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AUDIO - Josh Brower - HSP #98
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VIDEO - Josh Brower - HSP #98
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Josh Brower, DDS discusses changes over the past two decades, the truly digital world we live in now, and the predictable (and not-so-predictable) future.
I graduated from the University of Minnesota in 1997 after receiving a health professionals scholarship from the US Army. I spent 2 years while in school training with specialists at Tripler Army medical center on Oahu, 2 years training in Germany, and 1 in Louisiana prior to receiving an honorable discharge and entering the regular world of dentistry. I worked in public health, then as an associate, owned a solo practice for over a decade in a rural community, and now own multiple rural and urban practices with multiple associates working with me. I focus my dentistry on dental implants, surgery, and orthodontics and have spent a lot of time designing dental implants, teaching about them, writing journal articles, and helping others make it through the road blocks I encountered along the way.
www.smilesforsiouxland.com
browerj@gmail.com
800-516-7631
Howard: It is a huge honor for me to be interviewing a rock-star in dentistry. I mean, dude, you are crushing it. How many offices are you up to now, Josh Brower?
Josh: Well, I currently have two offices and I'm remodeling our third office so we can consolidate and get back in there.
Howard: So you're at three offices, then?
Josh: That's actually right now, but we're going to back to two once the big remodel is done in one of them.
Howard: And you're in Sioux Falls, South Dakota?
Josh: And Vermilion, South Dakota, yes.
Howard: Did you say Vermilion?
Josh: I did.
Howard: Vermilion is the border of the mouth, right? The lip? The Vermilion border.
Josh: That's correct.
Howard: I wonder why I city got named Vermilion; Vermilion means something else.
Josh: I don't know, their bird is the tanager which is also red, so maybe.
Howard: Interesting. That's where my Grandma Mary was born, in Sioux Falls, South Dakota.
Josh: Really?
Howard: Yes. Small world. She was born in Sioux Falls, South Dakota, and so was my grandfather, and then when they got married they moved down to Parsons, Kansas. Then my mom and dad were both born in Parsons, Kansas and moved to Wichita, Kansas so I haven't been up there. South Dakota is one of the most beautiful states ever. I mean, you've got Mt. Rushmore, you got the, what's the big Indian carving out there?
Josh: Crazy Horse.
Howard: Crazy Horse. That is a crazy huge project. I mean Mt Rushmore is probably only, what, 10% of the size of what Crazy Horse is going to be?
Josh: I think it's something like that. They don't work on Crazy Horse too much but the actually have walks and hikes around Crazy Horse, it's so big.
Howard: Do you think that it'll eventually be finished?
Josh: Not in my lifetime, I don't think.
Howard: It's just a massive, like I said, it's ten times bigger than Mt. Rushmore.
You are an amazing person, and I love your online CE course on Dentaltown that you put up.
Josh: Well, thank you.
Howard: What was the name of that? 21st Century Update to Crown and Bridge.
Josh: Yep.
Howard: Do you want to start with that? Tell the viewers what that's all about. That was an amazingly awesome course, I thoroughly enjoyed it and so did thousands of other people. Tell us about that.
Josh: I had graduated almost 20 years ago, and I have not seen any kind of an update book that's come out with anything with the new materials, how we're doing things. When I got out we were doing a lot of cast metal frame partials with surveyors, and flexible partials didn't exist, we didn't have zirconium. Implants were kind of just for the elite few that could afford them, and I wanted to do an update based on, the dentists that I have working with me now that are older showed me their typodonts from school, and I saw a huge difference from their typodonts to mine, to the new ones that you can go and buy today. What I did was is kind of did a comparison contrast between the materials that were around in the early 80s, to the 90s when I got out, to now, and then how you can apply all the different materials, and use of implants in that to kind of bring everybody up to speed with what's available.
Howard: Do you want to go over some of that right now?
Josh: Whatever you'd like, Howard.
Howard: I think that guys like you, been out 18 years, who are over-achievers, I mean, there's the average dental practice that's 500,000 a year, it's one dentist, two assistants, a hygienist three days a week and one receptionist, and then there's rock-stars like you out there, really intense people. First of all lets talk about the most common crown is the first molar. It's the most likely crown to be sent to a lab, it's the most likely tooth to be missing for an implant, what is your bread and butter first molar crown, and walk us through your technique.
Josh: For the most part I probably would be doing a zirconium crown just because I think they hold up well, you don't have to over-prep the tooth, you can use knife-edged margins, they hold up well in the mouth, and a lot of people just don't want the appearance of gold or can't afford it anymore. Five, ten years ago, I would have said PFM every time, and depending upon the person I used to have to have an occlusal table made in metal, now I could just go all white BruxZir, and a lot of those have an overlay on them, and the BruxZir crowns actually have different hockey pucks, if you've ever seen how they mill them out, and those are becoming poly-chromatic, or very different colored, so you can get ant to your teeth now done in a BruxZir or zirconium crown that in the past you had fewer options.
Howard: Now, a BruxZir is a brand name for Gildewells, does that mean you use Glidewell lab on these?
Josh: I don't actually use Glidewell lab for my single crowns, but I do use them for all of my temporaries. I am in love with the Glidewell Biotemps, and their transitions. I'm not sure if you're familiar with those, but they're ...
Howard: It's a whole separate lab from Glidewell, when you go to LA the Biotemps is a different building.
Josh: Well then that's the lab I like.
Howard: They're huge into temporaries. So you use them for temporaries for multi-unit cases?
Josh: I do. The majority of my work is probably multi-unit cases, and I think that whoever is the actual lab technician that's creating the Biotemp is fantastic. Really good artistic skills. I've tried a couple other labs, never seen anybody that can produce the same kind of anatomy results, occlusion, just everything is really nice with those. I think they have up to a two year warranty. Frankly I've got some elderly patients who can't afford porcelain, and they'll just say, "Well, you know what, I'll have you make me a new one in a year, two years if it breaks, and I'm just going to keep going with that." So they get a nice smile that doesn't require them to go to a denture right now, and based on their health maybe it will be with them the rest of their life. You never know.
Howard: The best think about old age, is it doesn't last very long.
So, let me stop you there. Labs will tell you that 96 out of 100 impressions that come in is for one tooth at a time, and you just said that the majority of yours are multi-unit cases. Why do you think that is?
Josh: I think a lot of it goes into the initial conversation with the patient. Howard, when I first heard you talk, you told this great story about a patient telling you that you just wanted to make the payment on your house and that's why you were offering that treatment to him, and you told him no that's not true, because my house is paid in full.
I never forgot that, and when I do a case, a lot of people think that they're trying to do dentistry in the best way possible, but we all know we're not doing it for a hobby. It is a business, and you've got to treat it like a business, or your business will run you. When I go in there and do the conversation, the first thing is I'm hear to help you. You came to me. First, how can I help you, and then what is your budget. What is it that you can afford to do. Then we will find a treatment plan that works within your budget that will get you as close to your goal as possible.
Most of those patients say, "I want a better smile," "I want to be able to chew." On my entry form I have a very detail list where they actually grade themselves as a patient, from 'I want emergency care only,' all the way up to 'I want comprehensive cosmetic care.' When I look at that entry form I know immediately what my conversation is going to be like before I enter the room, and then it's a matter of find out what their budget is, and after I know their budget, I'm just going to give them the plan that fits within their budgets, and then I'm going to give them maybe one or two higher than that and tell them, "If you can go a little bit further, we can do this for you."
A lot of my patients make comments saying they want the tire repair man, where, "I just need this tooth patched for the third time underneath my crown," and I just tell them, "Well, you've spent this much on your first filling, this much on your second, this much on your third, you're almost to the price of a crown. Why don't you just get the crown this time?" Then, if there's some other teeth that look similar to it and it's within their budget, I just start talking to them about their whole mouth, complete comprehensive treatment planning, instead of just doing the minimum so they can walk out the door again that day.
Howard: I hear this so many with the large practices where they transition from one tooth dentistry, then their journey is to quadrant dentistry, then their journey is to full mouth. How long along your eighteen year journey did it take you to transition from one tooth dentistry to case dentistry? What low-hanging fruit along the way, for some kid that's been out of school for five years listening to this, they're not even 30 years old, they just fix what's broken and shows up, how does a dentist transition from one tooth dentistry to comprehensive care?
Josh: That's a great question. I feel that I had a really, I don't know if I'd say unique, but a really good comprehensive dental experience. I was one of those military scholarship guys, so I went into the military to do my repayment after.
Howard: What branch?
Josh: I was in the Army.
Howard: And how many years did you have to pay them back? 4?
Josh: 3.
Howard: 3? For the Army.
Josh: Back in the day, before they coined the term stop-loss, it was very difficult to get a scholarship. There was three of them, and since it was so hard, they basically said, "You can go anywhere you want to go because there's only a couple of you." So I said, well, I'll go to Hawaii. I went to Hawaii while I was in school for the two summers that I had left, and then when I got done, they said, "Where do you want to go?" and I said Germany. I wanted to be right in the center of Europe so I could travel all over really easily by car.
Howard: Were you married or single?
Josh: I was married. I moved over there with my wife, and had one child at that time, had another born in Germany, and then a couple more now, back in the States. I did a couple years there, and then I did a year in Louisiana. I went from only specialist in the clinic in Hawaii, to multiple clinics in Europe that I got to work in with lots of specialist and new young guys like myself, and there you don't get to refer anybody out. They just tell you, "We don't want to do it, so you have to do it yourself." You pretty much get thrown into, you have to do everything, even if you don't feel comfortable with it, and if you get stuck someone will come help you out, but otherwise, you're not going to get any help, not until you're completely stuck.
The last place, in Louisiana had about 27 dentist, so that's when I really learned that most of what I learned in dental school was just wrong. I could walk from one chair to the next and see that one of these guys was doing it completely different than I had, and was doing it better and faster. I was fortunate enough to share an office with a guy the same age as me who's since gone on to become an endodontist, but fantastic clinician, who every day just showed me something new that made me want to do the best I could.
So I got a really good education, but I wasn't getting to do a lot of crowns at all because we had a prosthodontist everywhere. That was kind of prosthodonstic work. Wasn't doing any partials. The military is kind of that patch dentistry, just get them out so they can go back to fight, and that's it. I was really good at restorative dentistry, but I wasn't well educated in comprehensive care.
When I got out I went into public health, started up a clinic with a friend who wanted some help, and then after that, went into private practice in a more rural community, and there was more, just your bread and butter. Like that practice you were talking about where you've got four chairs, you've got one hygienist, one receptionist, one or two assistance, and that's kind of just the grind every day, and I just didn't like it.
After about ten years of that, I finally decided that every day I went to work I wasn't happy because I was doing the same thing. I really wanted people to come to me to make themselves happy, not because they were coming to me because they were in pain. So, I decided to switch the way I practiced. I had been well trained in implants and done some, but I wanted to start going into full-mouth therapy with implants and more comprehensive treatment planning. I went and did some more coursework in mini dental implants. Since most people don't want to do those, I didn't have a lot of competition, so people started to come in to see me for some more affordable therapies, some salvage solutions that hadn't been available before, and it just kind of kept growing from there.
I think if I can get someone's trust doing something that works for them, in their budget, then they tend to ask me to do the rest of the work, then they tell all their friends. The ref feral basis is really good.
Howard: Do you only do mini implants, for the most part?
Josh: I don't. I think that a lot of my friends who do mini dental implants only do them, but between me and you Howard, not that anybody's listening, I do both kinds. I think there's indication for large diameter implants when you shouldn't really use a mini implant, and I think the same is true. I think there's a lot of indications for a mini implant when you just can't use a large one: if the space is too small, if the bone's too thin, if the patient's not capable of undergoing grafting, or health-wise they can't support having a flap raised on them, I think the mini implant is the way to go. I think if you need some additional stability, you have support quality bone, you need to have some time with healing, I think conventional implant is the way to go there. I frequently mix them on my cases.
I know, in my opinion, there's too many dentist who believe only one or the other is the right way to go, but really thing that both camps are right. They're both the right way to go in the right situation and it's just your own clinical knowledge, skill, and training, that will tell you which one is best for you.
Howard: I do think the young experienced, untrained mind, is, everything's binomial. It's left, right, up, down, black, white. As you get older, you see that it's not black and white, it's fifty shades of grey, and if you sit there and say there's no indication for mini only root forms, you're kind of an extremist freak, and if you say you only use mini root forms you're an extremist freak, and smart, intelligent people know that there is fifty shades of grey. There's absolute indications for minis, and there's absolute indications for root forms.
It's funny because when I got out of school, do you realize when I got out of school in '87, the few people that were placing implants, it was mostly blades, subs, they were considered freaks. I mean, you would go to a course in '87 and people would lean over and whisper, "That guys a nut job. You know what he does? He puts bars into the ramus. I mean, the guy's a nut. Stay away from him, he's a butcher." They used to call them butchers. People that placed implants in '87 were usually called butchers behind their back. Isn't that amazing? I've gone from blades, to subs, to root forms. It's just titanium. There's a hundred ways to skin a cat.
What time of mini are you placing? What type of root forms are you placing?
Josh: I use a couple of different brands of each, I could use a couple of different diameters of each. The minis go down to about a 1.8mm diameter, and they stop just shy of 3 millimeters, and that's based on the FDA's approval initially on root form implants and what sizes were which. I guess, I use probably, I started out initially with a lot of 3M, the M Tech product that was made by Dr. Syndecks, and there's some really good clones. They call it a predicate use, if you go to the FDA and look up the forms, so if you check out which ones have a predicate use, that means that those are FDA approved based on this other implant that looks just like it.
I've used probably 8 or 9 different brands. I think right now I'm placing some intralock implants. I think that the collar, if you will, on those is very nice. I think they have cementable abutments, which some people really like, which nobody else has. I think that the fins, or the cutting threads, are really wide, but if I had someone that had very thin bone, maybe it came to a sharp point, I would use a Park Dental Research implant. They have a really wide collar, so as it goes down and it hits that thin ridge, it splits it just like an ossiotone and stops. It's almost just like an implant and a bone spreader at the same time.
Then, for the root forms, because I already own the surgical kit, just like most people, it gets expensive to start switching to other things. I do like the OCO Biomedical large diameter implants. They have a very nice design. To be honest, I helped design their macro implant, which is a 6 by 6. I really wanted something that would go under the sinus, but was still wide enough, because in the upper posterior maxill[inaudible 00:18:29], you have usually some pretty good width, but not a lot of height in most cases, and I wanted an implant that would go in there. I helped them come out with that, and they've even improved on it since it initially came out. I guess I use a wide variety, but my favorite phrase that I tell the patients is that if you come to see me, I can walk in the back and show you over 90 sizes and brands of implants, so I will fit my implant to your bone; I'm not going to graft you and force you to fit the one I already bought that's in the back that I don't want to go out and spend more money to buy another one of.
I think that people get a little bit guilty of that, as they, you know "This is the size implant that I want to do, so I'm going to make sure that their bone fits it," and I think that in most cases as long as the load is supported prosthetically, you can go ahead and just place the implant that will most fill their bone.
Howard: Well said, and what percent of your implants would require bone grafting?
Josh: Well, because I do, I would say, more than 50% of the implants I place are minis, so that means that in almost all of those cases there would be no grafting, so I would say in my practice I probably do 5% of the implants that I place are grafted, and some of those would be, if I take out, let's say, a central incisor and I want to place an immediate load implant, well we all know that is kind of a triangular shaped root, and I'm going to put in a circular shaped implant, so I might add in some graft material, just around the sides and back to speed up the healing process, get the integration going a little faster.
As far as do I have to graft to gain width before I put the implant in? That would be pretty rare for me. If I have to graft to gain width, the only time I would probably do that is if prostheticaly support-wise I could not get minis splinted together to work.
Howard: To do this have you gone from 2D radiographs to 3D, the CVCTs; are you doing this off 2D or are you using 3D?
Josh: I like the Ewoo brand, but out by Vatech. They're the largest cone beam manufacturer in the world.
Howard: Vatech. That's V A T E C H or C K?
Josh: C H.
Howard: V A T E C H, and are they out of Korea?
Josh: They are. Ewoo is their brand, and in America they're sold under VatechAmerica.com. I also have an i-CAT, and some of it is the software that you like to use. I use TX Studio with the i-CAT, which I think is a nice software, it allows some good planning. You can extrapolate your pan from the cone beam, whereas the Ewoo that I have is called a Duo, so it has a sensor for the pan, and it has a sensor for the CT, so it's just like a digital sensor. It's one second and the digital pan is up.
Howard: Spell Ewoo?
Josh: E W O O.
Howard: So you have two different cone beams?
Josh: Yes, I have different ones for different offices. I'm a big believer that ...
Howard: So you have two because you have two offices.
Josh: Right, but, I do have ...
Howard: You're remodeling a third.
Josh: Yes, and I do have two of the Ewoo pans and one just happens to also have the cone beam in it in one office. When you're behind it's nice to not have to wait for someone to get done taking their film.
Howard: How much did this Vatech cost? How much did the i-CAT cost?
Josh: I picked up the i-CAT from Renew Digital. I think they're a really good company to work with. They basically ...
Howard: So it was used?
Josh: Yes, it was.
Howard: Renewed Digital. Is that their website, too? Reneweddigital.com?
Josh: It's just Renew, R E N E W, Digital dot com.
Howard: Renew Digital, where are they out of?
Josh: I know the tech that installed it more than anything, he's from Georgia, but I don't know exactly where their company's located, because I think they take them in, refurb them, and ship them back out, but he was an i-CAT technician for many years and ran his own mobile unit. Right now, I think most of the large manufacturers that want to sell you a new cone beam have someone trade it in to Renew they will refurb it and resell it so that they can sell the newer one.
Howard: Do you ever see used stuff on the Dentaltown classified ads?
Josh: I have seen some used stuff, but every time I've looked into it, it's already sold.
Howard: I think one of the most hidden jewels in dentistry is, people think that Dentaltown is message boards and a magazine, but the classifieds are rocking hot. There's so many people that made a $100,000 decision and went and changed their mind for something, and you can get a used ...
So Renew, that's very ... and i-CAT, who makes i-CAT?
Josh: Well, Henry Schein is the US distributor for i-CAT ...
Howard: And were are they out of?
Josh: Henry Schein is nation wide, so ...
Howard: No, no, no I mean i-CAT.
Josh: I can't think of that off the top of my head right now Howard.
Howard: How much did you pay for your Renew Design i-CAT, refurbished.
Josh: There's a number of different, I don't know if you have a cone beam Howard but I'll give you the ...
Howard: Yes. I've got the Carestream.
Josh: Okay. Well, the Kodak Carestream is a good machine, but the support is difficult. I've had Kodak products in the past, and when they sold off a certain division I had a tough time. The majority of the used cone beams available are Kodaks, just so you know right up from. There's an 8000, a 9000 series, but the images are beautiful, just beautiful. So, I did a fair amount of research on it. I got the, I believe, it's the 14-bit with the faster capture rate, and I think when I had it delivered, installed, everything done, I was probably into it 55 to 60,000 dollars for that one.
Howard: On the i-CAT?
Josh: I did.
Howard: And what would that have been brand-new?
Josh: Oh, I know they're over 100,000, they're well over 100,000.
Howard: Good job, Josh.
Josh: Yep.
I bought the Ewoo first, and I did buy that brand-new, and that's a duo, so it has an 8cm square CT on that, and it also has the pan. I think I paid, this was back when everything was going to hell and a hand-basket, about 2009, so ...
Howard: So that was the meltdown.
Josh: They just said "If it's a cash offer we'll pretty much take what you give us," so I think I paid, brand-new 92,000 for that. A lot of people, in fact I talked to someone today, who said they didn't see a return on investment with the cone beam, and I think it's like a lot of new technology. Some if it is going to pay for itself quickly, and some of it will never pay for itself. I don't think cone beam is something you can afford not to have.
Howard: Meaning you can't afford not to have it because you're using it to place implants.
Josh: Not only that. Yesterday I was in my Vermilion office, and we had taken a pan and this patient said, "When I bite down on this lower right molar, sometimes it hurts, sometimes it doesn't." The hygienist had already gone and checked around, she said, "Well I didn't really see anything." I said, "Well, patient's complaining about it, let's take a PA."
It looked a little bit radiolucent on the pan, but there's a lot of artifacts. We took the PA, and it looked like maybe there was a little bit of widening of the PEO, maybe there was something in the furcation, but again it could be an artifact, it's hard to tell. As Gordon Christiansen said, "This digital stuff, you see a lot of things that just aren't really there." I said, "We took a pan that we had extrapolated out of that CT, let me go back and look at the CT." I go back and look at the CT and it's completely fractured, both roots horizontally. He's had endo[inaudible 00:27:04] on it, so he doesn't feel it. The roots are just shifting when he bites a certain way, and all the buckle bone's gone on it, and I get the patient and I show him. He goes, "Jeez, doc, I need to get that thing out of there. Can you put an implant in for me, because I know another root canal isn't going to work."
It went from me having a conversation of trying to tell him that I wasn't sure what was wrong, maybe we'd have to look at it, to "Wow that's really bad, can you get that out, and give me an implant."
It's one of those things, people believe what they see, and it's easy to show somebody something and have them ask you to fix it, instead of you telling them that you want to fix it. That's a lot of where my dentistry is at. It's a matter of having people ask me for things, instead of me asking them to do things.
Howard: That patient right there, what would you have done? Would you have pulled that? What tooth number was it?
Josh: It was 31.
Howard: So a second molar.
Josh: Yep, lower second molar.
Howard: So would you pull that, and place an implant, one appointment? Or would you pull it, bone graft, go back later? Tell us specifically how you would do that.
Josh: That's a great question. I love that question, because my staff even ask me that, "Are we going to put an implant in this thing today?" I work for my patients, and I just tell the patient, "If you have to have x, y, z done, I will do that for you. Here's the associated risks with it." I can tell you that I've placed plenty of implants within extraction sockets, molars included, the day of, and I've had success, and I've had failure. A lot of it, in my opinion, is mostly based on the patient's willingness to care for the spot.
Are you familiar with 'PRF,' Howard?
Howard: PRF?
Josh: Platelet rich fibrin?
Howard: Oh, yes. Where you draw blood and centrifuge it?
Josh: That's exactly right. So we've always had PRP, but if you centrifuge it at the right angle and the right speed, you can get that third layer in the center with the white blood cells, the stem cells, growth factors, all those kinds of things in there. What is nice about that layer, is you can actually compress it into a membrane, and it will grown into anything you need. If it's by bone, it grows bone. If it's by skin, it grows skin. It's white blood cells, it's not going to get any infection. It will grow in the worst possible conditions. Unhealthy patients, patients that won't clean their teeth, it's just like magic juice.
What I like to do in case is, let's say they're a grinder, like this patient was yesterday. I know that I need to be more cautious, and stress to them that they need to be more cautious, and that they should allow me to not load this thing immediately. That's an indication for me that maybe I would take the tooth out, and because I can see there's a granuloma in between the roots on the film, maybe clean that out, place a little graft with the PRF over the top of it, so now I don't have to use my old periodontal dressings, I don't have to do anything like that. I don't have to buy any expensive dermal grafts and sew it in. PRF, it's free. It comes right from the patient.
I would sew that in there, if they would let me, and have them back. Usually five weeks, the skin would be completely closed, and look like I'd never been there. At that point I feel pretty confident that if I use a two stage implant, or a more conventional implant, where I'm going to place it inside where the patient can't bite on it, get primary closure, if possible, or at least get the healing cap where they can't touch it, I feel pretty confident that I'll just let that sit, and the implant will heal at the same time as the graft.
Now, someone else they're saying, "Doc, I gotta have this tooth, I don't care if it fails. I'm going to be careful with it; I'm going to follow all your rules." If you try to place a conventional implant, sometimes you can get one root that's big enough to slide it in the mesial or the distal, if you can get the right angle. It's not very often.
You can put a mini in each of those roots. The mini's go up to almost 3mm, and that's just about the diameter and width of that apex on the lower molar, so you can get good primary stability with a mini on each of the roots, and that's usually the protocol. You need to have at least two minis if you want to put a molar on them. Sometimes on the uppers I've even done three. I saw a guy do four one time, but I think he was just doing it to do it. If they said they had to have it, I would take out the tooth, clean it out, I would place a mini in each of the roots, and I would probably graft with some PRF, and I would put a temporary on it that was tight to the tissue that day, and leave it out of occlusion a millimeter.
It goes from minis and immediate loading that day with a higher risk to as low risk as possible going with the conventional two stage. I'm not the guy that's going to tell them, "We're going to wait six months after I graft it, open it back up, place the implant. Then we're going to have you come back three months later, we're going to open it back up and torque test it." I really don't do that, and I think my patients turn away from people who say they do, because they frankly just don't want to wait. They want it now.
Howard: No, they want it yesterday.
Josh: One thing that is kind of unique to the way I offer my implants, is I truly do believe it should be based on what's the right thing for that patient and you. I price too many implants as the same price as one conventional implant, if it's for a molar, so I kind of base it per tooth instead of an implant. If I can use one mini for a smaller tooth, let's say a lower incisor or something, it's the same price as if I place a conventional there, and if I have to use two minis to get a molar in the back, it's going to be the same price as if I place a conventional there.
The pricing is such that they pick strictly on what's best for the, and it has no financial consideration at all. I think that lets them have a lot more options.
Howard: I want to ask you another question. What percent of your implants do you use surgical guides, and what do you think of surgical guides? When are they indicated, when do you not use them? It's a very controversial subject. Some people say, "No, you don't use surgical guides, that's like putting training wheels on a car. You need to learn how to be a surgeon, you need to learn how to lay flaps, see the bone." Other people are saying, like Jay Reznick, an oral maxillofacial surgeon and an MD, and he says, "No, use surgical guides every single time because if I freehand it, I'll be right 97% of the time, but I don't want to send an implant back to a referral that 3% of the time is not perfectly drawn."
So, talk about surgical guides. Do you use them?
Josh: You always cut right to the point, and I like the way you get into that controversy. There's another group that's a private group that I'm involved in and it's called Implant Masters, and there's a whole bunch of talk going on this week about surgical guides: who sells them, how to make them, what you need to use them for. It's exactly what you said, some people say, "I've got to have it every time," other people, the ones that usually stay silent are not using them.
Todd Shatkin has a really unique patent, and not everybody's aware that it's even offered. He's a mini implant guy, and ...
Howard: What's the name of his company? He's in New York.
Josh: Yep, it's Shatkin First.
Howard: Shatkin First. And Shatkin is mostly mini implants?
Josh: It is. They do sell the interlock brand, and they can get you the larger ones, but Todd, I think has done over 13,000 mini implants and he's got the same success as with conventional. I asked him one time, I kind of put him on the spot, like you're doing with me, and he said, "I place maybe 2 conventionals a year." He said if that's exactly what they want, that's what I'm going to give them, but 2 a year, if you've done 13,000, that's a lot more minis.
Howard: What kind of surgeon was his dad? Was his dad a ...
Josh: His dad was a oral maxillofacial surgeon, a plastic surgeon, and I think he had his MD as well. He's the one that actually got Todd into placing the mini implants. Todd tells this story of how they got some in the mail, and his dad said, "Hey Todd, I think we really need to try this and give it a shot," and it just kind of kept going from there.
Howard: I love Todd. I've been in his office, he's got a whole conference room, teaching ...
He's an intense guy.
How often do you talk to Todd?
Josh: At least once a month, sometimes once a week ...
Howard: He'd be a great podcast, too. Will you tell him we need to do a podcast? Me and Todd?
Josh: I will.
Howard: Go on with what you were saying about surgical guides, and what was the group, you were saying, you guys talk about this, implants what?
Josh: It's a private group on Facebook, it's called Implant Masters, and I was in another group, I'm in a number of different groups, and one of the guys was mentioning something about his other group, and I went over there. He sent me an invite and it's people that strictly are placing implant cases only. The nice thing about Dentaltown is that it's a free-for-all. Everybody can comment, everybody can say what they want, but this private group, like a lot of the private groups you see on Facebook, they do it because that's where you see a lot of people post a lot of their failures, and say, "How do I fix this?" Whereas some guy who believes you got to use a surgical guide might see on Facebook, or on Dentaltown, and say "Hey, you failed because you didn't use a surgical guide," and he really just wants an answer on why the implant failed, not why you think I did my case wrong.
Howard: That is exactly why we started the private groups on Dentaltown last year. All of Dentaltown, you can start a private group there too, where one guy starts a private group, and only that person can let you in or not. For that reason, for sharing ...
Josh: I'm also in the American Orthodontics Society, and I just went into their private group this week and actually answered some questions from some people that don't have a lot of experience. They were asking kind of early questions, and I ....
Howard: Was that on Dentaltown?
Josh: Yep. Dentaltown. It's called AOS Connect, and it's through Tom Chapman with the AOS. What he'd asked is, he hadn't got a lot of people joining it because I didn't know it was there, and so he sent me, I guess Dentaltown agreed to send out a link that said "Here's the group, please sign in, if you didn't know it was there." I signed in, and sure enough there were questions, so I started answering them right away.
Howard: So who sent you the email?
Josh: Tom Chapman I believe asked someone at Dentaltown to resend that email, because he said it was started a year ago, and I think they sent that email then saying, "Here's our group, click on the link and join," and then the people who didn't click on the link that day never even knew it existed.
Howard: I've been very bad at marketing those private groups. I wonder what I should do to market that feature better.
Josh: Put something on the homepage. Just what you just told me,"Hey, we've got private groups, where you can start your own group," just so people know what they are and you could do it.
Howard: Go back to surgical guides, though.
Josh: I actually learned how to do mini implants from Todd in 2006, and he's one of the inspirations that made me want to change the way I practiced. Todd's got this patent that he doesn't really taut or teach about, but it's really cool. You send him off your models, he will make you a surgical guide, send you the pilot drill, the implant, and the crown, at the same time. You use his guide, you drill the pilot hole, you take it out, you put the implant right where you put the pilot hole, and you cement the crown all at the same time.
Howard: Wow.
Josh: It's totally cool.
Howard: That's his lab, right? In New York?
Josh: That's his lab and his patent. He's the only one that can do it, so it's really cool, and I've done it. It's one of those things, I had to prove it to myself that it would work and I could do it.
Howard: Has he or you posted a case like this on Dentaltown?
Josh: I know Todd doesn't post because he's just so busy, but I don't think I've posted the case that I did. I have it completely written up, pictures. It's actually published in a journal article. The American Orthodontic Society, because they're all general dentist, asked me to do a two part series. The first was on how I was moving teeth with the mini implants, and then restoring them after I was done moving the teeth with them. Then the second part was actually kind of a lot of what I went into with the crown and bridge update. I have pictures of that published in there, and I can rewrite up the whole thing for you if you'd like to see a post.
Howard: Hell yeah. I call cases like that dental porn, stuff you've just got to see.
Josh: I had to do it, it's one of those things I did it once, to be honest, I myself have used that surgical guide and never another. The reason is that I had a very comprehensive oral surgery training. I've flapped everything that there is to flap, and I know where the bone is, where the vessels are, so I feel very confident.
Now, I think there's always a case to flap something, but had an oral surgeon teach me a little trick, and it's called a trapdoor flap. It's about a quarter of an inch wide, and an eighth of an inch release buccal lingual on both sides of it. You flip it open like a little trapdoor, and you peel it back, and you can look in there and see what you need to see, and stick a probe in and feel where the bone is and concavities. That's the exact size of the hole you're going to cut for your conventional implant anyway, so you essentially get primary closure with a flap, but there's no stitches or anything. When I get those knife edge ridges that really come to a sharp point, that's what I'm going to use, that little trapdoor.
But, I would say 99.5% of my implants are placed with no flap, and I did over 500 last year, and I've done just thousands and thousands of them. For me, it's about not taking away the blood supply so I get good healing of my implants, and every time you pull that skin off that bone you tear away its blood supply so then it takes a lot longer for it to heal, and if you have a poor healer, you're going to have a lot more issues after the fact.
Surgical guides I think are very useful for people that don't have as much experience, or they don't have the ability to understand how to prosthetically load in certain areas of the mouth. I would never tell anybody not to use one, and I would tell everybody who's never placed an implant to use one for sure. If you don't feel confident, don't do it, and I think that goes true for anything in dentistry.
I, myself, feel very good about the placement of the implants. I just posted on that Implant Masters. It was the same day they were all posting surgical guide pictures, but I didn't tell them I free-handed it, but I showed them the CT from all the different directions. What I tend to do is tip the implant within the bone so that it comes out right where the prosthetic is. I have never used a custom abutment, I just know where I'm going to restore it, so that's where I'm going to place it.
Howard: I want you to talk about this, Josh, in South Korea, where they make Vatech, where they make Medigen implants ... is it Medigen?
Josh: Yes, it is.
Howard: Medigen, Vatech, Samsung, LG, all that, they have 20,000 dentist in South Korea, and 15,000 out of 20,000 place an implant every single month. Then we jump across the pond and we're in America, we've got 120,000 general dentist and 95% of them have never placed 1.
Josh: Yep.
Howard: What do you think about that? I mean, why do you think 95% of dentist have never placed an implant, and in South Korea 3 out of 4 placed one last month.
Josh: You can say in one word. It's fear.
Gordon Christensen said at a lecture one time that one in six dentist gets sued every single year, and whenever you have someone that's will to say you did it wrong because it's not the way they would have done it, you've got a fear of prosecution. How are you ever going to get started in something if there's someone that's done more of them that's willing to say that you did it wrong?
Howard: Isn't that just kind of the ego, because, I drive my car, and I've got 4 boys driving cars, and I don't worry about getting sued because I have car insurance. If someone wrecks the car or crashes or whatever, I have insurance. The insurance companies should worry about me wrecking the car. I have fire insurance on my house; I don't ever worry about my house burning down, or paying for that because State Farm should have to worry about that. I have malpractice insurance, and I'm doing the best I can, and if I get sued, my malpractice should worry about it, I shouldn't worry about it. I think they're so afraid of getting sued because it's against their personal ego. It's like, how can I be a good dentist and upstanding in the community if I had a complaint at the board or got sued, and that's just crazy, isn't it?
Josh: I think it is, but I think, especially in the rural communities ... I'm here in the mid-west where we have a lot of towns of just a couple thousand people, and if there's two dentist in town and someone puts it in the paper that you got sued, your practice will suffer. It's a financial thing for them. But, I think you're right. It's all ego. It shouldn't be that way.
When I was in the military, you can't sue anybody in there, and everybody was very appreciative that you were even helping them. I've seen a lot of different things, and I helped defend 2 dentists last year who were having potential lawsuits against them for implants.
Howard: Okay, Josh, I'm listening to this podcast, I've got my Dentaltown app on my smartphone, I turn it to Bluetooth, I'm listening to you on my car radio, and I've been out of school ten years, I've never placed an implant, I've decided I want to place an implant, give me your advice. What's the first thing I should do? I've got to walk 10, 12 steps before I get to the second floor where I'm like you. What would step 1 be? I've never placed an implant and I'm driving to work right now.
Josh: I love that question because I get asked it quite often. The first thing I say is, do the upper first or second pre-molar every time.
Howard: Upper instead of lower, because lower you're concerned about paresthesia inferior alveolar nerve, big boo-boo. Is that why you picked upper?
Josh: Well, yes. You're not so worried about the vessels and the nerves, but in the lower you can also have quite a bit of a curvature, almost like a banana shape to the lower mandible as it goes to the back, and if you go straight down you could easily perforate and go straight through the inferior bore to the mandible, and not even know it, because you're in solid bone til you're 8mm down, then it takes a 45 degree bend to the buccal, and if you're not experienced, you won't realize that the mandible curves that far back in the mouth. Whereas, the upper, it pretty much stays. You put your finger on either side of that maxill it's going to stay right in the middle.
Howard: My first one, you're saying upper molar ...
Josh: Upper pre-molar.
Howard: Upper pre-molar, okay. So now you don't have to take out the sinus.
Josh: Yep, I'm not worried about the sinus, I know I've got plenty of bone, and you can place a mini. In almost every case you can use a mini for a single pre-molar.
Howard: Would you want me to have a CV, a 3D? I don't like CBCD, it's too complicated. Would you want me to have a 3D x-ray?
Josh: If it's your first one and you're nervous, I would use a surgical guide that you did of off CT and ...
Howard: Do I have to buy one used, or would I just need access to one? Like, in Sioux Falls. How many people live in Sioux Falls, South Dakota?
Josh: I think with the urban population probably about 250,000 now.
Howard: So does a town of 250,000 have a third party 3D radiograph place that you can send a patient, or not?
Josh: There isn't. I've offered anybody whoever wants to just to use my machine, to come over and use it, but I've never had anybody take me up on it.
Howard: I know. Dentists are so funny. Every time I meet a dentist who's in a medical dental building with five other dentist in the same building, they've never gone to lunch with any of the other dentists once in five years. It's like are you shitting me? Are you kidding me? And same thing with CBCT, I don't know a single periodontist, or oral surgeon, or endodontist, that has one that wouldn't let anybody bring a patient over and take one, because they're just dying to meet you. They just want to be your friend.
And no one's ever taken you up on that? That's hilarious.
How would this dentist in Sioux Falls, on their first implant, and doesn't have the CBCT, and really doesn't want to buy one yet, because they don't know what they're doing, how would they get a CBCT?
Josh: Well, we could go back to Todd Shatkin for a second. He only requires a panorex. So, if you send him a model and the panorex, he will make you a guide off of the bat. So if you don't have a CT, don't have access to one, you could still get a surgical guide from Todd. He would do it for you.
Howard: What's his W W W?
Josh: It's shatkinfirst.com.
Howard: Will you spell that?
Josh: S H A T K I N F I R S T .COM
Howard: Is he any relation to William Shatner in Star Trek?
Josh: I have to ask that, but as far as I know ...
Howard: So back to that first one, maxillary bicuspid, first or second?
Josh: I would say either, but if I got to pick, I'd go for the first because you know the bone is longer right behind the canine. If you decided you wanted to go, let's say a 15mm implant, that's a fairly good length. I think you could ...
Howard: Let's back it a little bit further. I want to take some courses on this. Would you recommend starting online, hands-on, what training would you recommend specifically?
Josh: If you want a place, or you want to learn?
Howard: A place.
Josh: If you want a place, I took my first course from Todd when he was working for 3M, the Mtech corporation, and I think hands-on is the way to go. I've taught the course for the mini implants for OCO Biomedical, and a lot of the guys that come to the courses have never placed one, but they're interested. I think that if you can take out a wisdom tooth, or take a tooth out surgically, you absolutely can place a mini implant. I think that you need more training to place a conventional implant, because of things like grafting, knowing how much bone you need around the implant, things like that. So I would say start with a mini implant, do a hands-on course where you actually get to drill the hole, place the implant, see the feel, use the tools. Then pick a nice easy case and if you're still concerned, I would have Todd make you a surgical guide, and follow it.
Howard: I want to ask, it's kind of a difficult question, because I know it's comparing apples to oranges, no way you can really compare, but if this dentist already extracts teeth, what kind of teeth that I'm already extracting would be an indicator if I could be doing implant dentistry? Do I have to be good at wisdom tooth, or partial boning wisdom teeth, or full boning wisdom teeth, or just like, taking out a first molar? Is there any comparison that you can think of that if someone told you what they're oral surgeon skills are, you could say, "Oh dude, you can absolutely do implants.
Josh: When you say implants, I don't think there is a difference between mini implants and conventional implants, conventional with grafting, and surgically guided, and all those things. To answer your question in a simple manner, if you would bill it as a surgical extraction, instead of a simple extraction, you could place a mini implant, in my opinion, with some training. I think you need to be able to possibly take out a difficult surgical extraction, if you're going to do a conventional implant. I think that you should do a course in grafting, maybe, bone and tissue, if you're going to do complex conventional implants.
Howard: That was well said, I've never heard anyone put it that eloquently, that if you've billed out surgical implants ... That's a clear way of explaining that.
Josh: So many times I've taught this course, I helped start one of the mini implant groups, I've got all those credentials and all the different implant groups, and what I can tell you is that the majority of the people that come still haven't placed an implant after they've come to one meeting, if they've taken the courses. It's sometimes hard to get people to get that little bump to actually pick their first case, so I'm always the one telling them, get that upper first pre-molar. Then, if they said, "Well I've got some conventional implants around and I've never placed that either." I said, "Well, you take out a tooth right? There's your hole. You can't really hit any vessels or nerves, because there's your hole. Put it in the hole. Close it up."
They find it that, you kind of get a little bit of that light in their eyes when you say, "Well, you've already created your pilot hole, you already know there's no vessel, there's no nerve for you to hit. All you've got to do is screw the implant into the hole that you just made. Do it for free. Get your next door neighbor, do your best friend. Do it for free, let them know it's the first one you've done. Be up front about it," but how can you mess up something where you already have 100% experience in taking teeth out. Why can't you just screw something into the same hole that you just took a tooth out of.
Howard: I want to switch gears completely away from clinical, and go to non-clinical. So, you're in a town of 250 with a dental office, and then up the street how far in Vermilion, you have another office.
Josh: Yep.
Howard: Then you're remodeling a third office.
Josh: Right.
Howard: Where's that at?
Josh: It's also in Sioux Falls.
Howard: Now, are these associate dentists employees, or are these partners?
Josh: They're associate dentists employees, but only because they choose to be. I am very open to any kind of relationship that people want to work with me on, because I prefer the group model. I like talking to people I like to share knowledge, and I don't want to tell anybody what to do. I'm sure, Howard, you have a lot of employees, and you're funnest part of your job is not telling people to do things, it's actually just being with those same people that you enjoy employing.
Howard: I really feel strongly about my thoughts on group practice. Whenever you see a dentist that's complete burned out, drinking a bottle of Listerine a day, eating 20 Vicodin. They're always alone and burned out and fried. When you walk into a group practice, and there's like 3 dentist working together, it's just so much more fun. I couldn't imagine practicing alone. I think of decades of my life, like for a decade walking every day and working with these dentists, even when they leave to go set up their own, they're still my football buddies at the bar and drinking.
Dentaltown was all about no dentist practicing solo again. I saw my 4 boys going to bed at 8:30, and then I'm sitting there worrying about this tooth, this case, or whatever, and when I saw the internet, I was like, "God, I just want to show someone else an x-ray or a picture." I am a firm believer in group practice, but I don't know if I'd want to marry one, because when you get married to someone, you're having great sex, and children, and kids, and holidays, and that fails half the time. Do I really want to marry a dentist with no social glues of sex, and children, and holidays, and vacations?
You said you're open to it, but you've never done it.
Josh: No, I have done it.
Howard: Oh, you have done it.
You did marry a dentist?
Josh: I did. This is a great way to explain it. The associates I have right now have owned their own practices, and did not like the stress. They both have more experience than I do. I think one of them has 25 years and one has over 30 years. They are revitalized because they have a newer, younger dentist to come in and do all this new stuff that they're not used to.
I started up and office, and I had a partner who had been out of school maybe 2 years. I know you're a lot better business man, your dad included, than me, Howard, but one of the things I always live by in the business world is you have to know how you're going to break apart a business before you ever form one. So, it was really well laid out exactly how we would separate if it didn't work, who is going to be making the decisions, how they were going to be made.
For a number of reasons, that I'm sure you've all heard a million times, it wasn't working out, so I pulled the trigger, and said let's separate this thing, and we went right down the list. Now, the only thing that happened is he didn't like the list that we had initially created, so he didn't want to settle, he didn't want to take his portion of the practice and we ended up going to mediation, and in the end, we did it exactly the way it was in the document because to fight it any other way was going to be more expensive for both of us and I think that's the key.
I know a lot of dentist who've had associates, partners, and failures, and it's been a really bad bad experience for them. I think that if you're up front right away, and just say "Hey, if you get in a car accident tomorrow, we need to know how this is going to break up," people can get it. I think it's just how you lay it out to begin with that matters.
Howard: What you just heard Josh Brower say is he had a prenuptial agreement, and if you're going to marry a dentist, have a prenup. If you're going to marry a spouse, have a prenup, and when you say it to your spouse, or you say to your partner, "I'd like a prenup," and they flip, if that ain't your first red flag, you know.
If you say to someone, "I want a prenup," and they flip out, if that's not your first indication to run. The second indication to run is when you go on a date, and they don't even pretend to try to pay. If you're a rich dentist, you're going to end up paying, that's okay, but they should at least fake it. They should at least reach for their card. If they don't even reach, they're playing you like a fiddle.
I've only got you for 1 and a half minutes, and I wish I had you for longer, but I want to switch gears again, there's a huge segment of the people that say your CAD/CAM, the Serona, a closed system to where you have a Galileo's, it's talk to your CAD/CAM to make a surgical guide, and then on the other side of the fence is what you're doing, is an open system, where you get an i-tech, and i-CAT, a Vatech, an open system, whatever. You went with the open system, there is a closed system. Why did you go open format versus closed. Why did you go i-CAT and Vatech as opposed to staying in one company, a Serona, and doing a closed system?
Josh: I think probably the same reasons that you do a lot of things, it's that if you're a good business person, and you should be if you're going to own a practice. You have to look at, why would anybody close the system? So they can charge you to un-close it. So I looked at it from a standpoint, do I want to get into bed with somebody, a $100,000 investment, and then they could charge me every time I want to print or email my PA out, or they want to charge me for a bridge that only bridges to their system. I think when you go with a closed system, it's nice for them to financially recoup their investment to develop that machine for you, but I think that you just get more and more entwined into those companies and it becomes so financially impossible to get out of that relationship, that they can make the price anything they want and you're just stuck.
Howard: And on that note do you use CAD/CAM?
Josh: I do. I have a TRIOS, which is probably the fastest scanning system out there. It's made by 3Shape. My practice, I'm very busy, so I don't have time to take the image in the mouth, and I honestly don't have time to train my staff to take the image in the mouth. What I do do is I quick take the impression, I scan the model, and then I email that thing off to the lab, and I just get back my crown.
Howard: So you're not milling in your office?
Josh: I'm not.
Howard: You're taking an optical impression of the model?
Josh: I am, just because of time. I could do it in the mouth, but I just don't have time.
Howard: So when you prepare a tooth for a crown, you take an impression, polyether or polyvinyl?
Josh: If it's a full mouth reconstruction, multiple units, I'm going to use polyether. If I'm going to use, like an implant, for example, where I have an analogue, I'm going to use polyvinyl because I don't need the accuracy because I'm just going to put the analogue in the impression anyway.
Howard: So you use polyether imprint gum by 3M ESPE ...
Josh: Yes.
Howard: But if it's implant then you'll use a polyvinyl siloxane?
Josh: Well, if it's a full arch, then I'm still using the 3M polyether, the imprint gum. I've used that, I love the panavex[inaudible 01:01:48] machine, I mean, I've got to buy two more bags of that stuff right now. I know they're 250 bucks a bag, and they're worth every penny because you can push through blood, it's like a tractor in a blizzard. It's what I want to get me through it. That's my go to, any difficult impression I'm going with the imprint gum, and anything that's a slam dunk I'm' going with the polyvinyl.
Howard: Which polyvinyl are you using?
Josh: I use the generic stuff for the most part. The Henry Schein brand.
Howard: Henry Schein generic?
Josh: Yep. I have some special markets pricing, and I think that it's the same price as anything I could order online through the other place.
Howard: What's the special markets pricing? Because you're a group practice?
Josh: You know, I don't know. I think Patterson has what's called a gold member, it just means that if you buy a significant amount of things you get a discount on it. It's kind of like Costco, you're going to buy in bulk so you're going to get a better price.
Howard: Well, I can not believe we went past an hour, it's an hour and 2 minutes, we're out of time. But I just want to say that dude I think the world of you. I think your online CE course crown and bridge, if you're listening in your car right now, you've got to watch Josh's online course. You're definitely what I call the thousand points of light in dentistry. You're just out there in the front, and I just want to thank you on a Friday afternoon, of all the things in the world, you spent an hour with your buddy Howard in Phoenix, and thank you for an hour of your life and your time, and I can't wait to see you again.
Josh: Howard, you're an inspiration to me, ever since I heard you speak the first time, I've tried to live my life more like the way you told me to that day, when you were yelling and screaming and swearing at us all. SO, thank you, thank you very much.
Howard: Thank you buddy, and see you around, see you on the boards.
Josh: Thanks Howard.
Howard: Bye bye.
Josh: Bye bye.