckle: Yeah. Well, [inaudible] exactly. And I was, again, there’s that gap. I mean, I see two sorts of people. There’s the ones who they go on a two day implant course and then the next week they’re putting implants into people’s zygomas and God help you. You know?
Prav Solanki: Yeah. Yeah.
Ian Buckle: And then there’s most of us who go on a course and then we go on another course and then we go on another course and we’re waiting for the perfect patient to come with the perfect treatment before we do anything about it. Patients love the fact I’m not encouraging you to do anything to … because we don’t do anything until we’re sure it’s going to be okay, you know? Patients love the fact that their health professionals are lifetime learners, you know? They love the fact that you’re constantly trying to find out more and they’re more than willing to be involved in those situations. So for us it’s like when you come on our first course, we’ll teach you the overlying concepts. We’ll teach you how to gather the information. We’ll teach you how to do some of the diagnostics. And then the next course, you’re going to bring that stuff around and then we’re going to work out how to put that through the [inaudible] process to be able to get to the next stage.
Ian Buckle: And like you say, we’ve got a platform that’s there as well. So certainly people that came on the last course, they’re able to put stuff on there and let me see what’s going on. I can give them some advice and then they can start to move their cases forward. And the safety net is there for them to feel as though I’ve got someone with me that can help with this.
Prav Solanki: Brilliant. One thing that Tif’s quite big on and I’m curious to hear your thoughts on this is the replacement events. You place a unit on someone’s tooth or you do some bonding or composite or whatever. I guess the first question is, what do you say to the patient? So do you education them about the fact that this thing isn’t going to last forever and we’re going to need to replace it in the future? Question one. Question two, does that fact determine what you’re going to do for that patient?
Ian Buckle: Yeah. It’s a big question, isn’t it? So the answer is … let me try and get this into two pieces for you. So do we tell them? So managing, if you ask me what’s the most important thing that we all do every day is managing expectations.
Prav Solanki: Yeah.
Ian Buckle: Full stop. All right? And there’s all sorts of potholes to fall into, et cetera. But managing expectations is the most important thing. If we look at the difference between a bit of whitening and bonding and maybe the most beautiful veneer, I do get patients who are looking at moving a tooth and sticking a bit of filling on, but they expect it to look like the best looking veneer. And there’s a gap in there. And I got to try and make sure that I don’t fall into that gap with them. They need to understand what they’re getting. And I have a lot of bad analogies that I use for people but sometimes we just have to explain clearly.
Ian Buckle: I mean, I’m fortunate because I’ve got lots of cases that I’ve done. I can say, “This is one we did with bonding. This is one we did with this. This is how it lasts.” I explain to them that nothing lasts forever and that we want to get them through their lifetime with a healthy, happy, functional good looking mouth, not through a wedding. People who have heard my stories, I always say because we get a lot of people for wedding smiles is though well, I want you to look great for this wedding but I want you to look great for your next wedding too, you know? And I say, “Okay, it’s my way. It’s a bit of humour.” But what I’m trying to say, “I know it’s a big day for you but soon enough it will be gone and we don’t want to have damaged anything between times.”
Ian Buckle: So if we understand where the teeth need to go, then we can choose the most appropriate options, okay? Now, there are a lot of times when moving the teeth and then whitening them and bonding is going to be a great way of doing things. I also see lots of patients where, and I’ve done this, so I’m sorry to whoever it is, I’ve spent three years moving teeth and then I had to restore them anyway because they were structurally damaged and everything and I probably didn’t gain any great benefit from it.
Prav Solanki: Right.
Ian Buckle: But it’s that understanding about where’s it going to go in the end? What is it we’re going to do? And that goal, we talk a lot about goal oriented dentistry which is the goal is for me to help you keep your teeth looking great, working well for the rest of your life. And so we need to understand the restorative cycle. Patients need to understand that if we’re going to place restorations, particularly crowns, that they’re going to last a certain length of time and I always tell them that they’re two parts to treatment. One is doing it and the second part is looking after it. And we have patients, I’ve been in this practise 15 years now, so we’ve got patients, I’ve actually got patients who come from our previous practise.
Ian Buckle: We’ve got patients 15, 20 years who are doing great. And they’re doing great because hopefully we did a good job and secondly they come regularly for hygiene. And any little bits and pieces we get to fix them and it’s a lifetime, lifelong relationship. And that’s true whether it’s composite, porcelain, ortho, any of those things. It’s a lifelong relationship, you know?
Prav Solanki: Yeah.
Ian Buckle: But we have to think very carefully about that restorative cycle and what’s appropriate for them. And then we also have to think about matching their expectation. The patient may want something and we also have our own line in the sand that we can draw, which the patient may want great big white veneers that stick out but you don’t have to do that. Let them go somewhere else if that’s what they want. So you can have your line of judgement that you think is appropriate for them but certainly if I’ve got a younger person, the less dentistry and the more enamel that I can preserve, the better it’s going to be. But there is a big misconception with patients and with dentists as well that as soon as you mention the crown word, that you’re drilling the bajebus out of a tooth. Most of the crowns that I do are on structurally damaged teeth or teeth that are small that need to be made bigger.
Ian Buckle: And I can do crown preparations without doing a lot of drilling on the tooth. I’m still trying to maintain as much of the tooth substance as possible. So I think the answer to your question is yes, it makes a big difference to me how we go about that. We explain to patients very, very carefully. And I have my, well, my eldest will be 31 next week which makes me feel really old and so a lot of people I see particularly in that era where maybe things are starting to go wrong and they’re looking for veneers or we can talk about composite bonding in a bit, hopefully, but whatever it is and I go, “Well, you know what? Because one thing is when you walk in the door, I’m going to treat you as if you’re my pal or in your case I can actually say, ‘Like one of my children.'” And that’s not something that I would do to them.
Ian Buckle: And okay, maybe you would do it. But certainly back in the cosmetic days, I used to see a lot of dentists who were placing veneers and walking around with braces on their teeth themselves. Be honest. We talk about the daughter test and patients will often ask you, “What would you do?” And I think that question is extremely valid and puts a lot of trust in you. And I think you should be very, very honest about what you would do. So, what we do is based on managing their expectation, the condition of the teeth and also the fact that this is a lifetime venture that we’re trying to get through.
Prav Solanki: We will come to composite veneers. That was the question I was saving, actually, that I mentioned earlier, Ian. But before we jump into that, what’s your biggest clinical mistake? Where you’ve looked back and though, “Oh, crap. I’ve really mucked up there” If you look back over your career, what would you say your biggest clinical mistake is?
Ian Buckle: Oh. Gosh. We haven’t got enough time. Yeah. Anyone that tells you, “Everything is great,” isn’t doing dentistry, I think. This is probably not the clinical mistake but my biggest mistakes are probably being in managing expectation or not managing expectation. My biggest mistakes have probably been and me being much more enthusiastic about their treatment than the patient was. Clinically I remember one case where I got really caught out and it’s someone came in with a lot of old crowns on their teeth and this is why diagnosis is so important and how diagnosis can be really difficult. But someone came in with a lot of crowns on their teeth and they were real ugly crowns. And I did some restorations for his sister and [inaudible] quite nice.
Ian Buckle: And actually their 15 years old now. So it’s a 15 year old story. And I definitely didn’t know as much as I know now and I didn’t know … I probably wasn’t as good at handling things as I was back then. But he wanted them to look like his sister and I was thinking, I saw it more as a mechanical thing. And I did my due diligence but there was old crowns on there. They were deficient, et cetera, et cetera. And I set up pretty well and he continued to destroy them. And the reason why and you can make me feel as bad as you want about this but the reason why that I later discovered was a drug habit. And this was a patient who was mainly noncompliant with a problem. And I didn’t find out about his problem, which maybe is defensible. But I also just thought that if I fix the mechanics, well it’ll be good enough to sort this guy out because whatever.
Ian Buckle: And actually, you know what? If your patient doesn’t clean their teeth or doesn’t come regularly or doesn’t do those things, you are cruising for a bruising. You know?
Prav Solanki: Yeah.
Ian Buckle: So that was one of my biggest mistakes. Another one that springs to mind was actually something similar in some ways because it was a daughter. Not a young daughter but someone in their 30s. And they had some issues. And as a part of it was that their teeth were awful and we went in and we restored them as nicely as we possibly could. But there was all sorts of issues between the daughter and the mother and whatever else. And sitting in the middle of that was not a pleasant place to be, particularly when their relationship fell apart. And guess who gets the blame when that happens?
Prav Solanki: [inaudible].
Ian Buckle: So, we can teach you some great dentistry but I also think when we come back to that complete dentistry thing, the complete examination, it’s about getting to know your patient. And these things, it looks like a long process but you can actually squish it up quite a lot if you’ve got someone who is ready to go, understands all those things. You can get a lot of stuff done quick. But there are sometimes and some people when you want to take your time. And you want to take your time because you want to get to know them. So, this is not about … I mean, I know I’ve heard Tif talk about it which is it’s fine if you leave the practise after two years. That’s fine.
Ian Buckle: I see my patients in the gym. I see them in Tesco’s. I don’t want to be hiding behind the Corn Flakes because something went wrong. So, it’s a different perspective. So get to know them. Date them before you marry them. Probably someone told me a long time ago. I think that’s a good expression. And you don’t have to jump in and do everything all at once. Having said that, if the patient is ready and everything is good and everything is in place, there’s no reason why you shouldn’t be moving forward.
Prav Solanki: So how long do you guarantee your work for, Ian? Someone comes in and has some units fitted for example. How long would you guarantee that for? [crosstalk].
Ian Buckle: [inaudible]. Well, okay. So I’m glad you said that bit at the end. What do I tell them? So what I say to them is, “Why? What are you going to do to them?” All right? And the reason for that is it depends. I have some patients who think that we’ve made them stainless steel super reinforced teeth that now they’ve spent all this money they can do whatever they like with them. And that is not the case. So, I tell them that the second part of their treatment is looking after it and we will be fair and reasonable about anything that happens in the first five years provided they keep up their schedule. You know?
Prav Solanki: Yeah.
Ian Buckle: And if they don’t keep up the schedule [inaudible] better off. And also as well things with composite and bonding, I usually tell them, “It’s going to last a few years. Maybe three to five years with porcelain.” I think we’re supposed to say, I don’t know five years or something. But I usually say five to 10 years or something like that. But I also tell them that I have cases that have lasted 15, 20 years because we did the post-operative care.
Ian Buckle: And in reality, and again I know it’s a problem with people and I know you want a straight answer, so that’s what I tell people. Why? What are you going to do to them? Are you going to be out on the street fighting? Are you going to be eating treacle toffee the whole night? Are you going to take on this programme? Are you going to be sensible? Are you be careful? Are you going to let me know when there’s a problem? Because if you are, then I would expect composites to last three to five years. We’ve got some that last a lot longer. Porcelain, certainly five years plus but we’ve got stuff that’s lasted a lot longer. In reality, I got a lot of great patients where [inaudible] don’t get too many problems.
Ian Buckle: But there’s patients that I’ve helped out more years down the line. Maybe their situation has changed and they need the bit of help. And then there’s patients that come in, haven’t been in a fight three weeks after you fixed them up and that’s not my responsibility. So it’s different things. But I hope that’s a straight enough answer to your question.
Prav Solanki: No, it is. And actually what you said was actually really useful which is qualifying that by, well, what are you going to do with? And educating them. Well, if you look after them, then this is what it is, really. Let’s move on to composite veneers, Ian. It’s a trend at the moment. A lot of dentists are very good at them. Some look better than others. But what I really want to get from you, Ian, is patient comes in and they want to improve their smile, and there’s a lot of dentists doing full coverage composite veneers. And that almost seems like for many a default go-to [inaudible] treatment.
Prav Solanki: And what’s your take on that and where do you think that is going? I’ve spoken to numerous dentists at length on this topic, Tif included, and then some people who teach this, people like Dipesh Parmar who produces some excellent work. But even he himself says that, “These things are not going to last forever and also it’s a helluva a job to put them right if things go wrong.” So give me your thoughts, Ian, in terms of what your feeling is on this movement and where you think it’s going.
Ian Buckle: So, okay. So let me try and [inaudible] perspective then. So nothing is better than health. And the best thing that we can do is to stop people getting mashed up in the first place. Unfortunately the main part that I do is fix people up when they’re damaged. So, helping younger people keep their teeth healthy and looking great I think is super, super important from a very early age. So I mean a lot of the people that I treat are more my sort of age with mashed up teeth and whatever else. So there’s more things that need doing. But we also, you see this age group where we see a lot of this [inaudible] composite veneers or whatever.
Ian Buckle: So to give a perspective over the years, years ago we started off with composite bonding. That was what people did. That was the aesthetic solution. But it chipped and it didn’t look great and whatever else. Then that’s when the cosmetic wave came in and we were able to change that over to porcelain because we could make these beautiful pieces that we could stick on that lasted longer, that look great and that moved to another level. And composite bonding sort of disappeared a bit more. And porcelain took over. And now we’ve got this resurgence of composite. And the question for me is why is that? Well, certainly composites have gotten to be a lot better. That’s for sure. And what we can do with them is great. And as you say, you mention people like Dipesh who are phenomenal with what they can do. But I think there’s also a lot of nonsense talked about these things.
Ian Buckle: So, when you glue something to someone’s tooth, you’ve altered that tooth. And they’ve then got something to look after. And one of the things, I always talk about health and function and aesthetics. And if you make a bad restoration of any sort, and you can’t clean it, you’re going to make problems. You’re going to have … then we’re going to start to have [inaudible] issues. And then like I say, nothing looks better than health and we don’t have health anymore. We’ve then got a composite that’s chipping and breaking because we just did it because that’s what’s in my toolbox. But I didn’t understand the aesthetics of the functional side of things.
Ian Buckle: I see a lot of patients that are having stuff done and the story is, this is chipping and breaking and this and this and this. And a lot of it is because the function isn’t correct. And that’s not just because I’m a functional guy. It’s just a tooth. If you think about it, someone comes in with worn teeth and they go, “I want a nice looking smile,” and you make their teeth longer, you alter their guidance, you alter their envelope of function and we usually recreate the problems that they’ve had maybe even more and they’re just going to break things off.
Ian Buckle: So, this is where it comes back to this idea of complete dentistry. And then once we understand the design of the tooth, so if we need to provide something to make it look nicer, where does it need to go? Is it going to be healthy? Is it going to be functional? And then what’s an appropriate way of doing it for the patient? The simplest way might be to move the tooth, bleach it and bond it. That would be a phenomenal way of doing it. Sometimes the teeth are not in great shape and we need to put a laminate over the surface and the laminate on the surface could be composite or it could be porcelain, and that can depend on the situation. It could depend on the budget and the patient needs to understand what they’re paying for and what they’re getting and what they’re not getting.
Ian Buckle: Or it could depend a little bit on the age of the patients, et cetera, or their expectation. So these things don’t last forever. The underlying principle should be tooth preservation because whatever it is we do is going to need something [inaudible] into it in time. So there’s two aspects that I’d like to stress for this. One is the planning. I always say two and then I’ll probably give you about six, by the way. So one is the planning. So if we understand where the teeth needs to go, then we can choose the most appropriate way. Not just go, “Oh, you want a nice smile. I’ll give you this.” Okay?
Ian Buckle: Yeah. I’ll give you a nice smile. I’ll give you Invisalign. You want a nice smile? I’ll give you veneers. I’ve even seen, you want a nice smile? I’ll take your teeth out and give you an all-on-four. Some of that stuff is disgraceful.
Prav Solanki: Yeah.
Ian Buckle: So it’s about the design. It’s all about the diagnosis. It’s all about the treatment planning. It’s all about getting to know the patient and then working out what it is we need to do. Where do these teeth need to do and what’s the most appropriate way to get them there? And if composite is a good way, perfect. If porcelain is a good way, perfect. But we have to know that our goal is to preserve the tooth underneath, okay? And if you’re going to do a veneer of any sort or any sort of adhesive restoration, there’s one thing that will make your work last longer than anything and that’s preservation of enamel, okay?
Ian Buckle: So, there’s two ways of preserving enamel. One is not to cut it off, all right? Which I strongly recommend if we can help it. And then another way is, oh, well, we’ll just make your teeth bigger and it’s now there, but that is not aesthetic in my opinion. It is not healthy because it’s usually difficult to clean and it’s often not functionally correct either. So it’s ticking my boxes as you can probably tell.
Ian Buckle: Now, if I’ve got a tooth which has lost the volume and we need to recreate that volume and maybe recreate a little bit of length, I could do that with porcelain, the composite, anything you’d like. And that’s going to depend on maybe the budget of the patient, maybe what other restorations they’ve got lying around. All sorts of things like that. The expectation of the patient. So, again, too often we’re given a procedure and then that’s all that we see when the patient walks in the door. And how do I … I’ve got the hammer, show me the nail. You know?
Prav Solanki: Yeah.
Ian Buckle: What I’m trying to say is, “Let’s think about why this happened in the first place.” Let’s think about what we need to do to correct this. And then once we’ve decided what it is we need to do to correct this, then let’s think of the most appropriate way of doing it for this patient. Not for patients but for this patient who is sitting in my chair right now. I got patients where actually they may be better off with porcelain but they’ve got a lot of issues going on. Maybe they’ve got a lot of functional issues. Maybe they’ve got some [inaudible] issues. Whatever.
Ian Buckle: And we’ll restore them in composite because we want to make sure that everything is going to be okay. And they also know that we can always move forward to porcelain later on, because composite is not going to last as long. It isn’t going to look as great, but it’s relatively easy to fix up if something goes wrong with it. Porcelain is much trickier to fix up if something goes wrong with it. So, I do have patients … I mean, I’ve got patients where two of them spring to mind straight away where they’re big functional cases, a lot of wear. We’re probably both a bit frightened about doing porcelain which is actually more suited to them. And we built them in composite and they come regularly for hygiene and 10, 12, 15 years later they’ve still got the composite in there because it’s doing well.
Ian Buckle: But it’s doing well because it was done in the right place with the right function and the right health and the right aftercare. And I think one of the things, oh well you can have this because it’s reversible. Reversible? If I stick a composite to your tooth, I’ve reacted the surface. If I stick a piece of porcelain to your tooth, I’ve reacted the surface. What’s the difference? I don’t know. The mistake that people think is oh, with a veneer or a crown I’m going to chop your tooth up. Actually, most of the time if you’ve lost tooth surface I’m actually going to put stuff on. And this is the importance of what we call the solution-driven preparation.
Ian Buckle: So if we understand the design and we understand where the tooth needs to go, I then understand what it is I need to remove or what I need to add to bring the tooth back to full aesthetics and full function. So a lot of the teeth that I treat have lost length, they’ve lost volume. And so we’re mainly adding things on. And if I’m adding things on, I mean to be honest with you whether I do it directly or indirectly is based on whether I’ve got a path of insertion. So I mean composite is out there. It’s a great material but it’s just got to be used in the right circumstances.
Prav Solanki: Yeah.
Ian Buckle: And people have to understand the limitations of it. Given a choice, I’d always keep a healthy tooth but some of the teeth that I see, particularly worn teeth, all the enamel is crazed and you can bleach it and bond it as much as you like. It’s going to look like a clean kitchen tile. You’ve made the effort but it still looks a bit average. And that’s when you need to put something over the surface to make it look nicer, and that could be composite or porcelain. But we are reacting the surface and we’re usually recreating volume. What I want people to think about because I think this is mainly what you were asking me about is a lot of the sort of Love Island type stuff which is put this in, put it on top of your teeth. Yeah.
Ian Buckle: And I say it doesn’t usually fulfil functional issues. If the patient likes it … well, I see a lot of things and I don’t understand why people do those stuff to themselves. But if the patient likes it, okay, that’s cosmetic. It’s not aesthetic but it’s cosmetic. If it doesn’t work well it’s going to break down and if it’s not properly contoured, you’re going to have biological issues. So, I hope that’s some sort of answer.
Prav Solanki: [crosstalk].
Ian Buckle: So I think it’s a great thing. And composite, I love composite. It’s a great way of fixing things. But it’s just not the answer to everything. Everything, it should be taken on its merit.
Prav Solanki: I was fortunate enough to visit your practise. I think it was pre-pandemic, Ian, and there was a couple of veneer units sat on your lap. Well, on your bench, shall I say. You picked them up and you showed them to me. I was a little bit frightened to touch them because they looked so fragile. They were absolutely wafer thin. But beautiful as well and looked so natural. So, I can say that I’ve definitely seen the work that you do and deliver and it looks fantastic. But I was very surprised at how thin they were.
Ian Buckle: Yeah. The thing is, I mean again, I mean you see some of these things I was going to say take your teeth. I’m not going to say that, but-
Prav Solanki: Why not?
Ian Buckle: There’s some great dentists in Turkey as well. But what I was going to say is a lot of the time when people do a veneer, they don’t have … if you said to most people, “Do a veneer,” they’ll do a preparation that’s out of the book. The preparation that we need to do should be based on the final design. And talk of Turkey teeth, Galip Gurel, great dentist in [inaudible] in Turkey. Fantastic dentist. Anyone who wants to know about veneers, look at Galip’s book and take his courses, et cetera.
Ian Buckle: But he came up with this approved … he’s just good at coming up with names as Tif is. He came up with approved pre-evaluative temporary restorations. And so what that is, if you’ve got a patient and they’ve lost volume and maybe length from their teeth, we make the wax up and then we can put the trial smile over their teeth if you like. And this is not a new thing. This is not something that [DSD] invented by the way. It’s been around for a long, long time. And you put that over their teeth and then the patient can approve them before we’ve done anything, okay? And then we can also treat them as well to make sure that we get everything just right.
Ian Buckle: And then that temporary restoration is actually going to be our guide for the preparation of the tooth because we’re going to prepare through the temporary as if it was the tooth. And very often when we do that, we end up doing very, very little preparation for the tooth at all. And these are all things that we teach on the course as well. We talk about the design and we talk about this [inaudible] temporary way of doing it. We talk about how to do it in composite as well. But that’s how you get engagement with the patient. We can work out some of the features of what I would call key diagnostic reference points. Bless you. Which is putting side ledge, lower incisor ledge and vertical dimension.
Ian Buckle: But we can actually prepare through them and that way we make sure we get the most minimal preparation as possible, that we preserve as much enamel as possible, and that way we’re going to get a much more longer lasting restoration. Very quickly just as a throwaway, you might want to cut this out later. But it’s always a story that reminds me which a few years ago I was at an Indian restaurant.
Ian Buckle: One of my daughter’s gone to the cinema so I went to the restaurant with my wife and my other daughter. So there was three of us in this little booth for four people. And there was a table of guys, a little bit younger than me perhaps sitting on the other table and they kept glancing across.
Ian Buckle: I’m a bit of an old style male. So I’m thinking, “Well, you can take your eyes off my daughter. If you’re looking at my wife, we can come to a deal probably.” And anyways. So this happened. And eventually we finished our meal. And as we finished our meal, one of the guys slid over into the booth, into the spare space and he’s sitting opposite me. And he says, “You don’t remember me, do you?” And I was thinking, there’s two very distinct parts of my life. One is dentistry which I try and be reasonably professional. And the other part was rugby which is a different sort of thing.
Ian Buckle: So some people it’s because I stood on them and some people it’s because I helped them. Anyways, he was very good at it because he left it just … he had perfect timing. He left just enough time for me to start sweating because I couldn’t remember him. And he said, “You see these? You did these 25 years ago.” Best thing I ever did.
Prav Solanki: Wow.
Ian Buckle: [inaudible] he actually called me back. It’s not often that I get lost for words but I sort of didn’t know what to say. And eventually I said, “Well, that’s good.” Because I didn’t know 25 years ago I had no clue what I was doing. So, but the reason why those stayed on was because they were glued to enamel. So even though I had much less idea, there’s a little story, a little anecdote that maybe will help people remember the preservation of enamel is crucial to the success of these bondage restorations. Making [inaudible] restorations makes it much easier for you and the technician.
Prav Solanki: Yeah. Well, we touched on the topic of Turkey teeth. A lot of the clinics that I work with, Ian, they get patients coming through the door saying, “Oh, well I can get that done for five grand in Turkey and I’ll get a holiday. Blah, blah, blah.” And also a lot of the clinics that I work with fix that sort of work as well. So tell me about your thoughts on and I don’t want to generalise. Like you say, there are some very good dentists there as well. But you know what I’m talking about. When people go in there and get in god knows 12 units of whatever for bagging price under holiday all baked into one, what’s your thoughts on that? And I’m actually curious to hear what you would tell a patient if they said to you, “Well, I’m thinking of getting my teeth done in Turkey.”
Ian Buckle: Well, one of the … as I say, we don’t want to [inaudible] everyone with the same brush but I think everyone knows what we’re talking about. And you see, this is like we’re talking about someone who just does implants or someone who just does this, the problem is when you go to those things is they think this patient wants to come and get a smile and wants to leave a few days later with the smile and that’s that. And so there’s already a sort of unwritten agreement between the two that this is what’s expected. And actually I think a lot of the time patients don’t really realise that.
Ian Buckle: And it’s always after the event that they realise what it is. So that’s one thing. I think some of these times they’re just looking to do whatever because it’s going to be done in three days and see you later. And also as well, it’s like a restaurant in a holiday place. Maybe they don’t really care because they’re not going to see you again. So it doesn’t matter. But from a patient’s perspective, what they’ve got to understand is exactly what we spoke about before which is step one is doing it. Okay? And step two is taking care of it. And you and they are not taking care of it.
Ian Buckle: And I’ll tell you [inaudible] my perspective you come to me afterwards, I’m not that interested. I don’t want to take care of stuff that other people have been doing. I like to take care of my stuff and the people that I respect. So that’s one aspect. The other aspect is that in order to make things fit and get the appearance that often it’s much easier to make a big preparation than a small preparation. There is no room for getting things wrong. So they’re much more likely to do that. And cut more of your tooth away.
Ian Buckle: So this is about giving you a good smile, hold the mirror up, see you later rather than show me that in five, 10, 15 years time. So, I don’t think that the patients realise that they’ve now entered the restorative cycle where they will need to get this replaced five, 10, 15 years time and that they may have problems. And we do get patients ring up and say, “I’ve had my teeth done.” So you ask the question, “What would you say to someone?”
Ian Buckle: I say, “Well, this is what I would do for you. This is how I go about it. And this is how we’d look after you afterward. And this is what it would cost.” And then you choose. And one of my good pals and practise advisors [inaudible] told me years ago and I didn’t do it for years because we all know best, but he said to me, “Ian, just talk to the believers.” If someone wants to go and do that, knock yourself out.
Prav Solanki: They’re going to do it. Yeah.
Ian Buckle: I’m looking for the patients and we get them all the time. You say, “You know what? I looked at that.” And the thought of going there and then not being able to take care of things, it frightened me to death. That’s why I come to see you. [inaudible]. Because that’s what I’m looking to do, too. So you might cut down your market a little bit, but I’m not in competition with [inaudible], you know?
Prav Solanki: Yeah.
Ian Buckle: It’s not what we do. I mean, just as a little aside sort of there’s a question that might have been in there which is what do you tell someone? Because I get people who say, “Oh, I had my teeth done in Turkey. I’m having this problem. Would you take a look? And this, this and this.” I always say, “Well, the first thing that I’d do is I’d say this to anyone who is coming to me from another dentist is the first thing that I’d like if anyone has a problem with my work is for you to go back and get it checked out.”
Prav Solanki: Yeah.
Ian Buckle: And if anyone persists, then there’s a nice big bill that goes with it. Because I always remember again slightly a funny story or anecdote years ago, perhaps [inaudible] back in the old NHS days, this guy came in. Got a denture. Crappy little denture. I kept telling him, “You should replace this because it’s not good for this, that and the other.” And it was in the NHS that you can imagine it was about 35 pounds or something to fix this. Didn’t want to do it. Wouldn’t do it. Whatever else. Cut a long story short, several, a couple years later he comes back in and we’re doing an exam for him. Takes this denture out. I’m thinking, “I’m sure that … Isn’t he the guy that I keep telling? Yeah, yeah, yeah. I keep telling him to fix this.” And he says, “Oh, this denture is rubbing me. Do you think you could fix it for me?” I go, “Well, did I make it for you?”
Ian Buckle: And he says, “No.” He says, “Actually,” he said, “I was on holiday in India and a guy made it for me there.” I said, “You know what the best thing to do is take it back and get it fixed. I’m sure they’ll do a great job for you.” And that was the first time I thought of that comment and I’ve been using it ever since. Because the truth of that story is as soon as you touch their denture, you’re not responsible.
Prav Solanki: Of course.
Ian Buckle: And that’s a problem for you. So there is a serious side to that as well, I think.
Prav Solanki: Yeah. And I think the takeaway for me from that, Ian, is that part and parcel of it is an education of the patient. Making them understand that doing your dentistry is only part of the journey, right? It’s looking after it as well. And informing that patient and making them aware of things don’t last forever and they need maintenance, right? And it’s a bit like your car. Get it serviced.
Ian Buckle: Yeah. Yeah. Well, [inaudible] I mean as I say, we’re very keen on treating patients for a lifetime.
Prav Solanki: Yeah.
Ian Buckle: And I say, I don’t think that, can you imagine? I mean, how interested I’m going to be if you went and had it done somewhere else. I want to take care of the people who have commitment to me, you know?
Prav Solanki: Sure. Sure. So Ian just to sum up, I’ve got a few final questions that I ask every guest. One of them is that if it was your last day on the planet and you had your loved ones around you, what three pieces of wisdom would you leave them with? Life advice. Call it whatever you want.
Ian Buckle: That’s a great question. [inaudible] talking about dentistry and then you said that. Okay. Ah. So you’re getting me all teary eyed now. So choose carefully.
Prav Solanki: Yeah.
Ian Buckle: In everything that you do. Be kind. I think be kind to each other is important. And always realise, always keep an open mind. I think there’s so many problems get caused because our mind is closed. Our mind is closed to other people’s ideas. And religions and cultures and everything else. And you know what? There’s actually, if we keep our minds open there’s so much we can learn from each other and life would be so much richer for the experience.
Prav Solanki: That’s brilliant, Ian. How would you like to be remembered? Ian was …
Ian Buckle: A pain in the ass.
Prav Solanki: [crosstalk].
Ian Buckle: Well, he tried his best. He wanted to help other people. And it actually probably comes back to what we were talking about before. It was like probably [inaudible].
Prav Solanki: Yeah. Yeah. I think you have, mate. I think you’ve definitely made [inaudible] proud. Without question mate. Without question. Seeing where you’ve come from. And similarly, I share a similar story as well. From humble beginnings. You only connect the dots later on in life and you only begin to realise what they did and why they did it.
Ian Buckle: Yeah. That’s right. It certainly is. It’s one of those things. I mean, fortunately I’m 59 going on 12, so that’s sort of a good thing.
Prav Solanki: Yeah.
Ian Buckle: I try and keep myself fit and well so I can keep annoying people for a bit longer yet.
Prav Solanki: Of course.
Ian Buckle: But there is that perspective that you get as time goes on. It’s, for me, it’s been … it’s really only happened in these last few years where you sort of get this perspective on life which I think is important to us all. And one of the things that we sort of haven’t spoken about too much but I try and talk about it in the course as well and particularly with younger dentists is to encourage them to put some money away and invest in their education and do all those things because I mean, again I know lots of people who have said it before. No one ever goes to their grave when you ask that question. No one ever goes to the grave thinking, “I wish I done another veneer prep.”
Prav Solanki: No.
Ian Buckle: It’s about all the other stuff that happens in between. And it’s about being able to do your dentistry as predictable and efficiently and as profitably as possible so that you can go and spend your time doing the things that you like with the people that you want to spend time with. Too many of us take our holidays 20 minutes at a time because we don’t organise the schedule properly or we spend all our time chasing our tail and then not being present when we got time with the people that we care about.
Ian Buckle: And I think I’ve made a lot of mistakes over the years and I’m more than willing to share those as well with people. But I think dentistry is a tremendous profession. I’m in the practise at the moment and the school that my children went to is just back there and I used to be able to drop them off at school and pick them up from school and they’d come here and then I was pretty much always home for bedtimes and reading stories and doing all that stuff. And they remember all that stuff.
Prav Solanki: Of course they do.
Ian Buckle: And they remember all the cool things. And then again, life changes. As they got older, they needed less of me and more of my credit card. And so we tend to have … we still have time together, but we tend to have instead of having a lot of evenings together, maybe we have chunks of time on holidays and things.
Prav Solanki: Sure.
Ian Buckle: And for some reason they still want to spend some time with me and I’m grateful for that. And you never get those things back. So dentistry is a tremendous job if you use it as tool rather than letting it be your master.
Prav Solanki: Yeah. Yeah. And one final question. I promise you it won’t make you teary. And that is that if you had 30 days left, how would you spend it? How would you spend it?
Ian Buckle: 30 days.
Prav Solanki: 30 days.
Ian Buckle: Oh god.
Prav Solanki: Do whatever you want, Ian. You’re not going to say veneer preps and all that.
Ian Buckle: Well, it’s an interesting thing. We move to the things that I like are probably illegal or immoral so I probably can’t mention any of those. But it might be that [inaudible] but I always remember somewhat of a story and I can’t remember who it was. Some monk or whatever and they said, “If it was going to be the end of the Earth, what would you … ” And he was digging the garden. He says, “What would you do?” And he said, “I’d probably carry on digging the garden.” And actually the reason he said that was because I’m actually quite comfortable-
Prav Solanki: Content.
Ian Buckle: … and content with what I’m doing. And yeah. I think I’d do that.
Prav Solanki: Nice. That’s lovely.
Ian Buckle: [crosstalk] not digging the garden, though
Prav Solanki: No, no. [crosstalk].
Ian Buckle: I’m not digging the garden. No. But I carry on doing what I’m doing. I’m lucky I’ve got a great family. I know some great friends. But yeah. There’s lots of nice things spending time on holiday. It’s great to be in different places. But one thing I’ve learned over the years is it’s not about where you are, it’s about who you’re with.
Prav Solanki: Totally agree, Ian. Totally, totally agree. Ian, it’s been an absolute pleasure. Thank you for your time.
Ian Buckle: [inaudible].
Prav Solanki: Yep. It will be a good episode, this.
Speaker 2: This is Dental Leaders. The podcast where you get to go one-on-one with emerging leaders in dentistry. Your hosts, Payman Langroud and Prav Solanki.
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’s has had to say. Because I’m assuming you got some value out if it.
Payman Langroud: 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.
Prav Solanki: And don’t forget our six star rating.