Dr. Paresh Shah shares how to get started with CAD/CAM technology in your office, best practices for success when implementing new technology, and the advantages of using fully crystalized lithium disilicate blocks.
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Read the audio transcript below:
Dr. Luisa Schuldt (LS): Hi, everyone. Welcome to Brush Up, presented by Oral Health Group, the dental podcast, where we speak with industry experts to discuss a variety of topics such as technology, finance and practice management. Today’s episode is brought to you by GC America. I’m your host, Dr. Luisa Schuldt, a prosthodontist and periodontist based out of Fonthill, Ontario. Today we have the pleasure to be joined by Dr. Paresh Shah to discuss LiSi2 (lithium disilicate) CAD Blocks for chairside use. Dr. Shah maintains a private practice in Winnipeg with a focus on implants, esthetics and interdisciplinary care. His passion for advanced education led him to found and co-direct a Seattle Study Club in Winnipeg. He’s used digital technology in his practice for over 15 years, and also serves as a key opinion leader for several dental manufacturers. He’s also been invited to give over 400 lectures internationally. He’s co founder of Elevate Dentistry, a dental education group that provides continuing education on a variety of restorative, anesthetic topics for daily practice. Welcome Dr. Shah.
Dr. Paresh Shah (PS): Thank you very much, Luisa. Appreciate it.
LS: It’s a pleasure to have you here. I see you have quite a bit of experience in educating and I hope you enjoy this version through a podcast as well. How do you use CAD/CAM technology in your office?
PS: Well, it’s a mixture of working with my lab as well as doing some in-house procedures as well. So there are times where I want to provide either a same day restoration for a patient, or there are times where I’m doing a more complex case and working with my lab in another province, but they’re sending me files to be able to print or mill, you know, provisional restorations or prototypes.
LS: Yeah. So, it’s very practical to be able to do that immediately. It sounds like you might use different CAD/CAM technologies such as additive and subtractive. Or do you focus mostly on the million…
PS: No, I use everything, yeah, everything in my practice.
LS: What would be your go to materials or workflows when incorporating CAD/CAM into your your daily practice?
PS: Well, I’ve been using like right now, it’s primarily, if it’s not a composite block, it is lithium disilicate. It’s a GC LiSi product.
LS: What would you say are the advantages of using the fully crystallized lithium disilicate blocks versus some of the other materials that you are using in practice? Or in which cases would you use it as well?
PS: Well strength, you know, longevity, or, you know, stability under function because of the strength and the fact that it’s fully crystallized. So, I don’t have to worry about necessarily using a furnace.
LS: Okay, it sounds like you have mentioned 15 years of using different digital technologies in your practice. Can you tell me a little bit about how you started using it and what motivated you to go down this journey?
PS: Yeah, it’s actually been longer than that, closer to 18.But I started with CAD/CAM system. It was one of the original E4D Systems, which is now Planmeca. And I did that for probably, I don’t know, six, seven years. At that time, it was a little cumbersome, because the technology back then, even with CEREC, was not as easily delegatable, and it was a little more challenging to scan and to design and to mill. So I stopped doing that, and then I added a mill, just pre-covid, back into my practice, and now the materials that we have available, there’s just so much more variety. The mills are easy to use, and the workflows are just far more efficient than they were 15-20 years ago.
LS: You mentioned the delegating. I guess the systems are so much more user friendly, easy for your team members to support you with some of the design and different steps of using the systems.
PS: You can. I do all my own designs, or I get my lab to do it. But in terms of when I’m doing inlays, onlays, and some crowns chairside, or just within my office, sometimes I’m not doing them same day, just because of the way the schedule works out. But it’s been easy to delegate, you know, handling the materials, you know, nesting the materials in the mill and, actually, you know, cutting off the sprues and polishing and everything.
LS: You were mentioning you do different types of restorations with the material, inlays, onlays, veneers, crowns. How does this current system help you practice minimally invasive dentistry? Versatility, in its use. Do you want to talk to us a little bit, or would you be so kind to talk to us a little bit about the advantages of using a universal resin, cement versus, you know, multiple different systems, or what your preferences are as far as cementation?
PS: Well, if I’m doing an onlay it’s going to be minimal, right? So it’s, you know, I did a lot of very conservative dentistry over the years, and, you know, I don’t do a crown if a tooth doesn’t need a crown. So, it allows me the ability to be conservative. And so, yeah, it’s all related to preparation and prep design. So as long as I can do something like, if I can do an inlay or an onlay, I’ll do it. And this material, we know, the lithium disilicate, has a great track record for many, many years. You know, for the most part, I use a variety of universal cements. I mean, I just want something that’s easy to handle, you know, easy to dispense, and you know, the cleanup so it’s all of those factors.Simplicity is important in the practice; you just want to reduce as many steps as possible and keep it as simple and reproducible as possible.
LS: Now, a few words from our podcast sponsor. GC Initial® LiSi Block is a unique block that features GC’s proprietary High Density Micronization technology for CAD/CAM dentistry to deliver high wear resistance, smooth margins and aesthetic final results. This makes it an ideal time saving solution for single visit chairside treatment. The unique ultrafine crystal makes it easy to grind and can be quickly milled in its fully crystallized stage. Thanks to GC Initial® LiSi Block’s exceptional properties, high gloss and natural opalescence can be obtained in a few minutes by polishing only and restoration is then ready for luting. The aesthetics of your restoration will be maintained over time. GC Initial® LiSi Block is available in four aesthetic shades and two translucencies. Going off again your experience of, you know, 18-ish years, we have clinicians in Canada who are all over the spectrum as far as the integration of digital technologies and the use of CAD/CAM. We still have patient clinicians who prefer using analog systems 100 percent of the time. We have clinicians that want to use digital 100 percent of the time and everywhere in between. And as far as materials for the restoration, we have clinicians that are working primarily with labs, others who are working primarily in house. Do you have any advice to people who are just starting on this journey, which might be the easiest first steps to take preparing in preparing to, you know, innovate and modernize their practice? Yeah. I mean, first of all, get a scanner. Great place to start.
PS: Basically, next year, it’ll be 40 years that we’ve had CEREC available. So, if you don’t have a scanner right now, you’re 40 years behind. It’s as simple as that. And so, if you’re waiting for accuracy and all those things, well, we passed that a long time ago. There’s a lot of data there in terms of adding peripherals, like, if you want to do a chair side milling and CAD/CAM, we have so many different materials that are available to us. I would start with a great lab. That’s how I did it. I mean, I haven’t stopped using my lab. My chair side or my in-office workflows are an adjunct. My labs aren’t local. They are in different provinces and even in different states, but we collaborate together. There are times where they’ll do some designs for me and some of the materials that I choose to use with them, they will provide for me, but some of the times they will actually design, send me the files and I’ll produce them on my mill. And so, it’s just figuring out how to work with them effectively and to optimize the care for the patient. One thing that is handy is patients do like convenience, and if you can provide them a restoration fairly efficiently in one appointment, they appreciate that. And so it’s not hard to incorporate this in today’s world, definitely not 15-20 years ago, there were a lot more challenges, but I think it’s a lot easier to incorporate CAD/CAM and even printing. These technologies are pretty well tested. Workflows are quite smooth and easy. They are designed to be user friendly.
LS: You mentioned a really great lab and finding a partner to work with in your lab. I mentioned to a lot of the clinicians I work with locally, that regardless of how you take your impression, the lab is working digitally. There are so many things that the lab will scan the model. Even if you made it in the analog way, that model is being scanned, you cannot avoid it. Just a matter of where it is being scanned, in your own office, in the patient’s mouth, in a way that’s so comfortable and easy and much less gag reflex, the patients can have a beautiful view of that model, digital model you created for them. I think they find it extremely interesting to see, or you just let the lab do it. But the technology is being used, whether you choose to use it in your office or not.
PS: Right. Yeah, absolutely, like you know, majority of people, if you look at the data, I mean, the majority of you know, big labs, their restorations are ceramic, like a very high percentage, as opposed to metal, probably well over 80 percent. If you want to have something like that, they’re manufactured digitally. It’s as simple as that.
LS: Yeah, and the artistry of their work is still there, but they’ll start out with the digital design. What applications would you feel most confident in using your CAD/CAM systems with?
PS: I use it for almost everything. I mean, the only thing that I might have some limitations with is depending on some full arch cases and depending on the lab that I’m using, because if the lab doesn’t have that experience with some of the newer materials, then it becomes a challenge. So you’ve also got to work with people that are comfortable with what you’re trying to do.
LS: We were talking a little bit about being able to delegate some of the steps in fabricating your lithium disilicate restorations. For your average restoration, how much time would you calculate yourself or your team members are spending investing on the fabrication of a restoration?
PS: You know, that’s a great question. So, like, right now, to keep things simple, I’m not doing anterior restorations, like definitive anterior restorations, because I just don’t. My labs are so good with the ceramics that I choose not to do that. So, I’m focusing more bicuspids posterior when it comes to that, as long as it’s, you know, it’s not incorporated in a, you know, big smile makeover, where high end esthetics is important, that it’s not really a lot of time, because I can send the restoration to the mill. Once the milling is done, my system will go in there, cut the sprue off, start polishing and probably take, I don’t know, within 10 minutes they could have everything done. I’m kind of guessing, because I don’t really worry as much about it. I have two dental assistants, and one of them does it, and then the restorations there, and then they’ll go through like I’ve taught them. And we have checklists for the protocol of how to condition the tooth, you know, with hydrofluoric acid and with, with your, how do we forget that right now? Your silane, and so they take care of all of that. For me, I calibrated them to make sure that they understand it. We’ve got some videos for them to follow, and that’s what they do. So, when I go in to deliver, everything’s already set.
LS: It sounds like you have a very smoothened out workflow, where you start the case, then your assistant takes over. There’s a minimal amount of time that the patient is staying in the chair, waiting. You, in the meantime, are caring for another patient, doing paperwork, doing whatever other responsibilities you have, and you return for the second phase and invest another small amount of time in that.
PS: Right. So, if we’re doing it same day, yeah, I end up blocking off 50 to 60 minutes. I don’t always have to use that amount of time, but I just do, and I just tell the patient, you can step out for a while. If you want to run an errand across the street or something, or if you want to just stay in and relax in the chair, you can do it. You know, part of this whole thing of incorporating CAD/CAM and same day dentistry is you want it to be efficient. You want it to be productive, but you also want it to be as minimally stressful as possible. And to try and cram it in and just nail it down to every five minutes, like, I get it but at the same time, like, why stress out the team if it takes an extra five minutes here and there, you know? And I used to worry about that back in the day when I was doing it; it’s like, oh my god, we’re wasting time. We’re wasting time. Well, you know, overall, it’s still efficient for the patient, and as long as you’re productive in some way on the other end, while you’re waiting for the milling and everything, yeah, it works out well. But it hasn’t been cumbersome training my assistants, because one of them is right out of school. She’s only been out of school less than eight weeks, and the other one I trained her out of school. She’s been out for just over a year, and she’s doing a great job, like she really is. It’s not hard. They just have to be willing to just take a little time to learn.
LS: That sounds like it’s a really fun journey for the whole dental team, not just the dentist involved.
PS: Yeah, for sure, I haven’t incorporated like staining and glazing with ceramics right now, because I want to incorporate it. You asked about how to incorporate it. Well, I want to make traction and make it comfortable and make the workflow comfortable for the patient, for my assistants, and also for the admin. Because how do they schedule? They need to know how to schedule it. So, if you come in and you want a same day crown or same day onlay, here’s what you get. If you say, hey, you know, I don’t have time for all of that. Can you do it and, maybe, can I come back tomorrow? Sure, let’s figure that out. And so we give them those parameters. And, ultimately, I didn’t want to start the staining and glazing with ceramics in the porcelain furnace until I got this dialed in really well, and probably in the next few months, we’ll add that in, and then we’ll get someone to come in and train on some staining and glazing and firing. But I chose not to just bombard everything, because I think you just need small victories. And after 33 years, you know, you start realizing one of the big things when you’re incorporating some of these is making sure that you minimize stress for the team, because it’s easy to go to a course and then all of a sudden, go, hey, let’s just do this. And everyone’s like, Oh my God. Now, how do we do this? And what happens? Everyone gets stressed out. You fall behind. Something doesn’t work. The schedule gets screwed up. And I’ve been through that.
LS: It sounds like there’s a good bit of versatility on exactly how phase A of prep impression and Phase B of delivery can be scheduled. And having that versatility is comfortable for everyone. It’s great for the patient not to have to be dealing for, you know, days or weeks with a temporary. You don’t have to worry about temporary cement materials, the temporary being lost, teeth shifting. There are quite a few advantages to making this, as you say, a same day or next day, or whatever variation or spin you might put on that.
PS: For sure. And the nice thing about like, look for indirect like, when I’m using my lab, I’m doing a lot of lithium disilicate, like, through the lab, milled, pressed, all of that. And I want to have a comparable material. We already know that it lasts a long time. So, the fact that it’s pre crystallized, and if we can get a really nice polish, you’re using an appropriate polishing system, and you’re following all those steps. So, I can still, in one appointment, use the GC LISI blocks. And because it’s fully crystallized, I don’t have to worry about firing it at all. And I can pick an appropriate shade, and I can, you know, provide a really nice restoration that I know once bonded in is going to last.
LS: Yeah, We see other materials on the market, let’s say in the world of additive dentistry printing, that are used for similar functions that you’re describing, inlays, onlays, the occasion, and they just don’t have that scientific, now time-tested evidence of strength.
PS: No, and you know what, that’s going to be a challenge for all of us. I think no matter what, we’re not going to have the ability to have those testings. Sadly, I think we’re going to be testing it. And, yeah, we will be. And the thing is, so we look at some of the material categories, we look at some of the strengths, and I try and look at it and go, Okay, well, you know, we’ve got lithium disilicates, and we know we can get strengths of 500 plus megapascals when we’re bonding it anywhere from 4 to 500 unhealthy enamel. We’re not getting that with some of our printed materials, but they’re comparable to, let’s say, the older Empress materials, where they’re like felspathic materials. So, if I’m going to use some of those materials, I’m going to pick and choose my occlusion, I’m going to pick and choose the size of the restoration, and I’m going to be just a little more cautious with how I put them in. But it’s not going to stop me from using it, but I’m going to pick the right parameters, yeah, for the materials. And I think that’s the big thing, is just understanding that we don’t have to be pushing limits. I think we have so many great materials, even milling that, you know, some of the printed materials, they’re great. Just be cautious with it. Don’t just go and just dive in and use it haphazardly. Like, even with the GC blocks, like, the strength comes from using like, bonding to enamel, bonding to healthy, to structure, not bonding to an old amalgam underneath there. Like, pick them the right way and use them the right way, and you’re going to have success, but if you cut corners, it’s going to fail. And it’s going to fail not because of the material, it’s because the operator is not using it properly.
LS: Dr. Shah, it’s been an absolute pleasure chatting with you about ways to streamline and make our practices efficient and fast. And just really great, great technology to be incorporating into our practices.
PS: Appreciate it very much, Luisa.
LS: And to our listeners, thank you so much for joining us. Be sure to subscribe on Spotify and follow us on social media to be notified every time we post a new episode. Keep brushing up!