Stop Being a Perfectionist – it’s OK to Fail – PDP184

Jaz’s Introduction:
Of all the clinical educators that I know, the kind of people that I have the most time for are those who are happy and willing to share their failures with us.

This next guest we have on today, Dr. Marco Maiolino from Siracusa in Sicily. Apparently on his three-day course on VertiPreps, the last day, like the half day is just dedicated to all his failures. And I really, really respect that. I try and emulate that. I love sharing. Well, I say love is a strong word, but I like to share my failures so we can all learn together.

And with Marco, like, what he writes on his blog, it’s just brilliant. There’s a blog he had titled The Imperfect Dentist. And now we need to stop chasing perfection. Perfection should not be the standard. And so it’s with great pleasure as part of Mental Health Month. April is Mental Health Month and so at least half the episodes will revolve mental health. It’s a great way to kick off this theme by exploring this idea of perfectionism in dentistry.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Before we join Marco to discuss about how it’s okay to fail, let me give you the Protrusive Dental Pearl. This time it’s a bit of a flashback to COVID times.

I had Dr. Barry Alton on. I’m just going to echo something that he said. He was an interference cast, and he taught me that it is impossible to be depressed and grateful at the same time. Let me say that again. It’s impossible to be depressed and grateful at the same time. So based on that, the Protrusive Pearl I want to share with you as part of mental health month is that every day when you finish work I would like you to write down or maybe make a mental note of three things you are grateful for that day.

Even if you have to really, really search hard for it, try to find three things. This could be something that went clinically well. This could be something that your colleague did and you’re proud of and you’re grateful for their contribution. This could even be just the thought of your child being at school and they’re safe and they’re happy and that makes you feel grateful.

This could be the cup of coffee you had and how much you savored that coffee. Actually, savoring is a big part of evidence-based happiness as well. So one thing I’m going to do on Protrusive Guidance is the day after this episode publishes, I will do that. On Protrusive Guidance, our own social network, the home of the nicest and geekiest dentists in the world.

If you’re not on already, head to protrusive. app and sign up today for the community plan. And you’ll see the three things I was grateful for on the day after I published this episode. Oh, and guys, before we join the main episode, let me update you on how it’s going with the whole project of never writing notes again.

Remember that episode I did with Kevin Shannon about digital TCO? This product, which will use the audio from your consultation to write your notes for you. And I asked you to be involved in an experiment where you pay half price, locked in, and you get an extended trial. As part of being in on this deal, I want you to give feedback.

So we created this space on our app, Protrusive Guidance. Call the Digital TCO feedback space. Anyone who’s on the app, any dentist can, can join the space. You just have to click join and we have a little chat and we have a little forum space and you know what? It’s been absolutely amazing. Your feedback has been brilliant, and Kevin’s been so responsive.

Like one thing I asked Kevin for was a confidence monitor. Like what if, like what happened to me, like my battery ran out on my road. That’s why I’ve got a dual channel one, by the way. I’ve got the one that comes with two microphones, right? But I didn’t realize the battery ran out, and so halfway through it stopped recording.

Now, on Dental Audio Notes, which I also use, it’s got this like a little waveform so you know you’re recording. So I asked Kevin, look, can we have this confidence monitor on digital TCO? And he added it, and he added so many different things. And also something called the risk bank, which I haven’t tried yet.

But when you mention certain risk, it kind of populates all the warnings that you desire when you’re discussing risks with your patients. So if you haven’t listened to the episode, go a few back, listen to that episode about how to never write notes again, and it will just blow your mind. I’ll just read a few bits of feedback we’ve had so far.

So Dr. Horn said, I’m late to the digital TCO party, but what a party. I used it yesterday. And it was amazing. Jaz’s Rode microphone set up worked great. And so by the way, I’ve done a comparison video of comparing the Yeti versus the Rode and why I picked the Rode, but actually the Yeti works as well. So you may check out that video. It’s on YouTube. It’s on the podcasts everywhere.

Anyway, the setup worked great and it really helped me with the quality of my notes. And then he goes on to ask questions, but actually it had some confusion about Emax versus full gold crown. And the answer was, Kevin said, actually you need to set up your template.

So there’s a bit of work involved for you. Like if you really care about having notes that are so seamless, and so high quality, but you don’t have to type. You just have to finish your checkup, generate, and it loads up all the notes for you. If you have that dream, like I do, then you actually need to do a little bit of work.

Like compared to the hours that we’re spending every day, trying to make sure our notes are awesome, just a little bit of work upfront and you’ll be able to get home to your children and your spouse sooner. And the notes have been just absolutely brilliant. So what you need to do is just watch all the videos in the how to use section.

So remember the website is digitaltco.co.uk/protrusive to be in on the offer. The other way to access that my website was down recently, so but I hope it still works is protrusive.co.uk/notes. That will take you to our little secret space where you can get this extended trial.

And I’m going to get in and watch the how to videos. I mean, don’t do what I did and just jump straight in. Even though it’s still awesome, I still want you to watch the how to videos, dedicate an hour just to watch all that, set up your templates how you want them, and then you never have to write notes again.

Because they auto magically generate based on conversation between you and the patient. The number one question I’m getting is, how do you speak to the patient about this? But what I say to them is, I just point to the microphone, oh by the way, new technology by the way, I’m just transcribing everything we’re saying, it’ll just help to generate the notes.

And everyone’s been fine, no one said no, I don’t want to be transcribed and whatnot, everyone’s been fine about it. People are used to like medical dictation and that kind of stuff, so it hasn’t been an issue for my patients. Like, for me, I refuse to practice without Dental Audio Notes and Digital TCO.

For any type of new patient consultation, any sort of discussion and treatment planning, any of my TMD consults, like, it just makes sure that notes are fantastic. It helps you to level up your game. And I just hate admin, which is why I love Digital TCO. So check it out. Let’s now join Marco for this episode and I’ll catch you in the outro.

Main Episode:
Dr. Marco Maiolino, welcome to the Protrusive Dental podcast. How are you my friend in Syracuse in Sicily? How do you say it?

[Marco]
Syracuse is on the east coast of Sicily. In this moment we have something like 18 degrees. The weather, obviously, is always, Sicily is in the middle of the Mediterranean Sea. And we joke sometimes that we are a little bit more North Africa than Italy, than Europe. Because we are at the same level of Africa. A part of Tunisia is at the same height of Sicily. So we have the same weather.

[Jaz]
Very nice. I’m very jealous because it’s here. It’s freezing. And my recording in my conservatory stroke office. So it’s very, very cold, but I’m so excited to come to Italy for my first time in June to learn VertiPrep from you.

It’s something that I’ve been doing already for some years now but wanting to take it to the next level. And just for the disclosure, I wanted to bring you to the UK to bring your workshop to the UK, but you convinced me that actually I really need to truly experience it. You’ve got a little bit of an experience your course.

And I said, okay, let’s do it. So the last time I took a group out to learn vertical preparations was with my friend Jorge Andre Cardoso. We went to Porto and that was my first time in Portugal. And now my first time in Italy is with you. So we’re super, super excited about that. But for those people who haven’t heard about you Marco and haven’t seen the wonderful stuff that you put out to the world, tell us about you, the man, the myth, the legend, the dentist.

[Marco]
The first thing that I wanted to start is about the reason because you are coming to Sicily. Because the point is one, the course that are guys in my office here is the course that I run together with my technician. And if you are going to do prosthetic dentistry, Vertiprep preparation, is all that preparation is we focus too much sometimes on the work that we do just in the dental office, that it is the dental preparation.

The problem is that when you’re working vertical preparation is just because the vertical preparations are some way different from horizontal. So when you’re moving to something with a different rationality, with a different the workflow. He had more problems. He said the horizontal have an established workflow that it is maybe much more clear around the world, but when you will come to the reason, because I want you to come is because you don’t do, you will not do just a course for dentists, but it’s a course where you will leave all the workflow from the dental office to the impression, to the communication, to all the parts, to all the mistakes, to all the problems that we create to our technicians.

And that after coming back to the office. It’s something about the real connection between the dentist and the technician and everything that is happening in the whole workflow. When I’m going around instead, I do several courses around, no? But when I go outside, I have another one in the next month.

They ask me always to focus on the dental part, how to do the vertical preparation on teeth. But I have to say that you will learn when you come here in June. This is just, I can say 30% about what is a successful work, and this is the reason, because I love that you are coming here and after this, that we are organize something in UK but always with a similar format. Because this is the real key, the connection and the team working with the technician.

[Jaz]
My experience so far has definitely echoed this in all realms of dentistry, but especially in vertical preparations where I have been in a situation where I have been introducing the vertical preparation to my technician and therefore it’s been a learning curve for me.

And the technician and so many mistakes. And one it’s frankly, just one cracked restoration and learning about space protocols. I’ve done a lot of stuff online with you as well, but now I want to take it to the next level and I’m trying to convince my technician to come with us, but life happens and sometimes timing is all about the different timing and stuff, but what I really admire about you, Marco, as well as all the great things I’ve read about your course and stuff is you’re a philosophizer, you and Pasquale are very similar in the sense that you were great at really, I mean, your clinical dentistry is just fantastic.

So many learning points, but the angle that you approach it and the philosophy and the reflection, I really liked that element. When you were studying to become a dentist, one of your other passions, like philosophy and that kind of stuff, how do you become such a reflective person?

[Marco]
No. Okay. No, it’s just me. It’s nice that also, because I started dentistry and my desire was not to do the dentistry. The day that I got my degree was one of the worst days of my life, because I was feeling like a liar, you know? There was all these people clapping, ah, you’re a doctor, also because I got my degree with the best mark possible, that means that is [inaudible].

But I was feeling a liar, because the day after my degree, I was not able to do anything, in the mouth of any kind of any patients. I was really zero about dentistry. So, after the degree, I started completely from zero. I started working with my father at the time when the situation in my office was a crazy one.

We were working without appointments, zero appointments. People was coming like in the bus they were coming to a barber, no? They just were coming, just knocking to the door, saying, I have a big hole in my tooth, I have pain, this night I will not be able to sleep. And I was finding something like 20 persons behind the door every single day.

And so I started in a very tough way. Okay. There was no time for doing excellence and no time for thinking. So I literally started from zero from this point, because for being here, I am quite ambitious and I am passionate about what I do. I started doing many courses, and after my first 5, 7, 8 years, also because I was very stubborn about things, and I am still.

After that 5, 8 years, I was able to do very good dentistry. But, I was realizing that I was able to do this just in some cases, no? Like, how can I say? 10, 15, 20 percent of cases. So I was able to go around because I started lecturing already in 2008, but I was feeling again, a liar because I was going around and showing just my best cases and I was able because 20 percent of one year of work, there are many cases, but what about the other 80 percent of cases?

And that was for me, differently from Pasquale. Pasquale has a similar start, but a different behavior. We are similar, but different about many things. But at that point for me, it was the start because I was feeling that there was something wrong inside myself because I was showing one kind of dentistry, but I was aware that I was not able to do that kind of dentistry 100 percent of the times.

So in that period, I started inside myself to grow the need to match both things. Is it possible to develop techniques, protocols in order to really to work? In a real way, in the real world, everything started from that point. Also, I am almost crazy about books. I read something like 40, 45, even 50 books a year.

And I love to read about Kahneman, about Nassim Taleb. I read all these books and I start, and I read this also again. I love all these kind of books about psychology, about cognitive biases. So I started recombining the needs that I was finding in my dentistry. The needs of my dental office because living in the South of Italy, South of Italy is the poor part of Italy.

You have to think that in Sicily we have a rate of unemployment about young people around 40, 50 percent. So try to think of the economical situation that we have here. Also people pay their dentistry without any kind of help from the government. We have nothing like the NHS. Here in Italy, we are exactly like a shop.

People has to come, they have to pay from their wallet and nothing more. So everything started when I started connecting my patient, my vision, my needs and my love for books. And also with Pasquale, it was some way similar. We started developing many kinds of thoughts about this. And this is when in 2013 with Pasquale at the time, we started thinking about developing a group that was Tomorrow Tooth about a different format.

So everything that was coming from Tomorrow Tooth, it was not something about just a technique, no, but it’s a technique that it is coming from an idea. And the idea is to do something that it is as much real as possible in the real world, because too many times we live in the world of idea, in the idealized world, in the world of perfection.

This is the reason because you go at courses, you go to courses, what do you see? You see just perfect cases. You see just amazing cases. You go on Instagram and you find just amazing cases with the bounce, flash, perfect lighting. You see just these kinds of things. Also, we have another problem in dentistry because we have a problem related.

Okay. This is a new one bias and they need to show your best because you want to show to the people that the best that you are, okay, it’s normal and the opposite is true as a human, we tend to hide our mistakes also because nowadays, in general, we have a problem about the culture of mistake. People tend to hide mistakes because they are scared that others will blame them.

They are scared about losing maybe their name, you can say, okay. And in medicine, this is even more important. Because we have a culture that is coming from 2, 500 years ago about the dogma that the doctors was always right. We can say Hippocrates already 2, 500 years ago was writing that the patient had to trust the physician no way more.

And the reason was that it was the technique, the physician himself knows that we have ignorance in medicine, but we cannot show our ignorance. We have to show it was like the Pope that was always right in the period of the religions. The same we have to show something to people that we are not and the culture of the mistake in medicine is still at that point.

There is an interesting super interesting book about If I’m, right Matthew Syed is Black Box. Black box is a-

[Jaz]
Black box thinking.

[Marco]
Perfect. We are right black box thinking is very you have to read this But You already did I’d say this for people that are following us in Black Box, it is very interesting because the book starts with a comparison about the culture of the mistake between two different fields, medicine and aviation.

The culture of the mistake in aviation is they live the mistake in a completely different way. Hence the black boxes. Why they have black boxes? Because if something happens, the black boxes are two boxes that record everything that it is going to happen on a flight. And when something happens, they have the black boxes in order to see what happened, to see the voices in the cockpit.

They know everything about what that mistake was about. Because the idea is that they have to learn from the mistake in order not to do this again. In their reaction, they have this culture. And for example, always in that book, you will read that there is a data that it is incredible at the beginning of the century.

So the mortality in US army pilots, it was something like 40%. Eight pilots every 14 were dying during training, not in the war, during training. Nowadays is that there is one accident every millions of flights. And where are we in medicine instead?

In medicine, the data that we have is that we are always at the same level. There was an interesting article that is very famous from the American Institute of Medicine. It was to [inaudible] Science. Do you know this article, I think? I will send it.

[Jaz]
To [inaudible] Science. I believe I might have seen this. Yes, it’s a lovely title. I think, I feel like I might have seen it, but do include it so I can, yeah, share it with everyone.

[Marco]
I will, I will share. Well, you will find it easily online. This article to [inaudible] Science. There was an esteem of the medical mistakes in us. And it was something that in US every year, something like 44, 000 and 98, 000 people die from medical mistakes. We have the data even in the following year, there is another article of the next of the following year, 2001 or something like that, that it was 120,000.

So even more from 40, 90 to 120. And there is another article of 2014 that it is, we can say yesterday that this team is something like 400,000 plus all the other complications. This is just the people that it is going to die, 400,000. And this is because, and what is interesting is that if you analyze medical mistakes, most of them are always the same, are very similar.

In the field of aviation they call these kind of mistakes that are always the same, situations you know, because the pattern of the mistake is always the same. What is the difference? That in the initial world, they do all the effort that they can in order to recognize the signatures and change the protocol or create something that it is going to protect.

In medicine, it’s that we have a different culture of mistake and we tend to hide. And this is the same that happens with our techniques. We do techniques that works perfectly in ideal and standardized cases. Like for example, in restorative, when you go to a restorative course, you see that most of the times you have always two teeth with crown, easily to put a rubber dam, all the margins are supra gingival, the soft tissues are always in good and healthy conditions.

You just see people with a good oral hygiene, but if you go to my office instead, I have to look for these patients. Most of the patients here in Italy are people in their 60s and 70s. Most of the people in my office are not young ones. And in Italy, and I think that this is the same also in the UK and in Europe, I think. The population is always getting older and older. So we will experience everybody this problem that the people that you are going to treat are older people and they have problems.

They are not able to stay reclined because they have back problem, neck problem They are not able to stay too much time with their mouth open. They take multiple medications. They are not good about brushing. We have to manage these people, but we never spend enough time talking about the needs of these people and the needs of the dentists working on these kinds of people.

[Jaz]
So we should be going to these courses and treating root caries and simulating subgingival restorations with inflammation and poor hygiene to actually get the real world, which is why I echo everything you said. Everything’s about real world and everything is about owning up to that. We know we do make errors in dentistry.

Like recently I was doing something to warm everyone up to coming to June. I’m doing the VertiPrep for Plonkers series. And one of the webinars I showed my over tapered lower incisors that I did. And the stupid mistake I made with the wrong angulation of the bur I was holding, and whilst it’s embarrassing for me to show it, I show it because we can learn so much.

And so if we learn from the aviation industry, if we had a bank of an area where we just uploaded our mistakes constantly and we kept learning from it, which is what I think I’ve seen you and also [inaudible] also be very good at showing mistakes and stuff. I think that is the way we can grow, but we often beat ourselves up a lot about these mistakes.

We have this perfectionist culture. Where do you think that stems from and how have you found it, in terms of a beginning and coming to accept that, okay, we are not perfect. And what advice would you give to a young dentist about the whole stress that we put on ourselves, that everything has to be perfect because in the real world, just like you said, we have to make compromises?

[Marco]
Yes. Okay. The point is that I’m for perfection as seminar problems. The first one is that we have to do a very good classification of what we are doing, what I mean. It seems simple, but when we work, we work with doing what? The problem is that we work in order to obtain an outcome. But, and about this, John [inaudible] wrote, anything fix in medicine or in dentist is the same.

We have different kind of outcome. John [inaudible] says that we have three different kinds of outcome. One is the Process Centered Outcomes. Process centered outcomes are result of clinicians, the result of procedures, technician performance. So it’s something about a technical skill and we focus too many times on the technical skill.

Let’s say about a shoulder, no? If to do a perfect shoulder all around, it’s just something that you need a technical skill. But that this technical skill, even if perfectly executed, translates into a clinical outcome, these are two different things together. So the first point is that we have to divide about process centered outcomes, clinician centered outcomes, that are science and findings, the technician observes.

Signs of the treatment efficacy, like, for example, you’re looking into the x ray, you see that the root canal treatment is correct, and you say that the treatment is perfect. But you know better than me that sometimes there are patients with a good root canal treatment and have discomfort. And even the opposite is true. How many times do you see endodontic treatment at half? And the patient is fine, this is-

[Jaz]
Aging population that the silver points and the voids, but how well it’s been there for 40 years, same as your patients.

[Marco]
Yes, this is what happens. And the third one is Patient Centered Outcomes. This is the most interesting one. These are the real outcomes that the patient. That it is the final customer that we can say about treatments really notice, t he point is that these three outcome, the process centered, the clinician centered and the patient centered are not always working on the same line.

In my experience, most of the times they are working, fighting between each other. So the problem is that when we talk about perfectionism, most of the time perfectionism is on the technical part, on the first outcome that we were discussing. The process centered outcome, but many times there is no translation in the real world with a patient centered outcome that it is the things that we should be more interested because this is what our patients are paying for.

The second toxic thing about perfection is another one that when you see all these protocols, they are focused on a standardized and ideal cases. When you are going to do a technique, a protocol, most of the times you have the case developed on ideal and or standardized cases, but the idea is that when you go back to your office.

You have not ideal standardized cases, so you don’t need a protocol and a technique. Why do you need to approach, to understand a philosophy of treatment? I don’t want to speak about philosophy as something just to speak about, but a real philosophy of treatment. This is the reason because many times, and I did this many times, you go to a course, you learn on the models, you learn everything.

You think that you will go back to your office and you will do amazing cases and Monday. The first patient is on your chair and you’re not able to apply the technique because the patient is not fitting in the ideal standardized case that you were needing. So we need the different things and this is the aim of my work.

My aim is not to give you a protocol a fixed one. I give you different things like a range of treatment and you can move in this statement. Also in the work you will move in a smooth way between the restorative work and the prosthetic work. So they are going to match together in order to give you even more chances. In order to solve the problems of your patients.

[Jaz] Interjection
Hi, it’s Jaz just interfering here with a really important message. As you know, I’ve been trying to support Sakina. Sakina is a Protruserati just like you and her daughter in Tanzania is just a year old and she’s fighting a battle with a condition called SMA type 1. Now you’ve heard me talk about this before and I’ve done videos and promotions and we’ve almost raised a million dollars Which is just absolutely crazy a million us dollars. She’s actually just shy by 20, 000, so we’ve raised 980, 000 and she needs about 1. 7 million to get this therapy.

However, once they reach a million, they could start to save her life. They could start to give her this drug and give the rest in installments. So we are almost there. Could you consider donating a little bit more money so we can be proud as a community that we saved the life of one of our own?

I’m sure if it was your child, you’d want the same thing. The website to donate is protrusive.co.uk/nafisa. That’s N A F I S A, Nafisa. And when you go on there, it’s a GoFundMe page and it’s in Canadian dollars, but that’s just one of their fundraising accounts. That’s very internationally friendly.

So don’t worry, that is the legit one. And that money does go straight to Nafisa. Thanks so much to all of you who’ve donated. We’re almost there. Let’s keep going.

Back to the Episode:
Marco, the interesting thing that I’ve been reflecting on while I was thinking of the questions to ask you today is, when you look at the standards for dentistry, there are certain standards that we must meet, right?

So we have like certain colleges that produce guidelines that ideally we should be aiming for this outcome and this outcome. And when we fall short of that standard, it hurts us, it hurts our ego, and we generally care for our patients and we feel bad. When we are making a compromise because the patient can’t open their mouth too big, or they’re not able to look after what we’re placing, how do we decide, okay, that in this case, it’s okay to make this compromise for that reason?

And how can you figure out that, okay, are you just a bad dentist and you’re not good enough? Or that actually anyone would have struggled in this case and we need to make peace with the fact that, okay, we can’t be perfect in this scenario, we can’t be perfect in all scenarios, but how do you convince the young dentist that it’s okay to fail? And what sort of guidelines would you give them? Looking at the standards and they’re thinking, hmm, I’m not meeting this.

[Marco]
Okay, the first point is that, we have to understand which kind of standard we are talking about. Because what I see is that most of the people put the standard as what they see in courses and conferences.

That kind of anatomy, that kind of aesthetic, that kind of soft tissues. But with a kind of patients and clinical situations. If, for example, I work a lot with old patients. This is my biggest problem with patients with xerostomia, they have not saliva. This kind of patients have so many decays, they do decays at 360 degrees, they have lingual class 5.

When you are dealing with these arterial patients, because young patients in my city, most of them are healthy. And unless you are a very famous dentist, and I’m not in that sense, or you’re living in a very rich city, and I’m not. And there is a high request from healthy patients about veneers about preaching these kind of things.

The people that you are going to treat are people with disease. Sometimes we forget that our patients are people with the disease and the disease is not just on their teeth. Most of the times, the teeth are just the mirror of a problem of a general health situation. I wrote a book about that, I will give you, also because I have the time.

I wrote this in Italian for my patients, but they read the translation in English. And it is about that most of the times the teeth are just the mirror of what your body is because for example that both decay and crooked teeth are a modern disease, you know this?

[Jaz]
Yes, if you look at the skulls from humans years ago we don’t find that as much. Absolutely.

[Marco]
Yes. I’ve been in the historical museum. Historical museum of budapest in Hungary with another dentist Andreas [inaudible] that it is very patient about this topic. And I’ve seen so many skulls and all of them, perfect straight fit, zero decay. So when we have a patient with decay, it means that there is something wrong about their lifestyle, for example.

So it’s much more than just feeling a tooth. It’s understanding what it is not well gone, because they thought this today. But maybe this is a sign of something that may have worse consequences all over the time. So the first point is about-

[Jaz]
You say it’s a mirror. I just wanted to add on that. You said it’s a mirror. I like that term. The other one I’ve heard of is that the mouth is a window as well. Like you’re seeing through and you’re seeing the general health of that person. The link between dental diseases and cardiac and also Alzheimer’s and stuff and oral hygiene. The perio link is quite spectacular.

So I love the mirror, but I also like the window as well. Like you’re seeing, what you’re seeing is the inflamed gum, but you’re seeing an unhealthy person attached to it.

[Marco]
Yes, we all know now that there are relations between diabetes, for example, periodontal problems or problems about cardiovascular problems. We know that there are these connections. But the point is, what are the standards? Because the point is also, and what do you ask to your dental practice? Because what I teach, for example, is not to do the case, the perfect case for courses and conferences. In fact, I replaced the word perfectionist in my practice.

With the word high standard, high daily standard, because what we have to work for in order to improve your life is not to learn the technique for doing the case is to learn the technique in order to rise your daily standard. If you’re able after my course, let’s say to have most of your cases on a scale of zero to 10 at eight, but all of your cases are going at eight.

For me, you’re doing something that it would be very, very beneficial for your life. Instead of doing one case, maybe at 10, and all the other cases at 5, because patients are not matching. So the first point is about which kind of goal we want in our life. Ideal one, real one, the best case, the average case.

I am focused on improving the average case. Most of the time also, the difference that we do are something that are not against minimum standards, we can say. For example, I do a lot about bioclear restorations in restorative. And what I do, for example, is a lack of anatomy, okay? But if you look at the x ray, there is a good septical seal, the composite is well adapted, there is a good adhesion.

So, the discussion that we are doing, I think, that are more not between us and, I can say, I won’t say a lawyer, for example, a legal problem, but most of the times are between dentist and dentist. The second thing is that when we realize that we have to make compromises, a compromise is not a real compromise.

It’s about understanding what is more important. It’s about putting priorities. For example, in a prosthetic dentistry here in Italy, for example, the priority is to give a good space to your technician for doing a beautiful crown. This is the first priority of the dentist. Especially the dentist that is specialized in prosthodontics.

Okay, instead, for myself, my priority study is the biomechanical one. Why I do say biomechanical? Again, it’s not just philosophy. It’s that preservation of biomechanics, in my experience, is the best parameter that is connected with the patient centered outcome. What I saw in the practice is that if you are following a sound biomechanical principle, the outcome of the patients we perceive, and so the success of the office, the real office, are very, very connected.

So, my endodontics, my restorative, my prosthetic, are all in the same philosophy of preservation of the biomechanics. So, in my case, for example, always the example of the crown. My aim has always been not to give the right two millimeter of space for the technician, but the opposite. How can I give you as less as possible in order to have a decent crown?

What they do unless I’m working on interiors are not super beautiful grounds are decent grounds, but preserving the biomechanics because that is my aim to preserve biomechanics because it’s really connected with the patient centered outcome. Instead, just to give the space for a crown with a shoulder of two millimeters and a half, I know that the crown will be beautiful.

But that goal, that it is not a patient centered outcome, but it is clinician centered outcome, is fighting with the final goal that it is to expand. The lifespan of a tooth. So you see, this may seem a small adjustment, but because we do a small adjustment in different parts of our workflow, at the end, the result is changing a lot.

[Jaz]
That was fantastic. And I totally agree. So it’s someone, the principles that you have taught me before in terms of preservation of the pericervical dentine. And it makes you think that, if you’re blindly following the rule book or the prosthetic guides, you get the Ivoclar image and it shows exactly how much reduction it needs, but I like your philosophy of what’s the least I can give and get away with because it’s going to preserve the most two structure.

Can you give us some examples of some early failures you had in your career that you think young dancer are making now and then how you look at those failures and the viewpoint of how you can raise your daily standard?

[Marco]
Okay. First I have a small spoiler. When I go my three days course inside, I use the last election is the lecture about failures. You will see the most beautiful failures of my life with up to 10, 15, 17 years, I have one lecture. This is the last one about this because you can learn all the techniques of the word. But if you don’t learn how to fail, how to rise and try again, you are not going anywhere at all. Okay, I had failures about anything I can say.

I had failures, okay, and the lessons that I got. I had failures, for example, a lot of failures about adhesion when there is not so much in order. We have this sort of dogma that adhesion is something almost religious, that adhesion is working always, even on dentine, on sclerotic dentine, is that adhesion is working in some situations.

When we have an abundance of enamel, for example, when we have not so much enamel, adhesion is going to fail because there is a load on this kind of interface between the resin, the adhesive, and the tooth that is going to be stressed over time. And there is an aging of this interface with the failure. So for example, and instead when I go on social networks, I see so many cases with people with the almost zero enamel doing the indirect adhesive restoration with all these fancy words, like ribbon, fiber, replacement of dentine, bioemulation something, all of these kinds of things.

Adhesion, when there is not so much enamel, most of the time will fail, especially if we have some lateral forces. Of course, if you have just a vertical one, it’s not. But in the real world, we are not able to control the forces.

[Jaz]
When do you think that failure happens? Because a lot of the data that you see is that anything that you do will usually one or two years will be fine in your practice. I know that maybe you would have experimented, not experimented, but you would have followed these principles from courses and try to do it. And then at what point have you found those cases where you had a doubt, but you did it anyway, with lack of enamel, because you thought, okay, I’m doing the modern adhesive principles. When did the problems arise?

[Marco]
Well, in my experience, most of the problems related to aging of adhesion in this kind of situations happen between 4, 5, up to 7, 8. 5-8, 4-7, this is the range that I’ve experienced. Most of my fails, I will show you in Syracuse, when you come in the lecture about fails, are between, we can say, 4 and a half, 7.

Because if you have not fails in this range, you have not, but because for sure in that pressure there is a vertical load that it is not stressing the adhesion. But if there is a tension of the kind of bond, Usually, between four and seven years, there is a degradation of the addition of dentine and the degradation of the adhesive interface leading to the failure.

Sometimes the failure is the simple dissemination of the post, of the restoration. Sometimes instead there is a partial dissemination and you have a new decay. For example, I had the decay when I was doing, for example, deep margin elevation, putting just the deep margin elevation on dentine, and after I was doing the easy restoration.

And I had decay under the deep margin elevation after always four, five years. I have several cases about this. This is the reason because I stopped doing that kind of technique. About [inaudible]. We love zirconia because it’s white. But with zirconia, because of the process, because we mill from the block, there are several drawbacks about zirconia. Do you know that with zirconia, the rate of desalination is up to 8 times more than PFM, for example?

[Jaz]
Yes, and what I read was the reason for this, because it’s so strong that something has to give, and it’s the cement that takes the load. Is that the kind of reason for it?

[Marco]
Not just this, but also that the internal gap of zirconia is much more. The metal. What you do when do PFM, you do this with a lost wax technique and the match that is between, let’s say the department, even if we have a sharp area and the crown is very precise when we do zirconia, the milling machine with the bur is not able to reproduce sharp angles because we have the bur.

[Jaz]
Yes.

[Marco]
That has to move and the bur is with a round bur. And also you need some freedom. What happens? I will show you is that if you have some sharp areas that are smaller than the bur itself, you have void in this area. The ground is something like this. This means, and we have done about this, this means that with zirconia, we have the internal gap that we have between the tooth and the ground, is way more than with metal.

And this is the problem about the cementation. The problem is that we don’t spend enough time. I use zirconia of course, but if you cognize the problem that zirconia has, you can work about, okay, how can solve this problem? The same I see is happening with the scanner, with internal scanner. There is so much enthusiasm also because we are pushed by the brand, by the companies I work with. The scanner I have, behind me here is my scanner. You see, I use my scanner.

[Jaz]
Which one do you use?

[Marco]
Medit. I have the Medit. Yes. A very simple one. But the problem is that intraoral scanning has several problems. Of course, several problems that are not present in every single case that you’re doing. But you have to recognize where that technique is fitting in the workflow, and where instead it’s better to move the conventional impression.

Instead, we are moving the word, scientism. Scientism is not science, scientism means an exaggerated trust in the ability of the science to discover the truth. We are doing the same in dentistry with the digital dentistry we have the digitalism. Okay? We have another word today from scientist in dentistry, we have the digitalism, and it is the exaggerated trust that working with digital devices will get a better outcome.

This is absolutely not true. In many cases, working with the digital dentistry, we have an outcome, maybe it’s quicker, and this is another point that we have to address, but sometimes the result is worse than we were doing in the past.

[Jaz]
What percentage of your vertical cases, let’s talk vertical, for example, where we are trying to capture sub gingival and the light will often not reach where you want it to go. There’s different ways to manage it, but I just want to know from you, what percentage of those times are you scanning, be it delayed or be it immediate? And what percentage of those times are you impressing for those type of restorations?

[Marco]
Okay, in this moment, I’m scanning just very easy cases, in patient with the low caries profile. So for example, if I have a patient, I want all the margins to be sub gingival. So I’m scanning cases where I can afford the limitations of the scanner, like the shallow reading of the sulcus. Like also, okay. So teeth without problems of failure, because if I want failure, I want to engage as much as sub gingival.

I do easy cases with the scanner, but when I am moving to old patients with xerostomia or patients with a high caries risk or a compromised the fit, I’m doing again, the hybrid workflow, doing the conventional impression. And after I scan the impression with the procedure that we’ll see is the double scan procedure. We know that we have the best informations about the case. And after we move to meeting zirconia. It would be a very long topic.

[Jaz]
Yeah, it’s good to get like a general overview because it’s nice for someone like you who’s already embraced digital, but I appreciate that. One of the things that when I look at my own work and I’m going to be critical of my own work here is that, okay.

I went from doing a hundred percent analog to almost a hundred percent digital. And that’s not right. I can’t now rely on digital for every way and accept those compromises where we can identify a compromise and where we can correct it using more traditional techniques. I think we need to know that there are some times that you will deviate away.

And that’s what I like about your protocol is that, okay, every case is unique and sometimes you’ll impress and sometimes you’ll scan, and that depends on the patient profile more than anything, actually.

[Marco]
Yes. The point is always what? And we don’t speak enough, we don’t talk enough about the limitations of digital dentistry. Nobody’s talking about all the problems that zirconia PFM, or press and for example, work with the lost wax technique, because we have also pressed [inaudible], that it is a great material. But we don’t spend enough time talking in general. This is the point. We don’t spend enough time talking about problems.

And instead it is when you start talking about problems in a good way, that you start finding solutions. And you start also creating a new higher standard in your practice. Instead, sometimes we just follow guidelines in a blind way, especially today that we have specialization. Specialization is another big topic, because nowadays, because there are so many specializations, we have the endodontist, we have the prosthodontist, we have the surgeon.

Each one is focused on its own. But the problem is that most of the time is focused on the technical part. So we have the endodontist man, for example, that it is so focused on managing maybe the apex. And they say that there is a cure. He’s going to open much more the valve chamber because his focus is to be able to arrive with his gutta percha to the apex.

After the case is done, technically speaking it was perfect and he’s going to the prosthodontist. The prosthodontist is not looking at the access. But is focused on giving the right space to the recognition. So each one is focused on its own. And I don’t know who is going to be blamed, if we can say, for the failure when we have the fracture of this tooth.

Because the problem also is the follow up. I am a general dentist. I do everything in my office. In the past I was also doing orthodontics, just to say. If you are the only one in your office, of course you have many limitations. Because, of course, you will find surgeons that are better than me, you will find implantologists better than me, and dentists better than me.

No way. But I have one good advantage. When I see patients and they have a failure, I have no body to blame because I am the only one. So if I have a patient with a fracture, I was the non-autist, I was the prosthodontist and I was also checking the technician and accepting the work and doing the cementation.

So I have to understand that the problem was in me. It’s that when you are going to different specializations, the problem is that the responsibility is shared between so many people that nobody feels the one doing the bad thing. So this is another point. And with the specialization is even more important where the driving principle that for me is biomechanics.

When I speak with the people working that way, I think that to be able to highlight one driving principles that in my practice is highly connected to the real outcome of expanding the lifespan of a tooth. I think that it is the most important part. Because at least if we have one principle where all the people specialized agree, it’s already a good starting point. And it is also part of the approach that we will do. The principle, the why.

[Jaz]
The principle is my why. It’s why I introduced vertical preparation into my practice. I could have just stuck with horizontals but I challenged myself to learn something new because the whole principle of biomechanics that you speak of is exactly the reason because there’s a greater why for longevity as our best outcome.

My final question Marco is what advice could you give to the young dentist a bit like you when you were, many years ago you qualified and you felt like you weren’t able to do the dentistry? What’s happening is they’re putting the matrix band on and every time that they’re seeing that they’re not getting the right seal because there’s bleeding and they’re feeling like a living a lie or they’re feeling like they’re constantly at every stage they feel like they’re picking the wrong wedge. Or when they’re taking extraction they’re taking too long things are breaking when things aren’t going right what advice would you give to young dentists to help them get back on track get their confidence back up and get them to doing the kind dentistry where the day flows better. What’s your top tip to to that dentist?

[Marco]
There is no other tip, because the problem is always the culture where we live. Today we live in the culture of fast and furious. And this is true also about teaching something. People think that they go to a course, I see this even on some ladies here, friends of mine, they go to a course, and they think that by a week, they are already expert in that thing. There is a learning curve that it is, you cannot skip the learning curve, you cannot skip the mistakes.

There is something. I can teach you everything. When you come to my course, I will say everything. I’m not giving you nothing from myself. But despite of this, I know that you have to do mistakes. And this is the reason because the last lecture is about failures. Because after discussing three days about all the details of vertical preparation, I have to prepare you for doing your mistakes and to grow from your mistakes.

The problem is that nowadays we have this culture of fast and furious, everything is quick, that we have, everything is rare, instead this is not going to work because we are humans. And this is another bias that we have, that because of all this technology, all these things, smartphones are faster, meaning machines are faster, but we humans are always the same since thousands of years.

Most of the problems that we have as humans nowadays is because we have changed our environment so much, and we’ve changed so little in the last thousands of years that these two things are not matching together. This is true about everything. There was a very nice sentence about this on the book of another Indian. It was The Almanack Of Naval Ravikant, if I’m right.

[Jaz]
One of my favorite books of last year. I absolutely loved it. Great, great book.

[Marco]
Yes. Yes. And there was a sentence that I have pointed here in my mind that it was, if you have problems about old things, don’t look to this century about the solutions. Because all there is the problem, all there is the solution. If you have a problem about something that has been created in the last 10 years, the solution probably would be a modern one. So when we talk about training, relation, learning, there is nothing that we can accelerate. We are not computers. But we have to simply to be honest about all the pain and all the struggles that we have in our learning.

You know that there is also another nice part that is also another tip, is that the Dunning–Kruger effect, you know, Yes, there is another bias that we have to acknowledge, and if you acknowledge this at the beginning of your career is even better, because you lead things in a better way. And it is that when you start, your confidence will be much more than your real skill.

And the first part of all the people, all the experts, is that your confidence will start to decrease. And your skill is that we start to grow. So there is a sort of a letter like this, like an X. And if you understand this as soon as possible in your career is okay, because when you feel that you start to accumulate mistakes and your confidence is going down, you usually get depressed.

Instead, this is the normal cure of every person that it is training to learn the technique. But the problem is that when you learn to play golf, to do a wrong shot is perfectly fine, but in that is restarted. Because we have a different, like in medicine, a different culture of the mistake, we blame ourselves. The problem is the mindset that we have in medicine.

[Jaz]
It reminds me of a case I was one year out of dental school and I saw this upper left second molar with an amalgam that had a ledge. We see it all the time, right? The ledge, the amalgam was slipping under the matrix and on the radiograph you see a ledge.

And one year qualified, I said to the patient, okay, not having any pain issues, that’s fine, but there’s a ledge here, it’s not going to be good for your gums. So I tried to correct it. Small mouth. I didn’t appreciate it. So much bleeding. It was a difficult patient. And then by the end of the restoration, I don’t even know if I improved the scenario with my composite.

It probably made it worse. But it made me realize that, wow, there’s a reason why the previous dentist struggled. We can’t just look at something and say, oh, this is bad dentistry. There’s often a reason why a dentist struggled. And I think that was a real big learning point for me. And based on everything that you said, I think the main lesson we can draw away from this is to fail, especially in our first few years, is a part of it.

And we can’t shortcut, we can’t skip all those failures, those failures, as long as we learn from them. And we keep improving, every day, a little bit and reflecting, taking photos and thinking, what could I do differently to fail better every time? And there are certain, oh, there’s only a few mistakes, which, you know, okay, we need to bring this patient back and redo it.

Most things are okay. This is slightly below ideal, But it was still better than leaving the carries as it was. It’s still some material there. Do you understand what I’m trying to say? I think a lot of times they’re very harsh, but we need to go through that pain process.

[Marco]
There’s another point that is interesting. It is that when we are younger, we in the duct, we always do something and we do mistakes. When you are like now, we are older, we can say, when to do something. But you know, even better when not to do something and to do wait and see. Sometimes most of the problems you are looking for the problems because you jump in all the cases like you did.

When I see a upper second molar and they recognize that the patient is not a good one, I do nothing because I know that I’m not the one that, I’m not Jesus doing miracles. I lead the miracles of the others.

[Jaz]
It’s the experience, but it’s the wisdom that you gain from your failures and the real, the true sort of skill of the clinician is picking your battles. And as a GDP that also realizing that a generalist. We should cherry pick and choose because already it’s such a difficult job. So we should cherry pick, but I’m just conscious of the time and Marco, I am so excited to see your failures lecture, especially, I know you’ve got so many with respect, I know he’s got some great ones to share in the sense of how much you’ve documented all these years and what we can learn from that.

Right. That’s going to be golden. So I can’t wait to bring a cohort of a Protruserati to you in Sicily. I will put your website and everything in the show notes. Cause not everyone can come in that June and I want them to know what other dates you have. So I will put that, but what’s the best way to, to learn from you? What’s your website? So we can just find out about what else you have on offer for us.

[Marco]
Okay. At this moment, there is my website that it is educational.studiomaiolino.net. And on this website, you have the BioVR course, you have the vertical course, and you have also the vertical lab course.

There is a course also for technicians, because most of the problems, this is the reason because my course here is with a technician, because most of the problems that I had people in the past. Following my courses was not on the doctor part, because you will see that practical preparations, once you understood a few things, it’s quite easy and there are just four or five critical points.

But the problem was in the communication and in the transition of the work to the lab and coming back. This is the point where most of the visuals were experiencing problems. So this is the reason because on my website you will find also the vertical lab video goals. The video course is something like-

[Jaz]
I’ll put that in the show notes and everything.

[Marco]
Yes, it’s something like 12 hours, like nine hours my part and three for three and a half hours is the part of the technician. And I did nothing. Of course, of course. When you come to the real course, there are some things that I have to show, like when you move your wrist, when you move your bur, there are things that I’m not able to, I mean.

Explaining is not working. It’s like, I try to explain you, for example, how beautiful is a woman describing the group picture of the lips. You have to see. Yes, you have to see, yes.

[Jaz]
What a great way to end the podcast. I love it. Thank you so much, my friend. I can’t wait to, I’ve been following your work for so many years. I’m like a little fan boy, so I can’t wait to actually meet you in June. We’ll keep in touch, my friend. And thanks for this philosophical episode.

[Marco]
Okay. We did something different this time.

Jaz’s Outro:
We did. Thank you so much. Well, there we have it guys. Thank you so much for listening and watching all the way to the end.

If you enjoyed Marco’s humility, please do give it a thumbs up or a subscribe, wherever you’re listening or watching from. Of course, if you’re on Protrusive Guidance, you get to answer a few questions and get some CPD. So why not? You’ve done the hard work already of listening all the way to the end. Any of the paid plans on Protrusive Guidance will make you eligible to get a CPD or CE certificate.

For those who were messaging about the trip to Sicily, we’ve been sold out for ages, so there’s about eight or nine of us going. Super excited for that in June. So I’ll kind of document that for you guys. I’m very excited to see Marco in person. But otherwise, I look forward to engaging and speaking to you all on Protrusive Guidance.

And I’ll catch you same time, same place next week. Bye for now.