No Post? No Crown? The ‘Anti-Biomimetic Dentist’ Part 2 – PDP153

Jaz’s Introduction:
And post are out of the equation. And if you have to use a post, you’re going to use a fiber post, not a cast post. Well, this sounds very familiar, right?

This sounds like the way that we’ve been heading, but Pasquale Venuti offers some different and alternative points of view that I think are very much worth listening. So I left you in a cliffhanger last time with that episode, The Anti Biomimetic Dentist Part One with Dr. Pasquale Venuti. Welcome back. This is part two where he will answer that question about the whole no post, no crown philosophy, what he makes of it.

But he also talks about something called PROCESS based reasoning versus OUTCOME based reasoning. So I guess the bone that Pasquale Venuti has to pick with the biomimetic group, the quote unquote “beef” he has with so-called biomimetic group, is that everything they’re saying, all the little micro steps in achieving the highest bond strength, which is very admirable, right?

But everything they’re doing is process based, right? It’s a little process. Tweak this, tweak that, and let’s see if who can improve our immediate results, our immediate bond strengths or aesthetics or whatever it might be. But you see, Pasquale Venuti argues that this process based reasoning is probably not what we need.

We want OUTCOME based reasoning, right? Because what Pasquale Venuti looks for is, okay, by doing these little micro steps, these extra steps, that which might be time consuming and might cost you more money. Are they actually going to yield a long-term result? i.e are they actually going to add years to the restoration and we just don’t have that data. Now, I talk about this a bit more towards the end of the episode, but Pasquale will do this all justice.

Now, the Protrusive Dental Pearl I have for you before we join the main episode is something that I’ve talked about before. It’s about using a mouth prop, like I’m a big fan of using rubber dam. And again, I’ll reference to why this is relevant at the end.

So make sure you stick to the end of the episode to hear why I am a hypocrite and I’m happy to say that, right? So I’m a hypocrite because I use rubber dam, but I’ll come to that to the end. Now because I use rubber dam, I use a mouth prop, right? So if my patient’s going to be having their mouth open for 45 minutes or an hour plus, I’ll use a mouth prop, which is like when there’s little plastic wedges that you put on one side, and it helps to keep their mouth open.

Now, what I say to my patients is the difference between holding your elbow out at 90 degrees, okay? And after a while your arm gets tired, right? And so it’s much better when you get to lean your elbow against a table.

Now your muscles can relax. It’s the same way with the muscles of mastication and the lateral pterygoids in particular. The mouth opening muscle, the depressor, right? These muscles can get tired by stretching open. Like have you observed some patients, they keep closing their mouth, right? They struggle to keep their mouth open, they keep wanting to close, their muscles get tired, they get fatigued.

So by giving a mouth prop, you’re essentially giving that elbow a table to lean against. Now the problem is, because I’ve talked about the use of a mouth prop before, but the angle I’m coming from now is if you ask the patient, hey, would you like to use a mouth prop? It’ll help to keep your mouth open. Then the patient’s going to say, no, no, it’s okay.

No, no, it’s, it’s, okay, fine. Just do what you do. You do what you need to do. I don’t want to be, I don’t want to cause any trouble. Right. You shouldn’t say that because you see patients don’t say yes to it, not because they’re afraid of it, because it’s the default answer, right? It’s a default answer that patients would give.

So instead, here’s what I say to my patients, ‘Mrs. Smith, I’m going to put this mouth prop in so that instead of keeping your mouth open the whole time, your jaw can relax against this little plastic wedge. It’ll stop those poor muscles from getting tired. I’m just going to put this in before I put the rubber sheets on.’

That’s it. No one ever says no. Okay? And whilst my patients might not realize it, they’re definitely better off because a number of patients who have an achy jaw at the end is way less. And this just makes sense, right? It’s a good thing to do for your long procedure. So anytime you’re using rubber dam, my nurse knows that I need to use my mouth prop.

And it’s better you propose to your patient in that way rather than asking your patient, hey, should we use a mouth prop? They’d be, no, no, no, it’s fine. So A, use a mouth prop and B, present it in a clever way. Now I’ve got lots of reflections littered throughout this podcast, and I’ll also catch you in the outro.

So then, and the next thing talk about Pasquale is the whole concept of a no post, no crown. So this concept of we want to avoid placing post as much as possible and we want to avoid doing crowns and instead do onlays to maintain the gingival third of tooth structure which is responsible for the strength of the tooth.

Now, my own personal views on post is that I haven’t placed a post for like maybe two years now because for me, if I have enough ferrule, then I think almost I don’t need a post that I can just rely on my composite and the crown will be engaged in a ferrule. If I don’t have any ferrule, then I’m thinking, why are we even using a post here?

So, just before we continue the interview, guys, I just wanted to talk about the ferrule if you’re a young dentist or a student and you’re listening to this and you don’t know what a ferrule is, it’s super important. Imagine you have a central incisor and it’s fractured at the gingival level. It’s like the worst kind of emergency you can deal with, right?

And there’s very little tooth structure. Now imagine you stick a post inside and you build up a core. Your crown is completely on core material. Think of the bending and the stress at that adhesive interface, right? This is not ideal. Now imagine now just to make it easier, we’re not going to talk about crown lengthening and that kind of stuff.

Just imagine now that when this tooth broke, instead of breaking at flush to the gingival level, it broke two millimeters. Supra gingival above the gum. Two millimeters supra gingival. Now, when you build up your core and now you prepare this tooth for a crown, for example, okay, central incisor, we’re talking here now instead of your crown being entirely on the core material and all the stress going through the core, it’s now gripping that precious two millimeters of tooth structure.

That precious two millimeter rim all the way around the tooth is the ferrule and inside the crown the most gingival few millimeters of it, that’s the ferrule effect being gained by the crown. So this is incredibly important for the longevity and success of your restorations.

If a tooth doesn’t have a ferrule, its predictability decreases massively. So for me that tooth is for the bin or needs. Some crown lengthening or something like that. Or even if I can’t get that ferrule from a vertical preparation for example, we can gives you a little bit more ferrule to play with.

Main Episode:
For me that tooth is unrestorable. So I’d love to hear your views on this mantra of no post, no crown, and find out how much you in your daily dentistry are using post, at the moment

[Pasquale]
So first, I don’t like slogan, that’s why I don’t like the slogan. No post, no crown. So it’s like a marketer.

We want to sell something with the slogan. So it’s not easy to separate things. It’s not easy to find a solution for everything. I mean, nowadays, of course, also thanks to the additive procedure. We don’t need to use so many post as before. I barely remember a molar in the last six months I used the post, for example.

[Jaz]
Mm-hmm.

[Pasquale]
So in the post region is very rarely that I use a post. Unless the tooth is completely broken or the patient is a bruxist patient, but in anterior area, the game is different. It’s different for many reasons. When somebody tells me that he doesn’t use post in anterior area, or, he doesn’t use cast post.

Honestly, I have a clear idea of who is talking with me. So he has no idea about dentistry because when you do a lot of anterior teeth, you realize that some teeth are different. I will give you an example, but I will show you later in the presentation. You have a broken teeth at the level of the gum, okay?

So you have to rebuild in composite for doing an abutment five millimeter of incisors, okay? An abutment of five millimeter. So sometimes especially lower incisors or upper lateral incisors are very thin you end up with an abutment of two millimeter in thickness so imagine, a massive composite, five millimeter high and two millimeter thick.

[Jaz]
Almost a cantilevering of off the tooth. Almost like you could snap it. Yeah.

[Pasquale]
Composite in two millimeter is easily to bend so it can resist. So the only way for some teeth to just use a cast post, because the only post that you can manage a 1.5 millimeter of thickness is just metal. You have no other aoption.

Another problem sometimes, especially in anterior area, the root is in not on the same part of the crown. So if you place a post, a prefabricated post, you will place a along the root. So you will end up with the post, you will destroy with the preparation.

[Jaz]
So guys, Pasquale Venuti made a really good point here, right? If you follow the root of the tooth and like when you stick a post into a root and you’ve done enough post, you’ll know what I mean.

You’ve stick a fiber post in, for example, and you observe that the direction of the post is going off to one direction. Let’s say it’s going off more to the labial, right? Because if you imagine putting in the root and it coming straight out of the root, well the crown of a tooth doesn’t come out straight from the root.

It actually angles right? And because that angle, that offset, what you find is that your post is too much to one side. So when you now build up the core and you start preparing the tooth, you’ll notice actually you’re shaving away the post crown. The post crown itself is too far to one side, and we can get around this issue with a cast post .

[Pasquale]
So sometimes you have to correct the position, so you have to customize the post. The only object use a cast post. So there are, even nowadays, of course, there are rare cases, here I use no more than 10 cast post. But there are cases that you have no other option. Unless you decide to extract the tooth. Of course this is an option, but remember this when you have no ferrule, okay, post because you will create a resistance form inside the root. Of course, you can risk as last resort, the crack of the root at some point, but it’s better than the extraction of the tooth. In my experience, I did till now almost 250 cast post.

Teeth completely broken at the level of the gum. In these 20 years of practice, I have zero root fracture at just one the bonding that I will show you later in the presentation.

[Jaz]
So these are cases Pasquale with no ferrule? Yeah. I mean there’s no external ferrule.

[Pasquale]
Zero. Zero.

[Jaz]
Okay. So this is where I have personally, I have shown from my worldview and my experiences, I tend to shy away and I tend to maybe send to the implantologist at that point.

But I learned from you and I say, okay, I respect your experience and to try these post, it looks like you’ve had a fairly good success rate with that.

[Pasquale]
So if you do a current cast post, okay, forget to extract the tooth in less than 10 years. So it’s very, very longevous even if you are completely down the gum. Of course, with the vertical prep you are able to recover a little bit of ferrule, just a little bit, but not so much. But anyway, the cast post is so stiff that it will avoid any bending of the residual dental structure. It will be quite longevous for some time.

[Jaz]
It’s a very controversial issue in dentistry, the use of post and stuff. But, I respect that when you taught me in Sydney was the benefits of a cast post compared to a fiber post which hopefully we can just discuss a little bit now as well, where do you lie on this usage of fiber post and obviously you’ve talked about the benefits of a cast post in terms of customization and stiffness. What is the big downfall of using fiber cast post?

[Pasquale]
Cast post has become quite disused in the last, so I know cast post has never been so popular because learning doing cast post is very steep curve. It’s not easy. So you need the skills from the dentist and skill from the technician. It’s not an easy approach.

And then you need to cycle the appointment. The patient has to come back again just for the post. So you mean in a fast workflow, it’s not easy to be inside. That’s why during the years thanks to this prefabricated post, cast post has become less popular. But there are no other option in many, many clinical cases.

So I told you there are 10 cases in my dental practice every year that I need a cast post, there is no other option, the only option to extract the tooth because either I place another cast post or a fiber cast post or a dentatus post. I will collect ferrule in one, two years. So, I mean, many Implantologists prefer to extract the tooth and place an implant.

Let’s say I’m not against implants, but there are some cases, some young patients or some patients that are very debilitated, some eight years old patients with a lot of health problems that maybe they will be better served by cast post okay? For the last five, six years of their life.

[Jaz]
What about those cases where you do have two millimeters of ferrule, and in those cases, would you just build up with composite and not use a post? Or would you be open to using a fiber post for convenience in those cases? That have a root canal treatment, obviously.

[Pasquale]
It depends on the occlusal and the biomechanical demand of the patients. So if you have an anterior area, for example, you have a lot of tensional stresses.

If you’re in cast post in anterior area, you are in compressive area. So when you go back, the post, honestly, especially because a molar is very big. When you build up a molar, the composite is five, six millimeter in thickness. So it’s quite rigid when you move forward, especially in thin incisors.

Composite is very thin, so it’s mechanical, not insufficient for the work is deputy to do. That’s why more I go forward the more is probable that I use a sample post. I do not use fiber post for one simple reason. I will show you later why I don’t use fiber post from the biomechanical point of view, but I do not use fiber post because I love the principle plan for failure.

When use fiber post, you will not retreat the tooth anymore. In case you need treatments, you are f***ed up 90% of the times. Because I did, cause I placed almost 300 fiber post, so I had to retreat, but I had to extract the tooth most of the time.

[Jaz]
It’s interesting because when we are taught post and crowns in dental school, the angle that we are coming from is that if you do a cast post, when a failure happens, a tooth will fail and you have to do extraction.

But, what they say is that when you do a fiber post, then the post will fail, and then maybe you have a second chance of the tooth. But obviously from experience, you’ve shown that you are buggered. What is the main complication you face in retreating a failed fiber post? Because I’ll be honest with you, I am not experienced enough to have dealt with the failures of fiber post in quantity. So I would very much like to learn that from you.

[Pasquale]
People concentrate on the fiber post. The problem is not the fiber post because then I’ve heard post detach. The problem is the cement that is beyond the tip of the fiber post. There is cement, so sometimes you have one, two millimeter of recent cement at the bottom, and you cannot retreat the tooth anymore.

That’s why when I use dentatus post, I ensure myself that the tip of the post will reach the gutta-percha I will never left any cement beyond the tip of the post, the tip of the post has to screw just a bit inside gutta-percha because if I have to remove the post just rotating, I will crack all the resin cement and then I will have free way to the gutta-percha-

[Jaz]
So you’re coming from the angle of retreating the actual root canal filling as well, basically, right?

[Pasquale]
I come from the humble that from the field of humbleness, I learn that we are not God. Sometimes we do wrong things and endodontically speaking. Sometimes the nature is not so friendly. So that’s why I know that sometimes have to retreat the tooth. I have the possibility and fiber post because not giving me any biomechanical advantage, because they make the treatments quite untreatable.

I will not use anymore in my practice. That’s it. With dentatus post I can reach the gutta-percha every time. I am sure to be in gutta-percha. I am sure.

[Jaz]
The common objection you’ll get from most dentists who haven’t been to any of your lectures and teachings is that the short metal post are going to put a lot of stress in the dentine and then you will get a crack.

I know, because I’ve been to your lecture about what is the advantage of it. But what would you say to these dentists who are concerned about the root fracturing in the short dentatus post, that finish in the coronal third of the root? Very often when I’ve seen you do them, am I right? Yes?

[Pasquale]
So I never placed the dentatus post that is not beyond the point of inflection. You mean the point of inflection? The point of bending is the level of the bone. You have to be sure that the post is beyond is cervical to the level of the bone. Because if you place a post that is below the level of the body is completely useless here.

Because the tooth will bend at that point. So your pulse is to be below. So placing a longer post in my opinion, at zero benefit unless the crown is completely broken at the level of the gum. At that point, the post has to be as long as possible. That’s it.

[Jaz]
Okay.

[Pasquale]
But if the ground is quite conservative, need to go so much inside.

[Jaz]
Okay, that’s good to share because again, like I said, there’s a lot of confusion about post, so it’s good to hear your guidelines. Guys, I’m just going to interject when I saw Pasquale in Sydney lecture, he mentioned one point, which he didn’t really elaborate on this podcast, but one of the functions of the dentatus there’s little gold color, like screw type post, right?

The reason he use it is to actually give his composite some stiffness, right? Especially for an incisor for example, if you are building up the core in composite, it can get very thin. So by adding this type of post in, which is metal, it gives it some stiffness. It’s prefabricated. You don’t have to send an impression and he just screws it.

Just a tiny bit into the gutta-perchar. The point he makes that the length of this post has to be more apical than the bone level has to be more apical than the bone level. Cause it’s at the bone level where the stresses are being concentrated. So if it’s coronal to the bone level, then it’s adding to the problem.

So if you are going to do something like this and make sure your post is long enough that it’s going beyond or more apical to the bone level. Fantastic. So, I think we’ve done a lot of coverage there on post crowns. Should we move on because I think we covered a little bit about fiber versus metal.

[Pasquale]
Yeah, sure.

[Jaz]
You’ve already talked about C factor already, so we can go to the last question, which is fibers and dentistry. Is that cool with you? Amazing. Okay. So we’ve covered a lot of ground there. That’s why we had to make into a multi-part episode, I think which is amazing. So thanks for covering so many and get sharing your views.

Lastly, can you tell us about this rise in the use of fibers in dentistry? What I mean is not fiber post. I mean, for those listening, these little fibers that you can place inside cavities before then you place composite on top is what I’ve seen a lot of my colleagues practice on social media and some proponents of biomimetic dentistry suggesting that there are many benefits in terms of stress reduction of using fibers. Have you got any experience of using these Pasquale, or any viewpoints on this?

[Pasquale]
So during the years, we are going to substitute what has proven to be good, what we think is good. You can think wherever you like if it’s good, but you have to prove it’s good. What I learned on my shoulder that I will not embrace anything that has not a follow up of at least 10 years. So if somebody want to convince me about something, has to show me follow ups at least of 10 years.

So when we talk about fibers for reinforcing composite fillings, I don’t know, for reducing crack propagation. I mean, there are a lot of alleged function of these fibers. So I cannot find any follow up paper in dental literature. Maybe there is some follow up one, two years. Okay. But even digital dentistry feeling done with the finger lasts at least five years.

No, I think it’s not enough from the rational point of view, in my opinion, they are completely useless. And from the outcome point of view, they are not supported by any outcome. It’s just a trend now in dentistry because we love to do new things in every field. So, but the problem that I will not to complicate my procedures, for example, when we do dentistry, some people use chlorhexidine before placing the art, because you can inhibit.

The metalloprotein, as you know. I don’t know if this is true, it doesn’t true. It doesn’t matter. Can you prove me that this will move longer? The longevity of my restoration?

[Jaz]
That’s exactly what I think.

[Pasquale]
If you cannot me prove something, I will not add to my step. Those many steps make the procedure very tough for me, for my assistance for the patient because there is a tomorrow dentist.

Tomorrow assistance, and tomorrow patients. I want to stress myself and the people surrounding me with the useless procedure. One of the reason that I do not love so much additive procedure that they require multiple steps. And it’s easier to do some mistakes when you do multiple steps. When you have just to mix cement and plunk a ground, it’s idiot proof procedure.

Now when you start to increase the stuff you have to put inside the tooth, you start to mess up or you or your assistant. Anyway, I don’t see any point to use fibers. Because a lesion work very well when you have the right condition and composite work very well if you are in the right condition. So I don’t know how fibers can increase the performance of the filling. I don’t-

[Jaz]
Yeah, so I was just going to say, I think you were coming to the same point was that if in 10 years time, or 15 years time, by knowing how things are, the papers come out and say actually those composites that had a fiber as part of their protocol, maybe done in some universities somewhere in hundreds versus those composites that didn’t have any fibers in similar cavity conditions, seemed to have a less rate of cohesive failure or something like this.

Maybe then, because I respect you as a clinician, I think maybe then you would say, yeah. Okay. There are some studies now, 10 years. It is significant in statistics that you might use it, but you know what’s going to happen. The problem with these studies is that, they will not control for their biomechanical status of these patients.

So this is where the flaws of the studies come in, in terms of getting homogenous, sorry population samples. But that’s in a whole another debate about evidence-based dentistry.

[Pasquale]
I would not be, they will never produce any paper. How many randomized clinical trials have you seen in dentistry at 10 years?

[Jaz]
Very few. Very few. Zero. There we are.

[Pasquale]
But the same, for example, during this pandemic, Pfizer presented the randomized clinical trial for the approval of the vaccine just of two months. During these two months, they divide the patient in two group. One group received the vaccine and one group didn’t receive the vaccine.

So in both groups, the death failure was the same. So, I mean, the vaccine didn’t add any benefit. You can read the paper. So we don’t know what would happen in six months, one year. But anyway, the paper is just two months. So the only difference in the two groups where in the group with the placebo, they get more Covid than in the group with vaccine.

But that trade and hospitalization were the same. That is medicine. That is dentistry. So, we have very few serious clinical randomized clinical trials, and most of them are just for a few months. So even about onlay so I will show you during the presentation that we have no dental lesion supporting the so-called biomimetic dentistry, zero.

We have some papers with 10, 20, 30 year follow ups about crowns, but zero paper about flat onlays just some clinical cases, some case records. That’s it. So they’re basing new slogan, a new group just on nothing.

[Jaz]
So guys, after this discussion with Pasquale, I started to look for some evidence, right? Because Pasquale says there’s no clinical evidence for any of this stuff working, particularly when it comes to Ribbond in particular as we’re discussing, right? So I reached out some really prominent figures in biomimetic dentistry and didn’t really get answers really, unfortunately. But then the legend, who is Taylor Paton, who’s our guest on our introductory episode to Biomimetic Dentistry, that was PDP135.

God bless your soul, Taylor. He gave me a lovely reply with some resources and references. What I love about Taylor though is that he actually said that, you know what, it’d be nice to have more clinical data, because when I clicked onto those links and the research that was presented that’s available out there, it was all on extracted teeth.

There’s a bench top studies, so what Pasquale says is very much true in a way, right? There’s so much process based reasoning, right? Oh, do this, improve that bond strength. But where is the outcome, compared to a standard Class II composite, for example, how much longer would a ribbond reinforce Class II composite really last we? Really need to know this before we take added time and added expense to do such procedures.

Let’s say tomorrow a study was done and it was like a 15 year follow-up, and what they found was that composites without the fiber lasted 11.5 years. And the composites with the fiber lasted 12 years, so half a month more, and it said that this was not statistically significant. I’m just making up a random scenario.

You probably wouldn’t want to use it with extra time and extra expense that you’re passing on to the patient. Does it really add significant benefit? However, if the outcome studies were very promising and it significantly extends the life expectancy of your restorations. Then of course we should all be using it routinely.

How important are these contemporary things like ribbond and stuff compared to getting the tooth clean and rough? What I mean by that and what I’m referencing to is a fantastic episode we did with Dr. David Gerdolle episode PDP077. This episode was called, I can’t Believe This Sticks Extreme Bonding Right?

Extreme Bonding Exposed and what David Gerdolle said was that as long as you get nice clean tooth structure, and you get a good etch pattern that these two are so, so crucial in bond strengths and longevity. So how much more do these extra steps, like using Chlorhexidine, using ribbond actually add? So this is the kind of data that we really want.

Now what I don’t want to sound like is I’m taking the side of Pasquale, like we’re friends and I respect him so much as a dentist and I’ve learned so much from him, but I don’t want to seem like I’m bashing biomimetic dentistry, and I’m totally bashing ribbond because that would make me a hypocrite. I’ll tell you why, right?

Remember I told you at the beginning about Rubber dam? I love using rubber dam. I’m a huge fan of it. I think it makes a big difference, like when you’re doing adhesive dentistry, right? And you’re not using rubber dam and you have a mirror and you know it’s that the mirror is steaming up. I always think like what’s happening to your bonding surface?

What’s happening to your etched enamel, right? Because I do make the effort, if I’m doing that, doing it that way, that I encourage the patients to breathe through their nose and if they’re an obligate mouth breather, I will definitely be using rubber dam like I used rubber dam for about 80% of my dentistry.

But guess what? There are no clinical trials supporting the use of rubber dam. So there we are. I’m hypocrite, right? I’m saying that I’m debating with you that perhaps ribbond isn’t all that because we don’t have the clinical long-term data. But here I am using rubber dam and I’m so religious about using rubber dam.

Now interestingly, there was recently an in situ study, right? What they did was they made like a splint with a wisdom tooth in it and they attached it onto a real patient, a real person, and they carried out the adhesive dentistry on an extracted tooth, but in the patient’s mouth with and without rubber dam.

And they found that categorically with rubber dam had better bond strength. So they kind of showed in an institute environment that it is beneficial. But why don’t we have a clinical study comparing patients having adhesive procedures with and without dam? Well, there are some ethical concerns and we might never actually get such studies.

Ultimately, I do think that biomimetic dentists, when they are doing what they do, the protocols that they follow, they’re so passionate about it and I really admire that about them. Right? And I think everything that they’re doing is with the best interest of the patient at heart. I really do think these clinicians are trying to get the best bond strengths and whether or not that actually translates to clinical success long term, we don’t know.

But we also don’t know that by rubber dam, right? So I’m saying great points, Pasquale about process-based reasoning and outcome-based reasoning. But I think biomimetic guys, I really admire that you are really trying to do something. You are doing the research behind it to the capacity that you can, and I’ve seen loads of biomimetic dentists, especially on social media, so passionate about what they do.

And that’s beautiful, right? It’s like when dentistry becomes an art, when you can really fall in love with the nuances of what you’re doing. That’s when dentistry I think becomes less like work and more like fun. So I think we can definitely take a leaf from their book. Well, I look forward to hosting the biomimetic group who will give their viewpoint as well.

And let’s listen to them. Let’s share. And I was going to, while you were saying that, I was thinking already, it’s the same with many aspects of dentistry, including occlusion. There is very little evidence in occlusion and stuff, so a lot of it is dogmas and a lot of it is marketing and that kind of stuff.

So we have to respect that. But that’s a whole another debate, and this is why I respect your way that you taught me. Look at the biomechanical demand of a patient and create an environment that is going to reduce the biomechanical failure and keep everything shallow in that patient compared to someone else who you can do anything in that patient and you’ll succeed.

[Pasquale]
Yeah, that’s it. So if you choose the right patient, you will succeed. The problem is, when you work in Manhattan, okay, you work in a posh office, okay? You receive some kinds of patients, some women, there are the wives of some oligarchs, you receive patients that do some work, some desk.

When you work in a village, you work with patient. They are mainly truck drivers. There are farmers. Most of those patients has very low income. Some many women live with husbands that are alcoholics. Many women have a lot of children with some down syndrome or some autism. So they have extremely low income for living.

They’re not living in Manhattan with a lot of girls to help them. So the profile of this patient is completely different. They cannot take care too much of their teeth from the oral hygiene point of view. They develop bruxism very easily because they live in very stressful way. So there isn’t even another problem.

It’s a genetic problem. Where are the people that go to Manhattan. That go to Manhattan the people that are the most beautiful and most successful people. So people there an advantage from the genetical point of view, all the people there, the best woman of the village will go to the city.

Over the years it always happened because a rich man will come from the city and will pick up the best women of the village, so who will stay in the village? Who will stay in the periphery? So the poorest people, the people with a genetic array that tend to be poorer. It’s not poorer, it’s just an average poorer.

So in the village there is also mostly inbreeding between people. So over the years there is a lot of inbreeding because we live it isolated for many years, for centuries in the cities, there is a lot of crossing over. Okay. From different races. So that’s why the genetic in some offices is different from the genetic in other offices.

It’s not just a problem of environment. It’s a multi-level problems. And people do not consider all these kind of things.

[Jaz]
You’re right, this is the first time it’s ever been discussed in this podcast and I was really waiting for you to discuss these high level philosophy because I remember just how you talk about dogmas and you love reading your books and the philosophies.

And I see your post on tomorrow tooth are very much a rich and historical events and how you analyze different data. So, we love that. I love that. I love to hear these perspectives. And I thank you for sharing that so much.

[Pasquale]
Because you think that if you go in New Delhi, in the most posh office of New Delhi, you have the same genetic pattern of patient of the village in Rajasthan somewhere on the mountains.

[Jaz]
Very well said, very well said. Very well said, Pasquale. I’m so, so thankful for your time. Thankful for all that you do.

[Pasquale]
All my pleasure.

[Jaz]
And then posting your cases, because I learned so much from them over the years. You’ve taught me so much, so much of my daily dentistry has been molded by you and your principles, which I have tested and I’m finding success from.

So thank you for improving me as a dentist and thank you for inspiring a community and I look forward to sharing with all the Protruserati this episode. Thank you so much and have a fantastic weekend.

[Pasquale]
Thank you.

Jaz’s Outro:
Well, there we have it guys. The end of this two part controversial series, like if you enjoyed this and you want to see Pasquale Venuti live, then he will be lecturing in Bucharest.

I’m going to put the details in the show notes so you can check that out. Do me a favor. If you like my podcast and you think that thought provoking and they help your clinical dentistry, or they make you feel more passionate about our profession, then share it with a colleague. I’d really appreciate that.

Oh, and don’t forget, if you’re Protrusive Premium on the app, either on the web app protrusive.app, or on iOS or Android, you can claim CPD for this and get access to loads of clinical videos. I’m constantly updating every month. Thanks again for listening all the way to the end. I’ll catch you in the next episode.