Basic Implant Occlusion and Work Life Balance – PDP012

Jaz’s Introduction: Hello fellow dental geeks and thank you so much for joining me for Episode 12 today. I am so sorry that I haven’t been posting so much at the moment. Basically, life got in the way. My wife had a baby. His name is Ishaan. I sort of referenced it in this episode. So this was recorded when Ishaan was two weeks, now he’s near a 10 weeks. So it’s taken two months for me to produce this episode. But going back on track now for lots more episodes coming up your way. I also had two other big events happen in my life. So one was my ortho exam. I’m doing a postgraduate diploma in orthodontics. And that’s now finished, please say a pass with distinction. So super happy about that. It was great to have been through the diploma but you know, when you’re like studying for an exam, it’s like finals. You like studying, studying, studying and then you just can’t wait for it to be over. So I’m glad it was over but honestly had a great time in Manchester with Mohammed Almuzian and the ACE group of orthodontics. So that was amazing, so good news to share with you in that aspect. And of course, if you’re on social media in dentistry, you would have heard about the Dentinal Tubules Congress 2019 it was a huge success. And I got to welcome to the stage Professor Marcus black because I was chairing the morning session on Friday, and also one of my heroes in occlusion. Dr. Michael Melkers. And he put on a great show. So the Congress was just phenomenal. So there is an early booking sort of system happening at the moment again, early bird discount for for the Congress2020, that’s a Dentinal Tubules Congress 2020 I don’t get paid to say this. I’m telling you because I want you to come I want to meet you there literally is the best dental conference/congress. I really is none of these things. It’s an experience. Along with his post I’ll post a link for you to become I think you can only book until the 17th or the 18th of October, so not long left for you to get your early bird discount to secure your place for next year. It’s held in Heythrop park in Oxford, which is a great place we sort of dominate the entire sort of resort if you like, and it is just phenomenal to come next year some amazing speakers like Mario Semenza, Didier Dietschi, Ed McLaren, Ian Dunn and Boota Ubhi, Tif Qureshi, James Baker, Andrew Chandrapal and Gurvinder Bhirth again. So do check that one out. So today’s episode is with implant Ninja, his name is Ivan, and it is full of gems, and it sort of went in a few directions that I wasn’t expecting to go for the better. And honestly, it’s phenomenal. So I’ll tell you how it’s broken down. I want you to think of this episode as it as though it’s broken into three parts. The first part we just discussed about implant and occlusion. So that’s the whole, you know, the crux of it, the clinical knowledge. And to people who are placing implants, it might be quite basic, hence why I titled it basic implant occlusion. But for those maybe dental students, DFs or those who just don’t deal with implants, so that there is some knowledge in there to be gained. And I also ask questions such as, when you’re replacing a canine, do you still want a, with an implant, do you still want to have canine guidance? And things like that, basically. So that’s the first aspect is the first part of it, we’ll be talking about implants occlusion. The second part of it, we’re talking about how Ivan, who’s a super busy guys, prosthodontist can achieve a good work life balance, and it’s very interesting, the way he’s designed his life, you might find that it’s very difficult to, for you to be able to recreate that. But actually, I think if you put your mind to it, you can set up a scenario where you’re working the right number of days for you. So you can have the right number of days focus on you know, the energy can go elsewhere in your life where you wanted to go. So we talk about how you choose work life balance that’s worth listening to. And at the end, we talk about how he screened his patients or rather how he has delegated now and trained his team to screen for patients who are red flag patients and what we call deal breakers, patients who he refuses to see. And this is so so amazing. This is knowledge and I want to apply it straight away. I’m going to train my staff up to to sort of watch out for these things when they’re dealing with phone calls or Facebook advertising stuff. Red Flag patients it’s really really great insight. So I hope you enjoy this episode as much as I enjoyed recording with Ivan, he’ to the top guy. And at the end, I can reference to his you know his online profile so you can learn more about what he has to offer. But before we dive into the episode I want to share with you today’s Protrusive Dental pearl, and this one is inspired by my good friend Zak, Zak Kara he told me to listen to James O’Brien’s podcast called full disclosure. So I checked it out. And I listened to the episode with one of my heroes, Malcolm Gladwell. And it was an interesting quote that Malcolm Gladwell said, it’s basically, there is something unattractive about someone who cannot change their mind. So there is something unattractive about someone who cannot change their mind. And I totally agree with this. And the context into which he was asked this was along the lines of what if you were proved wrong in one of your arguments, and one of your sort of theories. And what Malcolm Gladwell says, I really love is that you know what, I get happy in a way when someone proves me wrong, so I can improve myself. And I think as dentists, especially as reflective practitioners, we need to adopt this attitude. So if you are, if you know, hopefully not like this, but if you know, someone who is very, you know, “set in their ways”, and with new techniques, coming out better ways to do things, they are still, you know, keeping within that comfort zone and doing things the way they they’ve always done it just because of convenience, or economics or whatever. And they don’t like to be prove wrong, or they don’t change their philosophy or change their techniques or change their mind, then that is an unattractive feature about someone. So don’t be that guy, be someone who, you know, if someone came to me, and poo pooed, my work and said to me that you’re dealing with your case is all wrong, because of x y z, and that was credible, and there was evidence for it. And actually, I’d be like, you know what, thank you so much for showing me a better way. And I would like to think that I jumped ship completely overnight, and to do it, the, you know, the proven better way. So totally, it’s totally cool to change your mind, change your techniques, if it benefits your patients, if it benefits you as a dentist, so don’t be afraid to you know, just because you’re doing something a year ago to change your philosophy, don’t feel that people will look at you as Oh, you know, he used to it that way. And now he or she is doing a complete different way. What does that show about their beliefs or whatnot? Well, actually, you know, times are changing, techniques are developing you know, it’s a good thing to change your mind in dentistry and how, what kind of practitioner you are, change is good. So let’s dive right in with Ivan the implant ninja.

Main Interview: [Jaz]
Ivan, aka implant ninja. Thank you so much for joining me. You are from the States. Where about in states you speaking with me from?

[Ivan]
I am in Stockton, California.

[Jaz]
Oh, California, lovely place. And what’s the weather like today in California?

[Ivan]
Oh, it’s probably gonna be like 105 degrees. It’s, you know, we say California is not like, you know, it’s not like beachy, beautiful. I mean, it’s Central Valley. Lots of farms. Lots of problems. Like it’s not really like the nicest part of California.

[Jaz]
And did you grow up in California?

[Ivan]
Nope. So I was born in Lima, Peru, and I immigrated with my parents when I was two years old. We moved to Florida and then moved all around and ended up in Bay Area of California.

[Jaz]
Okay, and people from Peru, what’s the the national language approved? I’m sorry for my ignorance.

[Ivan]
It’s Spanish

[Jaz]
I thought so. So you are fluent in Spanish? Yeah?

[Ivan]
Yeah, I am. I mean, I speak like a gringo. But I still speak Spanish.

[Jaz]
Brilliant. And so tell the listeners out there a little bit about yourself about implant Ninja, and the type of practice that you have.

[Ivan]
Sure. So I’m a prosthodontist. I, you know, after my parents, I kind of like followed in their footsteps. They’re both dentists. And I decided that I kind of like their lifestyle. They, you know, growing up, they always went to my, you know, science camp, my field trips, and I wanted to do the same for my children. So, I decided I want to be a dentist and kind of have a flexible schedule. So I went to UOP dental school in San Francisco. Then I got married, I dragged my wife across the country went to University of Michigan, for prosthodontist.

[Jaz]
Is your wife, a dentist?

[Ivan]
No, she’s not. She is a hygienist. And so we actually graduated in the same ceremony. And she’s actually I met her in high school, because I would kind of a troublemaker in high school. And I ended up getting in fights and trying to like start a business in high school. So I ended up getting kicked out and I had to go to another city to go to high school.

[Jaz]
Wow, what a story.

[Ivan]
But it was great because I met her. And

[Jaz]
It’s destiny.

[Ivan]
Oh, yeah we’ve been together ever since. So yeah, I dragged her to Michigan. I think she was a little resentful at first about it, because it’s so you know, it’s so different from California. And I did my training there for three years.

[Jaz]
And she was also doing her hygiene school training there as well?

[Ivan]
So she so both of us finished our training. So I finished my dental training, she finished her hygiene training in California, and then we moved to Michigan, so I could do my prosthodontics. And just so she could, I guess just be with me. So she’s she got a license out there. I got a license out there. So we both work. We’re working at the same time.

[Jaz]
Okay. The reason I asked her about it, whether she’s dentist or hygienists is pretty much close enough really is because as dentist, we’re a very incestuous bunch. My wife’s a dentist, I know plenty of dentist married to other dentists. So even dental nurses or hygienists, or whatever, you know, so we do have a pretty closed loop.

[Ivan]
Yeah, it’s true.

[Jaz]
Fine. So tell us about implant ninja. That’s a really cool concept you’re going to have going there and tell us about how implant ninja came to be

[Jaz]
Sure. So I was in my prosthodontics residency, and I just started posting about my stuff I put start posting my cases, because one of the big pain points for me was when I was learning implant procedures in my dental school, there was not good resources. I remember I was doing a full arch case. And I was leaning on my instructor heavily for, you know, help with the case. And he told me to look it up on YouTube. So it was very, very, very hard for me to figure out what the heck I’m supposed to be doing with these cases, especially because like the senior dental students, they didn’t want to do these cases, because it didn’t fulfill their requirements. So they pass them off. And I was one of the people that was collecting as many implant cases as possible. So I decided that as I’m learning, I’m going to be posting things and bringing those in 2016 that I really started posting a lot and I found out that people really appreciate it a lot. So I decided to put it all together in a book. And it was a really, you know, really basic handbook. Nothing

[Jaz]
Is it the All-on-X?

[Ivan]
Yeah. The first edition of the All-on-X Handbook, and it got such It was like received so well, like a lot better than I thought it would be. And it was really actually I think, because it’s so unique. Most textbooks are so dry, and you know, you buy them to sit on the shelf, because you don’t want to read them. I don’t think anybody has time to read textbooks. So I wrote it in a way that’s like, you know, you’re having a beer with me. And I explained basically in plain English, what I’m doing. And so that was really popular.

[Jaz]
That’s really good. I really loved the title, you know, All-on-X. It’s just it was I really when I saw that on your website that’s cool. So I think that’s really cool. You had a lot of success with that. And then how that evolved into you’ve got lots of like a training series like videos now.

[Ivan]
Yeah. So I think that there were not too many dentists on social, on Instagram back then. And so I got, you know, I got a good size following. And I went to the DIA conference last year. And then I that’s when I realized that people were actually like, real people were actually listening. They came up to me, they said, hey, I’ve been following you for years. And I’m like, wow, that’s, not you know, I didn’t think anybody was listening. Right? I just and so since then I’ve gotten serious, you know, I try to really focus on the end user and the user experience and like what they would appreciate, so I think of them now. And so I kind of translated that into what I think is the best online dental implant course. Because like, I’ve seen implant courses, or I’ve seen sorry, online courses where you buy it, and it’s like a set of like, 10 videos or something. And I you know, that’s not that I think that’s given online courses a bad name. And so I’m very, very cognizant of that.

[Jaz]
How’s yours different?

[Ivan]
So mine, I really strive to do is make it interactive, and make it feel like I’m there. So the way I do that is by I have it in like quarter systems, you know, kind of like an academic school year. So we’ll start one shorter. And then there’s topics that are covered, and I’m available. And I’m doing like live demonstrations and things like that. So that’s kind of its way different. It’s pretty comprehensive in the set of like instructional videos, downloads, homework assignments, but on top of that, there’s a personal element to it. So like I actually mail you things, I actually like physically, feels like I’m physically there I think so that’s what I’m trying to do.

[Jaz]
That’s really amazing. I think something that I’ve set on time and time again and again on my podcast is standing on the shoulders of giants and you’ve had obviously mentors that you’ve followed, and you’re trying to package your contact to accelerate learning for others. And that’s what I think the new era of dentistry with all the different even on Facebook is certainly helpful forums, YouTube there’s lots of great stuff there that you can learn on and just messaging and study groups as well physical study groups, there’s always opportunities to learn and advance quicker there’s no point in reinventing the wheel.

[Ivan]
I think so but it’s I feel like it’s a little bit cluttered right now. That like for example, YouTube, you go to implant surgery YouTube, right? If you look up implant surgery, you’ll see like 100 different things, but you don’t know which one is you don’t know the context behind any of them. You’ll see implant going in, and then you don’t see like, okay, they didn’t tell me what they were doing. They just had some weird music in the background. Like I don’t know the follow up. I don’t know that. You don’t know anything.

[Jaz]
So you have to be careful, obviously, when you’re looking at content, when you’re trying to learn from that to actually, like I said, Have some context and some to actually make it educationally focused rather than someone just showing off their skills or showing off the hey, here’s a treatment.

[Ivan]
I think most people are just showing off their skills these days. And that’s why I feel really really confident that I’m going to be very successful because I’m very straight up like I’m not the best clinician, I feel like I do good work. I feel like I know these important things, you know, in and out, but, you know, I’m just like a regular dude that’s trying to share like what I’ve learned.

[Jaz]
Beautiful. So now that leads me very nicely on please share with me, Ivan. Okay, let’s discuss this as you know, my podcast school Protrusive Dental podcast, it’s got a bias towards occlusion, something I’m quite passionate about. I want to know from you about occlusion and implants. So let me tell you a little bit about my knowledge with implant and occclusion and basically with a single implant and and please tell me how you tackle it. With a single implant, let’s say replacing a molar and premolar, once you place your crown, after we know we’re doing a delayed approach, or whatever, it’s not getting too much into that, or maybe that’s part of it. So you can tell me, but basically, when everything gets together, the implant should not be holding shims. So shouldn’t obviously, are eight microns or 12 microns depending on which have you buy and it should be passing through. ie is the implant protected occlusion, So tell me, correct me, in terms of what I’ve said there in terms of a single implant and occlusion on that

[Ivan]
I think you’re spot on. And I think that if the patient has a full set of teeth, and they’re just replacing one tooth, it’s very simple, right? You just kind of leave that implant out not holding shim. And that’s pretty slam dunk case. The only other thing that I would add to that is that you would check the excursive movements. So you know how articulating paper has one blue side, one red side, usually I just put the blue side, have them bite down, tap, tap, tap into CEO. And then I would turn the articulated paper to the other side and have them do their excursive movements. And I make sure that my implant does not have any contact in excursions.

[Jaz]
Perfect, brilliant. So that’s the very simple case. Now, what about when you increase the number of implants? So this is, you know, we’re discussing before about the gray areas and you know, suddenly, well, what if you have like, three or four implants scattered? they’ve collected over time, and then you’ve also got natural teeth, which is maybe a scenario? I don’t know, is that a common scenario? Or not? Because it might not be common because either they need a, you know, full clearance and all on x? Or maybe they need they just have the one or two implants. But do you see that sort of a transition phase where there’s sort of strategic implants placed And there’s lots of teeth there as well?

[Ivan]
Yes. So I think the way to approach this question is, I think basing it off of a number of implants, is probably not the best approach. I think the best approach is seeing how stable is there occlusion otherwise, right? So if they have, I mean, if they have multiple areas of, I guess, multiple edentulous areas, and they are relying heavily on the new areas that you fill in, so if you have to restore occlusion to them, so they’re missing, I don’t know they’re missing two molars on one side, they’re missing three molars on another side, they’re missing canine or something. So if you’re reconstructing the occlusion into them, you have to depend on your implants to recreate those excursive movements and recreate some of the occlusal stops. So that’s like, that could be so many different scenarios. But you have to make that distinction, whether you’re recreate, you have to recreate the excursions and the occlusal stops, or if it’s already created, and you’re just filling in some voids. So, I mean, I would love to say like, Hey, if you’re doing more than three molars, you should recreate some of the working with some of the working movements, and some of the occlusal stops. But it’s real. It’d be hard for me to say that as generally

[Jaz]
It depends on so many factors. Yeah. And I completely respect that. And how about in situations whereby, you know, canine guidance is something that we use a lot for restorative convenience, the fact that it’s a good distance away from the temporomandibular joint. So the forces are less. What if you have a single implant replacing a canine and everything else in the tack? Now, in that situation I imagine that actually in that case, you don’t want canine guidance. Is it fair to then shift your guidance in that case to maybe group function and actually, to include or not to include the canine? Have you, I’m sure you must have encountered situations of replacing implants in canines.

[Ivan]
Yes, I think that is totally reasonable to do that. But so if they currently have canine guide, if they had canine guidance, and then you’re trying to shift them over to group function, sometimes it’s easy and sometimes it’s hard to some if it’s easy, if they are very close to being a group function, so if the rest of their teeth are just barely almost, you know, in contact with each other during the excursions, but sometimes that movement is a little bit further away. And so if that canine is gone, and if you can recreate the group function, I definitely would, but if you have to alter a lot to get there, then it’s a little bit difficult, you might have to do a little bit more work than you anticipated. To get that group function you might have to, you know, rebuild with some composite or rebuild with some crowns or combinations.

[Jaz]
Absolutely. So, let’s just now move on to full arch cases, something that you’re going to do quite a bit of so full arch dentistry. And when we look at complete dentures, so complete dentures with no implants supported the whole concept of the balanced occlusion or the lingualized occlusion so as the patient sort of excursus to the right, there’s still some contacts on a non working side to balance everything. How does it, is that have a role in implant full arch cases as well?

[Ivan]
I personally don’t think so. I, in my full arch cases, I restore them to a group function, it’s not going to be the same. It’s not the same proprioception it I mean, I guess what I’m trying to say is that with natural teeth, you want the heightened proprioception will help you to disclude your teeth and protect your teeth. But with full arches, I don’t have them rely on specific points about arch because what I think is most likely to happen is for that prosthetic material to fracture. And so I would rather put the patient in our group function, and no, I don’t have balancing contacts. I feel the balancing contacts, like in dentures is more useful for stabilizing the dentures. But these full arches don’t necessarily have to be stabilized.

[Jaz]
Absolutely. And one thing that I see a fair bit off is people coming in with, you know, a screw retained implant crown, let’s say, and they come in Oh, my implant crown is loose. And obviously, it just needs the screw tightening a little bit. Right? And I usually a quarter return. And that’s a very common, like in a mini emergency that you would see, is that right?

[Ivan]
Sure. Yeah.

[Jaz]
Do you think that you see that more in patients who parafunction as an observation that you made? Is that is that something that you buy into?

Unknown Speaker
So I’ll give you an example I, there was a patient that I placed in so, it was a scenario, where I go to other offices to work in their clinics, sometimes, and some clinics are faster paced than others. And I’m not proud to say this, but for one patient, I, you know, he had a treatment plan already, he had an implant already treatment plans for number 11. I looked at it, I was like, ‘Okay, great. Looks good. Let’s do it.’ So I did the implant. And then I went to restore him, you know, four months later. And then I was delivering the crown. And I kept checking the occlusion and the occlusion would never go away. So like, my blue dot never went away. Right? And I kind of took a step back, and I looked at the whole scenario. And it turns out that in his entire mouth, even though he had, you know, he had most of his teeth in his entire mouth. He was only occluding on the tooth that I was delivering. That was the only one. And so you know, he came back a couple times because the prosthetic crown kept fracturing. And he was a case parafunctioning on top of that. So I do see that my patients that have parafunctional habits tend to have more screw loosenings. Just kind of like, from my experience, but I don’t know if it’s, you know, directly related.

[Jaz]
We’ll never know in terms of that study probably is very, it would be very difficult to conduct but something I’ve noticed that patients come in and those with a bigger masseters and have other worn teeth. Those are the ones that come in, ‘Oh, my screws, again needs tightening.’ So that was just an observation I made. So Ivan can tell me any other principles or anything that you want listeners to gain in this sort of topic of occlusion with implant prostheses?

[Ivan]
I think it’s important to Yeah, I think there’s one takeaway from it, and you probably talked about it before, but to get shim stock. That’s like the easiest thing that anybody could do to improve their clinical practice, use shim stock, and the other conventional articulating paper. I guess, one good takeaway point would be drill home that no occlusion on cantilevers, right? So there’s no occlusion on cantilevers or full arches. And what I even do for several of my patients, and I tell them ahead of time that I will use a shortened dental arch concept. So I’m not going to be restoring for full arch, I’m not going to restore two pre molars and two molars, right? So I might shorten it by a molar, or if it’s a case where I cannot get enough posterior support with the implants I’ll even shorten it to one premolar and one molar. So you know, semi unconventional, but if the patient does not have a huge smile, and if they’re okay with that, then I think it works really nicely. To have a shorter arch and less stress on the implants,

[Jaz]
Less stress on the implants and less stress for you as clinician as well going forward?

[Ivan]
Yep, for sure.

[Jaz]
How often do you think implant crowns are, you know the longevity of them in terms of the fact that obviously they don’t have a periodontal ligament, so they take a lot more stress and strain within the prosthesis itself. And obviously, you get a very commonly crown chipping porcelain fracture, prosthesis fracture. When you consent your patients, obviously, you know, just tell us what is your, what do you tell patients? I’m your patient, I’m having a Upper premolar, or molar replace, what what kind of things Are you telling me in terms of what to expect from the longevity of both the fixture, the implant fixture and of the crown? Can you give us a flavor of that?

[Ivan]
Sure. I mean, it’s probably same thing that you tell your patients, I tell my patients, ‘Look, what is generally accepted for longevity, these things is 10 years, if you got it more than 10 years, you’re doing good. But a lot of that depends on, you know how often I see you, if you’re coming to all of your maintenance visits, if you’re getting your other teeth taken care of, then I feel like we can get you, get this to last for you a really, really long time.’ I’m not going to tell them, it’s going to last them 20 or 30 years, I’m not going to tell them it’s gonna last forever. I always under promise to all my patients, for sure. And then I try to over deliver to them. But yeah, I tell them that I wanted to get to 10 years and if we can get it longer, awesome. They got to come to the maintenance.

[Jaz]
Brilliant. And you tell them though, that ‘Oh, I’m expecting the implant to be maybe, you know, hopefully going strong. But sometimes the crown itself needs more regular replacing, or is that something that is not part of the process? I’m not sure you tell me

[Ivan]
Sure. Yeah, I’d say it’s a 35 year old patient, I will tell them that most likely to get this crown redone at some point. And I tell them that even though implants have a really high success rate, they also can have a higher complication rate in the long run. So this is not one and done. You’re not gonna, This is not the last you’ve seen of this implant, you’re going to have to do something to this in the future. Whether that is I don’t know, you’re gonna have to get it cleaned. But whether you’re gonna have to get some revision to it in the future is totally realistic. So I definitely warn them ahead of time because implants. I mean, our patients often think that implants are the solution, and it’s permanent, and they’re just not gonna have to deal with it anymore. And I just want to, I want to make sure to, to reset their expectations.

[Jaz]
But that’s really important. And I’ll tell you a story about a dentist in in England, in Sheffield, who I heard about, I don’t know who this dentist is, but you know, we all talk about this dentist who very famously, as part of this consent process for implant provision, he will bring the patients back for a separate appointment prior to implant placement. Okay. And he will give them a quiz, he will actually test them. Okay, you know, how long will your implant last? What type of complications can you have? So that should be like an examination, you know, like a school test, okay. And he also charges money to his patients for the privilege of doing this test.

[Ivan]
That’s amazing.

[Jaz]
So whoever you are, if you listen to this podcast, I love you. You’re doing great. That’s awesome. As consent to the max. Let’s leave that very fun discussion about occlusion implants. And let’s go to even more fun stuff. Ivan, can we talk about family and work life balance?

[Ivan]
Really, that’s like the most important topic for me personally, I think about on a daily basis. And yeah, there’s nothing more important than that.

[Jaz]
Amazing. And I talked to my listeners. Two weeks ago, my wife gave birth to a baby boy. So this is a huge part of my life. I’m may sound okay, or maybe I don’t I’m not sure, but I’m extremely sleep deprived at the moment. So it is.

[Ivan]
Is that your first?

[Jaz]
It’s our first Yeah, absolutely. How many children do you have?

[Ivan]
Congratulations. I just have one. I have one little girl.

[Jaz]
Brilliant. What’s her name?

[Ivan]
Her name is Olivia. And she’s two and a half.

[Jaz]
Amazing. So tell me how do you balance your wife, Olivia. And is it your practice? Do you own this practice?

[Ivan]
I own the practice. I don’t own the facility.

[Jaz]
Okay. So yes, you run your own practice, you run the practice or not?

[Ivan]
I do.

[Jaz]
You run the practice. You go to other clinics to place implants. You run a very successful implant training program, implant ninja. You’re very active on social media and I think you do a fantastic job of that. You have time to speak to me from the states to here for this podcast. How would you fit everything in and obviously some of you disclose now you’re very passionate about this. Please tell us, how can we run our lives better?

[Ivan]
Oh, gosh, I don’t know.

[Jaz]
Tell us about you. You do you. Tell us about how you make it work. What are your philosophies? How does it happen for you?

[Ivan]
Sure. Okay. So for me, family, above everything, for sure. But I’m the hardest worker that I know at least. So let’s see, I’ll just, I don’t know, like a formula, but I’ll just tell you what I do basically. So when I was going to, when my daughter was going to be born, she was born with a condition and it was uncertain whether to she’d be able to survive birth. And so my wife and I really focused a lot on finding the right experts to getting her, you know, safely delivered. And then her situation managed, because she was highly unstable for a while. And so I was unable to work, a conventional job. So I had to find the most, the highest paying job for the least number of days. And so I always, like looked at my time as, like, allocation of scarce resources. So anything that I’m doing my I have to allocate it for the biggest return. And so my daughter is doing fine now, by the same, I still got the same philosophy, I limited my practice to dental implants. And so what I did, even like three years prior to graduating, I made my website for my clinic. And so by the time I graduated, I was already getting phone calls to my cell phone for full arch cases.

[Jaz]
That is amazing. I mean, the level of dedication and enterprise that you showed there three years before, that’s great vision you have,

[Ivan]
Oh, thank you. Well, actually, sorry, it was two years before, because I knew that it takes a while to climb in the rankings in Google. And I really made my content very, very specific, so specific to the all on four. And I saw that most people just put marketing out there. But I actually made a handout. I made a PDF, like handout it was like 50 pages or something made it for free. For anybody that wants to learn, like on, a from a patient’s perspective, what Implant Dentures are all about. And all in four so that got me a lot of patients actually. And sorry, I tried to always keep cash flow as King. So I’m not gonna, I didn’t take out any loans for my practice, I just, you know, started seeing patients, I let the cash flow come in. And from the cash flow, I hired my staff, and kind of like, reiterated, and I got my practice going. And I kind of maintain that same philosophy. I don’t work five days a week, I only work two days a week with clinic. And I screen my patients very, very, very heavily. Anybody gives me a hard time. They’re out of here. Like, I feel like a jerk for doing that. I feel like like I’m a prima donna or something. But, honestly, like, I care about my managing my stress so much. Because life is just too short.

[Jaz]
This is amazing. This is just so good. This is. I’m loving this, as soon as you say that, you know, I’m sure anyone who’s listening to this or any dentist, listen to this right now. As soon as Ivan said, about this concept, you’ve automated had four or five names of different patients or patients that face come up. I know what I wish I screen them better. How do you screen them? Tell me your screening process? Is this within the two days of clinical that you have? Or is this a separate day or describe

[Ivan]
Within two days, it’s within two days, I have a list, I have what’s called a red flags list. And I train my staff to screen my patients for me. So my staff, my treatment plan coordinator will see the patient first. If there’s any red flags, they will, if they’re red flags so much that they’re you know that they’re nixed from the practice, they’re gonna dismiss the patient before the patient even sees me so they don’t waste my chair time.

[Jaz]
That is super connected. I’m sorry to chip in, but I really, really, really interested in this. So if it’s okay, when you can share what you mean by red flag. So what I interpret as a red flag, okay, is let’s see expectations that are not realistic, for example. So for example, someone says, I want implants, and I want them to last forever. And they’re adaman that’s the case. And that’s an obviously it can vary or any restoration anything. If they have expectations that’s a red flag for me. Is that the sort of thing you mean, Ivan?

[Ivan]
Yes, exactly.

[Jaz]
The red flags. Tell me what are these red flags? I’m really interested. Okay.

[Ivan]
I feel like I’m going to get some judgment on this because I’m so picky, but I’m going to share it with you anyway.

[Jaz]
Everyone, please don’t judge Ivan. I think what he’s onto is really good. And actually, you know, if it means that we have a more successful practice with less stress, less repeat dentistry, less failures, because if patients are red plans, you know, it’s typical that they have the most failures. So let’s listen to Ivan and don’t judge him.

[Ivan]
Alright, so there’s two categories, there’s red flags and those deal breakers. Red Flags means like, watch out. Deal breaker means I’m not going to treat you. Okay? So if there’s two red flags, so this is just how I train myself. There’s two red flags. We can’t see them. So these are the red flags.

[Jaz]
And so a two red flags are like a deal breaker. Yeah. Okay, this is like in GGG, do you like soccer? There’s two yellow cards and a red card.

[Ivan]
Make it a soccer analogy for my team to be more fun. You’re banned. Okay? So red flags. Now the first one is says the word perfect as in, I want my teeth to be perfect. Okay? Somebody says they want their teeth to be perfect, but they’re perfectly nice patient. Otherwise, if they’re like a really nice human being, and really compliant, that’s okay. I’m willing to work with them. Alright, next one is a smoker that just will not stop smoking. And, you know, going through like two packs a day or something.

[Jaz]
Alright, good. That’s very sensible. Good.

[Ivan]
Next one is a poor health. I know, it’s very general. But what I mean is like an uncontrolled medical situation that they’re not motivated to take care of on their own, if they’re not motivated or take care of themselves.

[Jaz]
Okay, so we’re talking like diabetes and just generally not look at themselves other conditions,

[Ivan]
Yes but not just diabetes, or diabetes, and they’re not. And they tell me straight up, like, I’m not working on improving, if they tell me that, you know, they’re just not going to help themselves.

[Jaz]
Or maybe they, you know, they have been prescribed, let’s say, a Cpap for obstructive sleep apnea, for example. And they just don’t care. They don’t want to wear it. And obviously that can have issues with you know, perhaps parafunctional, bruxism, that sort of stuff. Is that would that count this is obviously me going back full circle to occlusion again.

[Ivan]
No, exactly. It’s somebody who basically shows that they’re not compliant with other recommendations, others. Alright, the next one is they’re looking for the cheapest possible treatment. If somebody’s looking for the cheapest possible treatment, that means if something goes wrong, and you have to modify your treatment a little bit, that person is just going to lose it and or they won’t be able to afford the right treatment. You know, I tried to deliver really good treatment, but if somebody is trying to cut corners with everything, you really just can’t get a good outcome.

[Jaz]
Brilliant

[Ivan]
All right. The next one is depression. It’s really hard to work on somebody that has depression, especially if they’re relying on you to fix their problems to get you know, it’s too much pressure on you. Okay, yep. All right. Some another red flag is got a refund from a previous dentist for their work.

[Jaz]
Absolutely all they say that ‘Oh, yeah, I just sued my, obviously I sued my other dentist now I’m here to you that to go watch out on that one as well.

[Ivan]
Oh, sorry. So that so sued. So that’s actually my deal breakers category. Any lawsuit? They’re out of here. No second chances. I have two more red flags. Next one is that they talk so much that they interrupt you during your explanation. So somebody that always interrupts you. They basically take up double the chair time of anybody else.

[Jaz]
Yep. True. And if I came to your clinic, I would probably not be getting an implant. But this is something you have to deal on your podcasting. Sorry.

[Ivan]
Good. Alright. And the last one is just generally a bad vibe. So I trust my staff’s vibes, if they get a bad vibe from somebody, and they just can’t explain it. I just, I really listened to that. That counts as a red flag.

[Jaz]
Awesome. And honestly, I have no judgment. I have literally. I mean, I don’t know we’re talking about there was zero judgment that everything you said was completely reasonable, in my opinion.

[Ivan]
Okay, well, thank you that’s good to hear. I’m glad that we sympathize with each other because these are really important for me to keep my stress levels down and work family life. Because if you’re not managing your stress, it spills over to your family life. And what ends up happening is you think about it at night before you go to sleep, you know, you think about should I have done something different in that case?

[Jaz]
We’re all guilty of that. But yeah, deal breakers, go for it.

[Ivan]
So my deal breakers, I’m just gonna list them all in one sentence. So drug abuser, involved in a lawsuit, complained to the dental board, IV bisphosphonates and patient wants a bone in the mandible with radiation at above 55 Grays. So let’s say that’s not their, It’s not their fault, but it’s just I’m not going to place implants on.

[Jaz]
Yes, because it’s high risk treatment that you know, as part of a life decision that you’ve made to, to have less stress in your life that you’re following that and that’s completely cool, man.

[Ivan]
Thank you. So yeah, that’s how I filter my patients. So I filter it heavily. And I try, I’ve actually another thing that I’ve done for work life balance is raising my fees, got to raise your fees, too. So that way, I feel good about the treatment that I’m doing. I feel good about spending more time with my patients. And I guess just jumping over to social media really quick. It’s really hard to be active on social media as a clinician, you know, if you’re, first it’s hard to capture the media on your patients, you’re stopping mid procedure, you’re taking pictures, you’re taking video or something, you could potentially compromise your patient’s treatment. And then in between patients, you’re like posting and you got to write a, you know, a clever caption on your post. It’s really hard, and I feel like people can get burnt out on and I was showing burnt out on for sure.

[Jaz]
Okay, so how do you get out that, man?

[Ivan]
So it’s all about the system. So before I was manually doing, I was taking pictures, I was uploading no more. I can’t do that anymore. I am so busy that I have to have my team do it, but they have to follow my system. And so we developed the system for social media, where we have to surf on any given clinical day, I have implant surgery in the morning, we record that. And we have a system already, I have to do intro, I do voiceover and then I do an outro. They record that. And then,

[Jaz]
and this is like a Instagram story like that?

[Ivan]
Sure. But the thing is like, I don’t make it, before I used to make it so that I take that in to put on Instagram in an Instagram story. But I want to make sure that I get the highest return for my content, because content is the hardest thing to make, because it requires your time. So what I do is I make one long form piece of content. So one long piece of content about my day. So that’s going to be a clinical video, that’s going to be something that interesting that happened to me throughout the day, and some pictures of my cases. And then my staff will go ahead and process that into a video, they’ll clip that into stories, they’ll do it already for me. And they’ll pull relevant pictures that seem cool, or little clips of video that seemed cool. And then they will save that to automatically post using, you know, like, you know, one of those automated social media posting things. I use Hootsuite. And so that posts it automatically. And then they’ll determine what’s relevant for LinkedIn, what’s relevant for IG post, Facebook posts. So there’s a lot of different social media outlets. So I want to try to get the most bang for my buck, so to speak with my content, because that’s the hardest thing to make. So now that I have,

[Jaz]
I’ve been I mean, I’ve got a picture of all these, like 17 year old girls working in your clinic. Because that’s the only people who are so proficient with all this, like technology stuff I like, I feel as though if I was to implement this in where I like, people like what the hell is this? What is an Instagram?

[Ivan]
No, no, it’s actually totally the opposite. I actually have I mean, it’s actually just not 17 year old girls, I feel like, the thing is, if you had a 17 year old girl, you might not be able to stick to your regimen. So I’m very, very strict with my protocol, we follow the protocol, everybody’s on the same page, the content gets distributed, boom, it’s good. So it’s got to be very, very systematic. That’s the only way to do it

[Jaz]
And obviously you’ve allocated, protected time for your staff so that they can carry this, these duties out at, you know, to the best of their ability, and to be able to follow the system then also, at the same time is doing all processing, taking phone calls or booking patients and being a treatment coordinator. How would you allocate these roles?

[Ivan]
The stuff because in order to know what is interesting for social media, the person has to know what a dentist likes. So it’s actually my treatment plant coordinator. My treatment plan coordinator at the end of the day, he will look over all the videographers footage, so I actually have a videographer also, all he does is record and edit. About my treatment plan coordinator will review all of the content, see what’s interesting, put it you know, put it together chronologically, and then he will distribute everything.

[Jaz]
That is amazing.

[Ivan]
It saves me so much.

[Jaz]
I’m just just amazed. It’s so so good. So this is exactly wanted from you about work life balance. So we already talked about how you keep stress levels low by filtering out red flag patients. You’ve talked about how you’re maximizing your time in the clinic, with the way that everything’s arranged, with how the social media outlet is happening. Is there anything else that you want to talk about social media wise?

[Ivan]
Social media wise, I, before I had a system, I kind of like held back on content production because it all depended on me. But now that it’s systematized, I can make as much content as I want to because there’s a system and now I can go back and actually answer comments and DMs, it was really hard for me to keep up with DMs, because I get like, 100 a day. And then I don’t want to be a jerk, you know, and like not really answer real answers. And a lot of people ask me also, treatment planning questions in DM. So that’s something I still struggle with. But I am actually getting back to everybody now. I think that’s it for social media, man. Aside from that, just the my last thing is I have a dedicated space for work in my house. So it’s actually my garage. I have a huge wall of just whiteboards and that’s where I plan, I have my computer there that I do all of my other work on and I have a dedicated workbench where I can do my demonstrations and things of that sort. So I usually get up really early, always early six o’clock and knock out as much work as possible before 11

[Jaz]
Amazing. So you’re obviously two days clinical, a lot of treatment happening those days. And then those other days you’re you know, you’re working on your sort of social media aspect, you’re recording footage. What else you’re doing and you know in the non clinical time.

[Ivan]
Sure. So for me, online education is the thing that’s like, if I could pick one thing, it’s just online education that I’m pushing that super hard, because I think that is the hugest opportunity that’s available to dentists right now or I guess healthcare and So I’m just pushing that I’m actually working on getting into VR. So I ordered a virtual reality headset tomorrow I have a full arch surgery and I’m going to I’m going to record it and I’m going to record it with a 360 camera and my macro camera so I’m going to record both. Aside

[Jaz]
That is amazing. Anyone who’s listening please check that out. That’s going to be especially if you’re obviously placing implants or you’re learning to place implants to have to see in the VR is a really cool. Do you know if anyone’s done that already?

[Ivan]
I have no idea but I if anybody’s done it, I don’t think I’ve done it well, because I’ve checked out some things I know I’m I really wanted to feel like you’re like literally in my office. So that’s the goal and I’m just having a lot of fun with it. Aside from that

[Jaz]
It sounds that and I can tell by the way you talk about it sounds like you’re having a lot of fun in your life and that’s exactly what it’s all about. Amazing and that’s a really nice story there. Brilliant. I think we’ve got loads of good content there for you know about work life balance and about occlusion. I really enjoyed that. Thanks so much, Ivan. Any anything else you wanted to put in the podcasts, anything wanted to ask you for the podcast or anything.

[Ivan]
And also, my daughter is having a series of surgeries in the next couple months. And so many of your listeners could put out some good vibes for us, we’re going to be relocating to Seattle to have her surgery done and we’re gonna have some dedicated time just to help my family get through this. We’re very positive about it, very optimistic, but you know, any prayers or you know, good vibes will be appreciated.

[Jaz]
That is very sweet. Well, you know, from the Gulati household, from my household we’ll be sending all the positive vibes and prayers and I hope everyone there’s a lot of power in collective prayer they say so all the best to Olivia for the surgery and All the best to you and your wife in terms of the stressful period be going through, but I hope everything goes well and please, you know, get in touch. Let me, let us know how it goes.

[Ivan]
Thanks so much, Jaz.

Jaz’s Outro: So I hope you enjoyed that episode with Ivan. He shares lots of really lovely tips. You know, implant occlusion, work life balance. You know, our wishes daughter Olivia all the best and know at the time of this episode coming up, he’s probably in Seattle with his wife and Olivia undergoing her operations. So I hope everything goes really well for you, Ivan, when you’re listening to this. All the people listen to podcasts are with you and you know, our thoughts with your family. Thanks for sharing some amazing knowledge with us. Really appreciate all the stuff about red flags, and deal breakers which I think everyone will love. Thanks for listening. As always, everyone, thank you for all the kind words you’ve been sending to me over the last couple of months. We appreciate it. And once again, join the Facebook page Protrusive Dental podcast, I share a few in educational stuff on there. So please do like the page and share it. Next episode I’ve got a couple of recorded actually, I think next one will be Prateek Biyani for dental students, how to smash your dental exams. I’ve also got a few more which I’ll sort of lay out on my Facebook page. But thanks again for listening. I really appreciate it. Leave me a review on any sort of podcasting platform you’re listening on. Catch you on the next one.