I first became aware of Dr. Jose-Luis Ruiz through his association with Dr. Gordon Christensen and the many lectures they were doing together. He was course director for the University of Southern California Esthetic Dentistry Continuum from 2004 to 2009, so I had several opportunities to see him lecture here in Southern California. I was immediately drawn to his approach because he emphasized techniques that can be used by dentists twice a day, not twice per year.

One of the critiques of many clinicians who teach esthetic dentistry is that they tend to ignore occlusion, but that cannot be said about Jose-Luis; it is an integral part of every course he gives, whether it is esthetic dentistry, adhesive dentistry or implants. He also gives a multilevel occlusion course than includes implementation of your dental team — an essential part of effectively adding a new procedure to your practice. If you’d like more information on his courses, please visit drruizonline.com.

Dr. Michael DiTolla: As we get started, tell me a little bit about the Los Angeles Institute of Esthetic Dentistry and your involvement there.

Dr. Jose-Luis Ruiz: Thank you. Well, it is really my pleasure to share my points of view in dentistry and my experience in dentistry, which I love — our profession.

The Los Angeles Institute of Esthetic Dentistry is a location where we provide a number of workshops. The purpose of it is to provide workshops at a reasonable price. They are very practical. The colleagues that take those courses will learn things that they can actually implement — not a pie-in-the-sky dentistry, but real dentistry that is based on good science and that is predictable. So that is the purpose of the Los Angeles Institute of Esthetic Dentistry. I am the director and founder.

I also believe that full-mouth rehabilitations — the “roundhouse,” as we know them — that some people were so proud to say they were doing a lot of, I think it’s overtreatment.

MD: Well, you know, it’s funny you mentioned that it’s not pie in the sky. Because I practice here at Glidewell, I get access to some really interesting statistics. We’re probably the biggest lab in the country, so I think some of the trends that you see in our laboratory probably hold true when you look at the entire country. And one of them is: right around 75% of the cases we get from dentists are for 1 unit of crown & bridge, and another 11% are for 2 units of crown & bridge. So, you look at it, and it’s 86% of the cases that we get here are for 1 or 2 units of crown & bridge. There are a lot of courses out there for full-arch dentistry and full-mouth rehab, and there’s nothing wrong with that. It’s just that when you look at what a lot of dentists do, you realize that the 1- and 2-unit stuff is pretty much how they make their living.

JLR: I absolutely agree with you, and I also believe that full-mouth rehabilitations — the “roundhouse,” as we know them — that some people were so proud to say they were doing a lot of, I think it’s overtreatment. I personally have, over the past 10 years, stepped away from full-mouth rehabilitations. I used to do a lot of them in my first 10 years in practice. And I find, today, as a more experienced dentist, that I can restore people’s mouths with far less than 28 or 32 restorations. Even on people that have very serious problems, I can often rehabilitate them with less than a dozen restorations — and even much less, in most cases. So, I think that single-unit dentistry is by far the most important that we need to be really good at, so our patients don’t end up having to face extensive dentistry in the future.

MD: Yeah, I agree. Because even if a dentist does, I don’t know, three or four full-mouth cases a year, that seems to me that it is almost more of a hobby than something you become really good at. It seems like the things that we need to be really good at are the things that we’re going to do a couple times every day. And, as I look around the lab, it does seem that if dentists could really get that single-unit crown wired, their lives and their patients’ lives would be much improved.

One of the things that I think is overlooked a lot is occlusion — even basic occlusion, for maybe 1 or 2 units next to each other. And I know that you teach some courses in occlusion. Tell me a little bit about how you think occlusion is perceived by the average dentist, and about what you teach in those courses.

JLR: Excellent, excellent comment. I agree with you. Single-tooth or couple-of-teeth occlusion, or understanding and management of occlusion, is indispensable in dentistry. And, first of all, I think that it is often overlooked because, just like you were saying earlier about there being way too many courses on full-mouth rehabilitation, I think most courses on occlusion that I have ever gone to (and I’ve gone to a lot of them — to all the big names in dentistry) are geared toward full mouth and changing people’s occlusions fully. In the courses that I teach, I try to be very clear that most people don’t need to have a whole-mouth change. Occlusion should be simple; it should be practical. I feel that most dentists — and by “most dentists” I mean probably more than 90% of general dentists out there — really don’t want to deal with occlusion. They want to just make sure that the tooth doesn’t feel high, and that’s it. And that leads to a lot of problems because the number one reason why restorations fail, break, people have sensitivity or, sometimes, our patients end up having root canals, is occlusal trauma. And that leads to a lot of problems.

So, in my courses, I like to keep occlusion simple. It is understanding, first of all, how to diagnose it, because that is the first step. Knowing the seven symptoms of occlusal disease — it is not just muscle pain or wear, but there are a number of other symptoms. For example, I don’t know if your readers are aware that the number one reason why people have sensitivity on their teeth (cervical sensitivity) is occlusion. We spend millions and millions of dollars on Sensodyne^® (GlaxoSmithKline; Philadelphia, Pa.) and stuff that we paint on teeth to stop sensitivity, when, without a doubt, the number one reason — the overwhelming reason — why people have that cervical sensitivity is occlusal trauma. And if we get rid of the occlusal trauma, we get rid of the sensitivity completely!

MD: Wow, that’s amazing. I’ve been out of dental school probably 22 years, and I’ve heard it go back and forth between toothbrush abrasion, and then it was parafunctional activity, trying to figure out exactly what’s causing cervical sensitivity, and also what’s causing abfraction lesions. How do you feel about abfraction lesions, whether they’re sensitive or nonsensitive, and how do you treat them when you see them on a patient?

JLR: That’s another controversial subject. With abfractions, I absolutely believe that their primary etiology is occlusal trauma. They become worse, maybe, because of improper brushing and toothpaste abrasion, but their primary etiology is occlusion. Almost every time I see an abfraction in somebody’s mouth, I can trace the occlusal interference that caused it. And I’m not big into restoring them because, you know, even if it’s sensitive, once we balance that tooth, even if it’s just that single tooth, the sensitivity goes away — every time. So it’s not always necessary to restore them. Of course, if they are ugly, I will repair them, so the patient looks nice. But if it’s not an esthetic concern, I often just leave them alone.

MD: Wow. So if it’s asymptomatic, you don’t feel the need to rush in there and put something in just for the sake of putting something in?

JLR: Exactly. No, I don’t.

MD: Interesting. Now, I’ve heard before at courses, and maybe it was at some of the occlusion courses that you referred to a little bit earlier, that we should be doing an equilibration on any patients who we are going to do a crown on, prior to prepping. A certain part of my brain acknowledges that — says, “You know what, that’s probably true; I should probably go and check and equilibrate this patient” — and on the other hand, I know that I rarely actually ever do that if I’m doing a single-unit crown. And I always think, “Gosh, I wonder if I should have equilibrated?” Do you have any particular feelings on whether or not everybody, just your average patient who is getting a crown or two, needs to be equilibrated before you start to prep?

JLR: That’s a very good question. I feel that that’s one more of those pie-in-the-sky beliefs in dentistry where, realistically, the great majority of patients will not be inclined and willing to pay to do a proper equilibration. And what I mean by proper equilibration is: If we are going to equilibrate someone’s mouth, we must do proper diagnosis, mounted casts, trial equilibrations, and understand the muscle activities of that patient, and we need to do it right. And if we’re going to do it right, it’s going to be expensive, and it’s going to require that the patient wants to go through that. I believe that very few people are really inclined, at the beginning, to do that.

So, we must be able to do a single crown or a couple of crowns or onlays without full-mouth equilibration. By the way, I don’t like to do too many crowns; I usually do onlays — porcelain onlays. But whether we do a crown or an onlay, we need to be able to equilibrate that one tooth appropriately, so it will not damage the dentition, not worsen the patient’s occlusal condition, and at the same time have a healthy life. It will have proper centric contacts. It will allow the patient to chew appropriately. But they will not have interferences — lateral working or nonworking — so the restoration will have a healthy, long life.

MD: Interesting. That’s a good point. So, obviously, if you’re replacing an old PFM crown that has been on for 10 years, and it’s got recurrent decay, you’re going to do a crown on that tooth, I would think.

JLR: That’s correct.

MD: Although I know they’re trying to grow enamel at USC, I don’t think they’ve actually been able to do it quite that well yet.

JLR: (laughs) Not quite yet.

MD: But maybe walk me through a patient who you see. And I don’t know if you have any kind of hard-and-fast rules. But if you see a patient who’s got an MOD amalgam — and obviously every tooth is going to be a little different; maybe there’s a buccal pit alloy or an OL amalgam thrown in there — take us through how you would decide between an inlay versus an onlay versus a crown.

JLR: Well, basically, if the tooth has cusps, and if all the cusps of the tooth are strong enough clinically, from my perspective, to be able to withstand function, I will always go with the direct restoration. Whether it’s an MO or an MOD composite restoration, that would always be my choice because it is less aggressive on the preparation. It will require less cutting of the natural tooth, and it will be more cost-effective for the patient. Ultimately, my goal is always to give the patient the simplest possible solution to their problem.

The next level would be if one of the cusps is damaged due to decay, fracture or something else. Then, that will have to be covered, and it will turn into an indirect restoration. I will do a single cusp onlay or a combination inlay/onlay. If multiple cusps are damaged, then I will consider doing a full-coverage onlay, or some people like to call it an overlay. And those are the different steps that I would follow to treat a single tooth.

MD: Do you see then much difference between, let’s say, a traditional kind of MOD onlay and what I might call a “small crown,” where it’s kind of like a crown that has the margins 2 mm supragingival? What would you call that? A large onlay or a small crown? Or does it even matter?

JLR: I think the difference between a small crown and an onlay would be that a small crown will have axial reduction. I mean, they are very similar, and they could almost be built the same way. As long as it covers every surface, it is a small crown. But the difference in terminology would be: A small crown will have axial reduction and that’s what would bring those margins to 1 or 2 mm to the gingiva, versus an onlay, which will not have axial reduction. It will have more of a butt margin, possibly with a bevel or possibly not. And the forces applied to the porcelain are different when we don’t do axial reduction.

MD: I know you teach a class on supragingival dentistry. Tell me a little bit about your philosophy on that, and then how that gets executed when you’re actually in practice.

JLR: Absolutely. For a long time I have been promoting supragingival dentistry. And the first aspect of supragingival dentistry is the ability to use translucent restorative materials that will allow us to have a better blend of restoration. So you are absolutely right: If the margin really sticks out from the tooth, then the patient will be unhappy with it, and the dentist will tend to hide it. If we use translucent materials, then we are able to leave a margin that will blend better with the tooth, will not be as unsightly, and the patient will not have a problem with that. So, we start by having to choose materials that are more translucent. And even the materials that are not as translucent, we can always use them in the best possible way to minimize opacity. So, my view is, in the posterior area of the mouth, leaving a margin above the gum with a translucent restoration will possibly leave a slight difference in color, but most patients will not be offended by it in the nonesthetic zone. It will blend well enough to look good. And I think when we make it clear to patients the benefit of leaving margins above the gum, people always are satisfied.

My practice is in Burbank, in the studio district of Los Angeles, and everybody here in my practice is in the movie industry — in front of the cameras, behind the cameras — and they have high esthetic expectations. But they also have an understanding of health. They don’t have a problem seeing a slight difference in color between the tooth and the restoration, if they feel that their tooth is much healthier — as long as nobody else can see it, and as long as it’s not really ugly. So, the intention is to provide that translucency so the margin will blend better, even if it’s not, like, perfection.

MD: Exactly. That was one of the great things about cast gold: Patients definitely wanted supragingival margins. If you dared to cover the whole buccal surface of their tooth with gold, they weren’t real happy about that.

I know you are associated with USC. I went to the University of the Pacific in San Francisco, and I remember hearing about the faculty at USC: that they love their gold; they love their 7/8 crowns, their 3/4 crowns. We did mainly PFMs up at UOP, but I always heard that USC loved cast gold. When I graduated and got into practice, I practiced with my dad for a couple of years, who was an old-school dentist, and that’s when I finally started doing cast gold. I fell in love with it, but I also realized pretty quickly that there were hardly any patients, if any, who found the material to be esthetic at all. Tell me a little bit about your history with cast gold and the role that it plays in your practice today.

JLR: Very good question, as well. There’s no doubt that cast gold is an excellent restorative material. I mean, the wear is spectacular, and we can be supragingival, and we can be quite minimally invasive if we use it correctly. But in my practice today, I probably do two a year. So it’s very rare and has to be somebody who just had it in the past and they don’t care how it looks.

At USC, you are absolutely right. Ten years ago all the education was toward gold — indirect cast gold. That was the number one choice. And we just had to convince the patient. That was really the approach: You need to educate the patient and convince the patient because that’s the best for them. But it has changed and, today, the first choice of restoration on an indirect situation will be a tooth-conserving onlay.

MD: A lot of the dentists who use our laboratory and dentists at my lectures, too, have told me that they prefer to cement, rather than bond restorations, when indicated. And when you talk to most of them, it’s not necessarily the complexity of the bonding process that discourages them; that’s a small part of it — total etch is obviously more complicated than a typical crown & bridge cementation. But they complain about the postoperative sensitivity that they get with the total-etch technique. And I know that there are a group of dentists who prep full crowns rather than partial-coverage porcelain onlays, for example, because of the fact that they want to be able to cement and not have to go through total etch. Not so much because they’re lazy, but more so because they hate postoperative sensitivity. When you have a patient who’s got no sensitivity, they come in, you do this great thing for their tooth, and then they’re sensitive for the next couple months afterward, it’s discouraging for everyone involved. Have you heard that same thing from some of your attendees, and do you have a way for dentists to deal with it, so they can be more comfortable with these partial-coverage supragingival margin restorations?

JLR: What you are telling me is what I hear all the time, and it’s true: Regular cementation is more predictable. We know when we use traditional resin-modified glass ionomer cements like Meron (VOCO America; Briarcliff Manor; N.Y.) that sensitivity is usually minimal and they’re easy to use. On the other hand, total-etch techniques are complex and unpredictable sometimes, where everything seems to go wonderfully, and then all of a sudden the patient ends up with sensitivity. And then of course the issue of, if we put the margins too close to the gum or below the gum, then we have the terrible situation of having to have perfect isolation control — no bleeding of the gums, no saliva getting in the way — and that just makes life more complicated. So what I teach in my courses is, first: Keep the margins above the gum, using translucent materials that will allow us to do that.

MD: Give me an example of a translucent material.

JLR: Well, pressable feldspathic porcelain is translucent, and all my onlays are made out of pressed ceramics. My veneers will be made out of layered porcelain. The goal is always to choose the ingot, or to choose the material, that is translucent.

But going back to the cementation, I would keep the margins above the gum, so we don’t have that stress of having to control the bleeding and stuff, which is really hard. And, secondly, use self-etch bonding systems, like Clearfil™ Esthetic Cement and Clearfil Protect Bond (Kuraray America; New York, N.Y.), which are far more user-friendly. And it doesn’t mean we can be sloppy. We have to be attentive to detail, but they’re easier to use and, in regard to post-op sensitivity, are far more predictable. My experience with post-op sensitivity using self-etch in supragingival margins is excellent. It’s never a concern in my practice. And I think many dentists are familiar with those bonding systems because they use them for their Class II composites and their Class I composites. And I think, when properly used, we have a predictable situation.

MD: I remember seeing a CRA report, where they did a survey of CRA evaluators. And I seem to recall that because of postoperative sensitivity concerns, anytime there is a large amount of dentin present, I believe three out of four of the evaluators were using a self-etch system. And they were using total etch more on a minimal prep veneer, where they had more enamel exposed.

I personally have completely switched to self-etch bonding systems, all the time. So I don’t use total etch at all in my practice.

JLR: Exactly, you’re absolutely right. I remember that particular CR report. I personally have completely switched to self-etch bonding systems, all the time. So I don’t use total etch at all in my practice.

MD: Wow. Not even for a minimal prep veneer?

JLR: Not even for that — just for simplicity. Just because I don’t like to have, and I don’t like to recommend, lots of different bonding systems. I used to use one for veneers and one for everything else, and for the past six or seven years, I’ve just used one self-etch bonding system for everything. And I’ve had absolute predictability with that — when properly used, of course. And that means etching the enamel every time. That’s one of the very important steps. If the restoration is mostly on enamel, we must etch the enamel. And then we can use the self-etch bonding system.

MD: When I went through LVI, I don’t know, probably 18 years ago, most of the veneer preps we were doing, if not all of them, were into dentin — in fact, into deep dentin sometimes. And I think that’s part of the area where some of us began to notice that we were seeing more postoperative sensitivity than we should be seeing, or than we traditionally saw. If you took a patient who had 10 veneers done and they had sensitivity on three of them, I always kind of thought in the back of my mind, “I bet if I had prepped these for full crowns, which is more invasive, and then cemented them conventionally, that she would not have had this postoperative sensitivity.” So my pattern has been that I’ve gotten more and more conservative with veneers over the last 20 years, to where there’s now a marked attempt on my part to stay out of dentin. Tell me a little bit about your history with veneers and what you teach in your veneer course about the contemporary way to do porcelain veneers.

JLR: Well, I think you are absolutely right. I think that dentistry went through a very interesting pendulum, where the very first veneers, 25 years ago, were minimum preparations — very, very minimum preparations. And, I guess, we saw a lot of those, and they were over-contoured. As our esthetic goals became higher, we decided that we needed to prep more aggressively to get better contours. Now, we are back into the no-prep veneer type of situation, where we start seeing a lot of over-contoured, bulky veneers.

My personal approach is minimal preparation, just like you. My goal? I like to stay in enamel, if at all possible, and use super-thin veneers. This comes with the understanding that I believe a good technician should be able to do a veneer that is less than half a millimeter thick. I mean, 0.3 mm is sort of a dream, but I believe less than half a millimeter is fairly predictable. So my preparation, if the preparation is necessary, will be usually that: half a millimeter or so, and a little bit less in the cervical area, if possible. And that’s what I teach. It’s all based on good esthetic diagnosis. I need to look at the patient’s face, look at the patient’s teeth, and be able to recognize, if I bulk up those teeth a little bit, whether the patient is going to look better or worse. I have a very well-defined, 25-step or 25-parameter smile design that helps me come out with those decisions very quickly, and I have been teaching that also for about 10 years or so.

MD: That sounds like a very thought-out, scientific way to do it. That’s a good approach because a lot of dentists, I think, just hop in and start reducing without keeping the end result in mind about what they’re trying to do. And as easy and as fun as a no-prep veneer can be, I just don’t see many true no-prep cases where I’m doing eight or 10 no-prep veneers. What I do see a lot of is, maybe we’re replacing some old crowns on #7, #8, #9 and #10 — some old PFMs maybe with some all-ceramic crowns — and then we might do some no-prep veneers adjacent to those. And, to me, the no-prep veneers seem like a great way to kind of finish off a smile, rather than kind of be a primary treatment modality. Because you just don’t see too many cases that are that deficient on the facial.

JLR: I agree with you, yes.

MD: Let me ask you another question. As I go through the laboratory and look around, it seems that about 85% of the impressions we get here are taken in double-arch trays. I’m interested to know how you feel about double-arch trays for maybe 1 or 2 adjacent units, what your typical impression technique is, and when you move up to bigger trays.

JLR: I think that double-arch trays are excellent. I use them routinely for single crowns or single onlays. I prefer to use it when we have a distal tooth that’s still in contact, if at all possible. If the patient has pretty stable occlusion, I will even use it on the most distal tooth. If I do anything in the anterior area of the mouth, then I will always use a full-arch tray. If it’s a bridge and the distal tooth is involved, then definitely a full-arch tray as well.

MD: OK. And what are you doing these days for retraction? It’s probably dependent upon what kind of restoration you’re doing. Obviously, in supragingival dentistry, one of the nice things is not having to worry about gingival retraction. But if you are, let’s say, replacing a crown that’s got slightly subgingival margins, what do you typically do in the anterior and/or posterior?

JLR: You’re right. I mean, in real-world dentistry, we have to replace a lot of old crowns that have subgingival margins, and in those cases I will do my tried-and-true double-cord technique. I like to use Ultradent’s woven cord and dip it in a little hemostatic solution. I use a small cord first, and then a slightly bigger cord for my second cord, and that’s a pretty predictable technique. I tried other things, and I keep going back to the cord.

MD: Yeah, I feel the same way. I get questions about retraction pastes and diode lasers. And it’s not to say that I love packing cord because it’s far from my favorite thing to do.

JLR: I agree. I hate it.

MD: I just can’t find anything that works as well.

JLR: That’s right. It’s predictable, easy, inexpensive and uncomplicated.

MD: Exactly. Thankfully we’re in a state where our assistants can do it, if they’ve been properly trained and have the right degrees.

JLR: That’s right.

MD: Let me ask you this: Shade-taking is always an issue that comes up here at the laboratory when dentists get restorations from us that don’t quite match what they think they should match. I would be interested in hearing if you have any tips or tricks for shade-taking. And is it any different for the onlay restorations that we have alluded to? Are there any secrets you have for taking the shade on those preps versus, say, a full crown, where you’re looking at dentin as opposed to probably still looking at some enamel walls on an onlay?

JLR: Well, answering the last question, which is the onlay: Basically I would use a VITA^® shade guide (Vident; Brea, Calif.) for an onlay, and choose the right shade for the tooth, and always request a translucent restoration. When you use a translucent material, the material itself will kind of absorb the color from underneath, and I get a nice blending, so I don’t worry too much. And often those restorations are in the nonesthetic area, so it is close to being a great shade.

Now, when we talk about dentin replacement and the more opacious restorations, like a PFM or a zirconia type of crown, then that requires a little more skill. I think it is very, very important to, first of all, assess the level of opacity that we are trying to match. Because a lot of times we are trying to match other crowns, and most of the time those crowns are going to be more opacious. Then we want to communicate with the laboratory that we want slightly more opacious restorations. If we do a single-tooth crown or veneer in the anterior area of the mouth, that is one of the most difficult things we can do in dentistry. And if I can avoid it, I will. But, of course, we can’t always do that. And that’s when I will try to create a map. I don’t use any special shade-matching instruments. I will just try to create a map for the technician, and will certainly use a photograph as well. That combination of written information in regard to more chroma on the cervical and more translucency on the incisal — or whatever we are seeing — and then a photograph; that combination will give us a nice approximation of something that will be acceptable to the patient.

MD: Yeah. I think sometimes dentists feel like, well, you do programs and I do programs, so we have to take pictures because, otherwise, it’s a little difficult to teach if you can’t illustrate what you are trying to do. So the use of a camera to us is kind of second nature. And dentists say, “Oh, I’m not very good at photography.” But it’s really pretty simple, the kind of photography we’re talking here. We don’t change the settings on the camera very much. It’s simple and straightforward. And I would say, on the anterior cases that we receive here at the laboratory, only about 5% of them have a digital photograph come with it. Some of these are cases that might be a crown on tooth #8 sent from Pennsylvania, and there’s no …

JLR: There’s no way to know.

MD: And I’ve noticed something. I don’t know if you’ve noticed this, too, but when there’s a photograph that accompanies the case, the lab technician just tries harder. Not only do they know what they are shooting for because they can see the prep and the adjacent tooth, but it’s almost like they just get the feeling that this is a dentist who cares more.

JLR: Yes, and has higher standards.

MD: Yeah, and the technician absolutely tries harder. And I think you get better results from sending a picture, even if it was out of focus, or even if it was a picture of the wrong patient. I just think the technicians try harder and they do a better a job. So I’m assuming that you send out photographs with a lot of the cases that you do.

JLR: Oh, yes, for sure. And I have to say that we really don’t have an excuse for not using photographs today. I’m a bad photographer, no question about it, and when I had to use film, it was a nightmare. But with digital cameras, it’s a no-brainer. You don’t need to be a good photographer. You can take as many photos as necessary, and you can look at them immediately. Now they have these little printers with a docking station, so you can print in seconds.

MD: And, again, I taught my assistant what I knew, and then I sent her to a couple of courses, and now she takes all the pictures. It’s very rare that she even asks me to help on any pictures. And she has probably surpassed my level. It’s a perfect thing for dentists to be able to give their staff something else to do to make their job a little more interesting, a little more exciting.

JLR: I agree with you. I don’t take any photos. We have very similar philosophies.

MD: Right. Let me ask you this. We just started making, believe it or not, mini implants here at the laboratory.

JLR: Wow.

MD: It was something that Jim Glidewell wanted to do. He wanted to, I think, make them a little more affordable for dentists. And because of the fact that we do a lot of the relines of the dentures over these minis, he thought we should probably be involved in this. I know you guys do an implant dentistry class, and I think part of it focuses on mini implants. Tell me a little bit about how often you use these minis, and how you use them.

I believe that in dentistry, just like we were talking about the pendulum on veneers, I think the pendulum on bone grafting has gone way excessive in dentistry.

JLR: Well, I have to say that my philosophy of implant dentistry is just like everything else: It has to be practical and simple. I believe that in dentistry, just like we were talking about the pendulum on veneers, I think the pendulum on bone grafting has gone way excessive in dentistry. Every course that you see out there is about grafting. Everybody is telling us that we should be grafting almost every single case. And that is just overtreatment for patients. Only the rich and famous can afford it, and it just doesn’t make any sense to me.

I personally use narrow implants, and I have for many years now with very good success. I use narrow implants so I don’t have to graft and still can have enough bone around the implant and, when necessary, I will use a mini implant if the ridge requires such. I find them to be very predictable. If properly treated and it’s a good quality mini implant, it will integrate, and you’ll be able to place a nice restoration that will serve the patient well. Or use them also for overdentures — no problem there.

In my courses, I teach a more real-world approach where, if possible, we try to place implants without having to do bone grafting, as long as we have enough bone around the implant. Research is very clear today showing that if we have angulation on implants, it does not become an issue of failure. That’s a lot of research on that, where slight angulation due to the bone position will not decrease the life of an implant.

MD: Right. Well, as we wrap this up, I’ve got to tell you, a couple of times you used words that I am absolutely passionate about, like “practical” and “simple.” What I try to do, and I know now that it’s a part of what you try to do as well, is take these kind of ideal world situations and figure out a way that the average dentist — and I consider myself an average dentist — can integrate these principles into what they do, day in and day out. Because the reality is that in — as you refer to it — a lot of the pie-in-the-sky classes that are out there, something sounds great and looks great, but when you get back to the office, it’s really difficult to do this on the real patients who aren’t independently wealthy, don’t have all the time in the world, and need to get back to work. And you have to be able to implement this stuff. When it comes to practical and simple, our dentist customers here at Glidewell basically demand that. And I can tell that you and I are kindred spirits when it comes to some of this philosophy.

JLR: Yes. I feel the same way.

MD: So I want to encourage our readers to head over to drruizonline.com, if they want to check out some of the courses that you’ve got coming up. I’m going to make it out to one of the supragingival courses, because I know that I should probably be doing more supragingival restorations than I’m currently doing.

JLR: Thank you, Mike. I’d be honored.

Dr. Jose-Luis Ruiz is in full-time private practice in Burbank, California. Since 2006, he has been named a leader in continuing education by Dentistry Today. Contact him at 818-558-4332 or ruiz@drruiz.com.