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Howard Farran:
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It is just a huge honor. I can't believe I get the god of dentistry on. First there was Pierre Fauchard out of Paris, then there was G. V. Black and you are absolutely the heir apparent of both of those gentlemen. Gordon J. Christensen, DDS, MSD, PhD. I don't need to read your bio but I will in case there's some kid that was just born in a cave.
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Gordon Christensen is founder and Chief Executive Officer of Practical Clinical Courses, PCC. Chief Executive Officer of Clinicians Report Foundation, CR. And a practicing prosthodontist in Provo, Utah. Gordon and his lovely wife, Dr. Rella Christensen, are co-founders of the nonprofit Clinicians Report Foundation, previously named CRA, which Rella directed for many years. Since, 1976, they have conducted research on all areas of dentistry and published the findings to the profession in the well known CRA Newsletter, now called Clinicians Report.
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Gordon's degrees include: DDS from University of Southern Cal; MSD, University of Washington; PhD, University of Denver, and two honorary doctorates. Early in his career, Gordon helped initiate the University of Kentucky and University of Colorado dental schools, and taught at the University of Washington. Currently, he is an adjunct professor at the University of Utah School of Dentistry.
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Gordon has presented thousands of hours of continuing education globally. Made hundreds of educational videos used throughout the world and published widely. Gordon and Rella's sons are both dentists. William is a prosthodontist, Micheal is a general dentist, and their daughter Carlene is a teacher.
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Basically, he's a member of every numerous professional organization there is.
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Gordon J. C.:
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Too many.
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Howard Farran:
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If you can think of it, he's a member. I'll read a few. Gordon's a Diplomat of the American Board of Prosthodontics; a Fellow and Diplomat of International Congress of Oral Implantologists; a Fellow in the Academy of Osseointegration, American College of Dentists, International College of Dentists, American College of Prosthodontists, Academy of General Dentistry, Royal College of Surgeons of England, and an Associate Fellow in the American Academy of Implant Dentistry. Some of his other memberships include: American Academy of Esthetic Dentistry; International Association of Dental Research; Academy of LDS Dentists; American Academy of Restorative Dentistry; American Academy of Fixed Prosthodontics; Academy of Operative Dentistry; and International College of Prosthodontists.
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Gordon, you are ...
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Gordon J. C.:
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Too many.
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Howard Farran:
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I've told you several times, I got out of school in 87 and I was kind of lost clinically, and I made 12 ... I figured since all the muslims go to Mecca and Medina, I would go all the way to Provo where every good dentist goes on their journey. I think I went up there 12 times and you rocked my world. I mean, you rocked my world.
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And another dentist who went with me to all 12, was Mike DiTolla and he still credits you for basically lighting his rocket. You could talk about anything. I want to start ... This is Dentistry Uncensored, and I love you cause you've never been politically correct, no one's ever owned you. You could throw any company you wanted to under a bridge, and they all knew it.
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So, Gordon, so help me out on some of these decisions. I can take a 3M SV [inaudible 00:03:02] for $17 and send it to my lab. 3M also makes a scanner for $17,000. I just graduated from dental school an hour ago with $350,000 of student loan debt. Should I use the $17 3M [inaudible 00:03:20] or the 3M ... What's the scanner called?
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Gordon J. C.:
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Okay. Let's talk about digital scanners for a few minutes. The 3M's not dumb, you know that. They make some of the best impression material on the earth. They are extremely popular. They're either number one or number two in impression material sales. So, why would they make a scanner? And they've had it now for several years, I've been in on a lot of the preliminary development of that, just as a consultant. They now have the lowest cost scanner.
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Let's just look for a minute at how you make a crown. There's three ways to make a crown as everybody who's listening to this understands. You can do it the conventional way where you prep, make a conventional impression, physically send the impression to the lab, the technician makes the crown, and you seat it on the way to the appointment. That would be right now, according to data from Glidewell about 90% of the dentists send impressions, or digital into their huge lab for which they do about two million crowns a year. That's a ton of crowns.
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So, 10% are scanning and sending it in. There, you prep, you scan the impression, you send the impression to the lab by email, one click, the technician makes the crown, you seat the crown on a later date or if the technician was close to you, you seat it on that day. Which, I think is really the future. I think eventually dentists, and there are 40% of them now, who are either corporate or in a group practice and that 40% are with somebody else, so why not have a little room somewhere, a 12 by 12 foot room, with a [inaudible 00:05:04] machine. You pump the button on Monday, I'll do it on Tuesday, and 20 minutes later, you got the crown in your hand. That seems to be a logical thing.
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But, we're seeing in that second alternative I just stated, the prep scan impression and quick it off to a lab, about 10% of the impressions come in to Glidewell, which represents every state in the union and most of the provinces, and a lot of other countries.
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Then you got the third level, which you know well, and that is prep, scan the impression, and mail it in your own office. And that's only in approximately 10,000 dentists right now, out of 141,000 general dentists. So, that has not made a major impact over the 31 years it's been around.
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Now, what scanners ... by the way, interrupt me any time, what are the advantages of scanning? Since only 10% are doing it, there must not be an enormous amount, or 90% would be doing it now. When the air rotor came on, everybody had an air rotor in six months. This has been around now, 31 years ... but it's been developing that long. And we have basically 10% of the dentists. What are the advantages? Yeah, you got a really large monitor you're looking at, and that monitor allows you to see that tooth preparation in detail that you never dreamed possible. Otherwise, you're looking at something the size of the end of your little finger. And therefore, the preps are better. It's a pretty dumb dentist who sees the regular prep in a large image and does not make it better the next time.
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There's not as much gagging, barfing, there's no impression to be on the patient, they're just sitting there, peacefully. The infection control is nonexistent because you click it in one millisecond and it goes to the lab, so there are no bloody cotton rolls and big pieces of phlegm on the impression, which you see. We just did a survey on that. How many impressions are disinfected by a dentist? And do you know what it was? It was pathetic, 23%. In other words, 70 some odd percent, are going in with every kind of organism conceivable. This would eliminate that.
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There's immediate transfer to the laboratory by one computer click, the accuracy is better, and depending on the business model, it can be less expensive. Can be less expensive. Now, what's happening with these scanners at the moment? There are six that are the most popular. And, I'm going to name those and we'll go through them in a little bit better detail: the TRIOS, last year, the 2016 in Glidewell data, which is the biggest lab in the country, that's why I use it as an example of the nation ... Glidewell increased TRIOS 266% in one year. That had the most advanced mid last year. Carestream, 76%; Planmeca, or what it's been called D4D, 70%; Cerec, 46%; 3M 31%, and iTero, owned by Cadent and Invisalign, at about 22%.
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So, all of those numbers are pretty impressive. And as you look at what has happened in the increase of scanner use, from 2012 to 2016, it's gone up, I'm approximating, six or 700% since that time, in those brief four years. Will it continue to go up? I think so. But I'm going to look at each one of these six devices with you in detail. They range from $17,000 to mid 40's, $46,000. $46,000 is a heck of a lot of impression material, as you would think. A full arch maxillary impression, done with a premium material, ranging around 60 cents a cc, would be about a $40 impression in the stock trade. So, all you got to do is divide $40 into $46,000 and you get some kind of idea of how many impressions you got to do.
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The typical general dentist does about 20 indirect units a month. That's 240 in a year, but most of those are done with a double arch tray, 70% of them are done with a double arch tray. The double arch tray does not require $40 for the impression, it's more like $10. So, again, if you're going to make that division, you see, it's quite a few impressions. We're not doing it for money purposes, we're doing it for the advantages that I mentioned previously.
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Let's just look at the negative of all but one of the six scanners. That doesn't mean the sixth one is the best, it just says all of them have these two major disadvantages, and I'm sure any manufacturer listening to this will agree. The camera end of the scanner is way too big. I would like to see it, and so would everybody else, about the size of a pencil. If it were the size of a pencil, you would have no trouble getting it into the first molar, second molar area. A typical person can open their mouth about three of their own fingers, that's about 40 millimeters. But as you go further backward, obviously you got a lot less space. In a person who's arthritic or a [inaudible 00:10:38], they're not going to get that big mother camera in there real easily.
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So, the camera is too big on every one of them, though the smallest one is the 3M one, the True Definition Scanner. The other challenge with everything but the 3M, is that they've got a huge pod on the rear end of them. And you tend to grasp these right about at the junction of the camera wand and the pod. And the pod would be four or five centimeters in diameter, and the length would be seven or eight, I'm guessing on that, but it's a huge appendage hanging on the end of this camera, which you know well.
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Now, is that negative? Yeah, it is with a small hand. I have small hands. Most females have small hands. And when you grasp the camera, you have your fingers toward the end of this pod and camera affair, and that makes this pod weigh it down on the wrong hand. It's pulling the camera up from the teeth. Well, as you look at these, all of them have this characteristic except 3M. How did 3M get around that? If they got around it, the rest should be able to get around it. But even their camera is about two to three times the size and diameter of a pencil. I would like to see it down to the size of a pencil. We've got all these microchips and all this exotic computer [inaudible 00:12:13] out there, why can't we get it smaller, for crying out loud? A Nikon camera, a Canon camera, has very tiny tiny microchips in it, and you know the sensitivity of those.
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So, everyone of the major sales brands, TRIOS, Carestream, Planmeca FIT, Cerec, and iTero have the disadvantages. I'm not trying to be negative, I'm just saying we're about like automobiles in the, I'm going to guess, 1920's to 30's. In other words, they work, but how is the automobile then, compared to where it is now? I see that same evolution going to have to take place before everybody leaps out and spends their $17,000 to $45,000.
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Now the True Definition, I've sounded very positive about that, let's get a little negative for a minute. It had a cart until recently, and most dentists to not want a cart. They have too many carts, now. We've got a cart for laser, we've got a cart for the new Sonendo endo gadget, we've got a cart for these gadgets, soon we won't be able to get our fat rear end in the operatory and walk down the aisle. So, most are liking to have some object either hanging from the ceiling, or sitting on the left or the right. And now here's another advantage of 3M, theirs is an iPad, their current one. That's only been a few months ago that they got rid of their cart at the suggestion of many us, certainly including me, I've harped at them for five years on that cart business.
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The ability to have a very small monitor is good. Well, it's like an iPad, same size. Given that orientation then of 3M is positive, with this exception, requires a slight amount of powder. And that powder many feel quite negative about because conceptually they think back to the original Cerec which was not a powder, it was like a snow storm over the teeth. Now, the slight amount of powder takes 5 to 10 seconds to put it on, it's an extremely thin layer, but because of the stigma on powder from many eons back, some are still negative about putting the powder on.
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And, I suggest to anyone of the observers of this podcast, to look very seriously at going to a major meeting and perusing the booths of these, at least the six companies that I've mentioned which are the most popular ones, and looking at those cameras, using them on models that the companies all have present, and see which ones turn them on, which ones do not turn them on. I feel strongly, I feel very strongly as a matter of fact, that it's not going to be many many months before the digital impression concept will take over.
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Here's essentially my suggestions, restorations made from digital impressions are proven to be more accurate, we were the first ones to prove that, than the polyurethane or vinyls. And patients prefer scanning when asked, "which do you prefer? Do you prefer the impression material or do you prefer this non objectionable stuff in your mouth?" They prefer the scanning. And negative, the devices are still exceedingly expensive. I'd like to see them all around $10,000 or less. Several years are required to make the return on investment of buying a digital impression device, and spending all that money and comparing it to the amount of impression material [inaudible 00:16:10].
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And in a positive realm, the cost of the device to make digital impressions is compensated by patient convenience, elimination of numerous steps in the laboratory procedure, and dentist satisfaction. I'd give this 5 to 10 years before most dentists, excepts geezers ready to die, are going to have a scanner. That's basically where I am.
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Howard Farran:
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So, impressions are 90%, scanned to lab is 10% at the labs and chair side, it's 10,000 of 140. What do you think of the ... what's your general summary of chair side E4D owned by Planmeca or CAD/CAM owned by Cerec, owned by Densply, Sirona.
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I mean, a lot of kids are coming out of school and saying, "Hey Gordon, you're a prosthodontist. Do I need to buy a $140,000 CAD/CAM from E4D, Planmeca or Dentsply, Sirona to be a good dentist? Do you think I need to go that route?"
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Gordon J. C.:
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I'm extremely biased, Howard. Because after 37,000 [inaudible 00:17:15], which is about what I've done myself, over the years, that's what my senior tag tells me. I've had relatively few real problems. We know that the margins of [inaudible 00:17:29] restorations don't even come close to fitting as did restorations made of gold. And well, we'll never get to that level because gold was malleable, you could varnish it down, finish down. One of the first research [inaudible 00:17:42] I ever did, I was able to get gold margins, type two gold, properly [inaudible 00:17:48] to one micron. The typical [inaudible 00:17:51] restoration at this point, we're in somewhere between 40 and 100 microns open.
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There is a significant difference there, though, in the cements. The cements of ages past were all soluble where the cements today are relatively insoluble. So, I'm not sure that that margin of opening makes much difference. The anatomical characteristics of the restorations of today, can make a pedestrian laboratory technician look pretty good because they don't have to have much dental anatomy knowledge. There's so many libraries now, you punch a button and it comes like mysterious image out of a cloud, so it's going to make it much easier for laboratory technicians to make an adequate anatomical characteristic.
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But, you're question, do you need to do that to be a good dentist? I'm very mixed. If I were a typical general dentist doing 90% single crowns, I would say no. As a prosthodontist doing many multiple crowns, it's even more of a no, because it takes me quite a bit longer time to do this, do that, do that, do that, do ... but, particularly, to scan an entire arch. Get the kind of basic cooperation without slobbering, and licking, and talking we're going through while I'm doing the scanning. It would augment the average dentist ability to make a good prep. It will augment their ability to have adequate, if not good, occlusion. But, you take the stud dentist, the real boutiquer, and they will do better with conventional methods. There's a candid opinion.
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Howard Farran:
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Okay. Switch from crown and bridge on natural teeth, to crown and bridge on implants. What do my homies need to know on implant prosthodontics?
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Gordon J. C.:
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What's happening in implant prosthodontics? That area is really on the move. I have had the opportunity to work with the Zests company over the last while with the ... all of the, you know, the Zest's locator, and you're all using locators. However, one of the major advancements in recent months, frankly, has been the advent of the holeless, now there's no holes, in a prosthesis for an edentulous case seeded over implants. And that, if some of you have not heard of it, it's not been popularized heavily yet, is the F, standing for fixed, -T-X. In other words, standing for fixed treatment.
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What the heck is that? I have been doing surgical implant placement now for 31 years. And, I have done many of the original brand of work, all on ... well, the original six, the All-on-6 extended from metal frame and forward, and from sinus forward. There were six implants placed and there were cantilevers then, about a half an inch long, that were placed distal to the last implant. And, they generally replaced about 12 teeth instead of 14 teeth.
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I've done many of those. And I've now watched them for 20 or 30 years. They have been relatively successful, however, many patients have complained of inability to clean, foul breath, the screws breaking, having to redo the resin part, the tooth part of the overall prosthesis, which is never advertised by the companies who promote these. It's as though you are going to get that tomorrow and you wear it to the funeral with you, when in fact, you don't. If we were showing pictures in this podcast, I could show you what it looks like in about 7 to 10 years. About 7 to 10 years down the road, the resin teeth are worn down, and the prosthesis is probably been taking off at least four or five times. I like to take them off once per year.
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Well, let's go back to where we were. The Locator F-Tx eliminates the holes in the teeth, the access holes for the screws. And that has been one of the most miserable and objectionable concepts of the whole procedure to me. Every year, get them in, take the plug out of the holes, find the cotton or plumber's tape, or ... by the way, there's a new material there, coming from Taub called Magic Liquid that makes filling that internal portion of the hole excellent, because you can just pick it out. It's an [inaudible 00:22:55] soft resin, you just stick in a little picker in there and pull it out.
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But, you would have to take the cork out of the top. Which is usually a [inaudible 00:23:03] composite resin, then take out whatever you put [inaudible 00:23:07] screw, then find the screw, and very often the screw was stripped, or was loosened, then you had to put a new screw in, which is $20 to $40, the patient is whining, they're sitting in the chair an hour, half hour. A half hour to take the thing off, another half hour is the laboratory cleaned it, then another bunch of screws, and more composite in the holes, so what an objectionable, miserable thing.
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So now, Zest with this F-Tx has no holes in it. If you have not seen it, I'll just describe it. I mean, if the viewers have not seen it. I know you've seen it. This has no holes in the teeth, no holes in the denture base, and it has a locator like attachment on it that has upwards of 20 pounds of retention for each one of the implants. You can not push that hard, you can only push somewhere between 10 and 25 pounds with your fingers, therefore, it's popped over one of those and then you move forward, pop it over the next one, move forward, pop it over the next one, and then finally, you get four to six, I still don't like all of four, I prefer All-on-5 or 6. If you lose one out on All-on-4, you're 20k in the hole.
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So, then, how do you get it off if it's got 20 pounds of retention on each one of those and you want to take it off in a year to see if everything's cool with the implants, and maybe to clean the implants, maybe to clean under the denture, how do you take it off? There's a hydraulic prosthesis lifter that looks like a balloon. A very tough, piece of flexible plastic that's placed under the pontic areas on each side, one at a time, one pontic one side at a time. And then you put some liquid in hydraulic pump and pump, pump, pump, pump, and that bladder inflates and pops the one side off. Then, you go to the other side, because you can't take it all off at once, and pop it off, now within, what, two minutes? You've taking the prosthesis off.
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The little balls that go down into the female part of the implant have been destroyed when you take it off, so therefore, there's about a $70 charge to get some new balls to put on the male portion of the prosthesis. And you have now satisfied a significant challenge in the past. I really objected to taking the screws out and replacing all of the prosthesis portion that went with it. That's one of the major jumps, since they're hyping All-on-4, so strongly now, I'm frankly a little negative. But there is some advantages to removable. I think any dentist who's doing this kind of dentistry knows what those advantages are.
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Well, let me give you the advantages of the Locator F-Tx. There are no prosthetic screws, there's no cement, the angulation correction is 20 degrees times two, because it moves both directions. This is stress free and passive fit. It's a very good solution for immediate function cases, if somebody's trying to do all in one day, which again, I disagree with, but that's my bias. I prefer to see a remote range where I can trust it. And it's removable by a dental professional. It doesn't have to be a dentist, it can be a hygienist, even be an assistant, it could be anybody who's trained to do this. So, I see some advantages to being able to do this without a problem.
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There are some advantages, however, to removable over an edentulous case. Let's go there, because that is about four to five times less expensive than screwing it down. If you screw it down, you're into 20 or 30 thousand depending on the ego of the dentist, per arch. If you put, say four implants in, and now I would agree with four. Because if one fails on removable, what is it? Put another implant in, let it heal for a few months, and attach it to the already present dentures, it's not a total redo. Let's say you put four implants in. And, you put standard locators or ERAs, or even spheres, balls ... By the way, there's a new sphere orientations from Sterngold that everybody listening in should know.
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You may tell them whatever brand of implant you're using, and what diameter it is, and then what length of a collar you want on the abutment, and they will send you return mail whatever it was you requested. Let's say the implant is one millimeter under the [inaudible 00:28:32] and you wanted to stick one millimeter above the [inaudible 00:28:35], tell them you want a two millimeter collar, and the ball on it. If the bone is only moderate rigidity, I would strongly prefer the balls to the more rigid attachments. A little rubber washer can be replaced for a dollar, and you can do that every 6 months to 18 months, depending on how rigorous they may chew.
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What are the advantages of doing it that way? Well, cost is number one. Because a typical American family making somewhere between 50 and $55,000 a year, can't afford a 20 to $30,000 fix. But they can afford a 5 or $6,000 one which would be All-on-2 removable. All-on-4 goes about $10,000. So, it's a significant difference in cost. They can take it out, clean it. They can have much better facial form because you don't have to relieve it significantly to allow them to put a pipe cleaner or water picker or whatever under it. So the facial form is [inaudible 00:29:44]. They have the ability if it breaks, to have it repaired in well, half hour and it's back in their mouth. And if an implant fails, you can add an implant by just putting it in, letting it heal, and attaching it to the base.
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That's probably the newest thing in the more complex implants supported prostheses. The secondary thing that has been extremely, I think, paramount changing, is not using abutments that you screw on and then cementing over them. You know as well as I, the screw comes lose on those about fairly often. As it comes lose, there's another pain in the rear. It's usually 5:00 right before a meeting you're going to, and they come in and say, "It's a little bit lose." And now you've got to figure out, did the dude who put the implant crown on that do it with provisional cement, final cement? Did they fill the hole down into the screw or did they leave some cotton, or [inaudible 00:30:56] or something in it? So, you never know. And you try to whomp it off, you break the crown, you know all the problems.
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So, right now, I would say candidly, that if the implant is near perpendicular to the occlusal plane, the standard of care ought to be screwing through the crown. Not making an abutment and attaching it to the abutment. Pretty obviously, that eliminates the cement problem, it provides ... when it does come lose, and I did a survey, American Academy of Aesthetic Dentistry recently, and I had them guess, guess, how many percentage wise of crowns cemented over abutments have come lose in their career? I got a very ... well, it's totally empirical, I got a number around 15%. That means that out of every hundred crowns you cemented, you have 15 of them you're in this miserable situation with. So I would caution dentists to get away from abutments.
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When, as I said before, the implant is near perpendicular to the occlusal plane, if it's sticking facial, and unfortunately I still see a lot of those. I deal with quite a few surgical specialists and some still have not figured out we want them to be perpendicular to the occlusal plane, if they possibly can be. So they're sticking out at various odd angles, as high as 45 degrees. I had one just recently almost parallel with occlusal planes. Sticking out like a coat hanger. Unbelievable.
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So screwing through. Let's say, it comes lose and you screwed through the crown, what do you do now? You pop out the cork on the top, and you find whatever's down in the screw hole, you take it out, you take the screw out, you clean the hole out with whatever, with phosphoric acid, Ivoclean, if it's zirconia, you can't use phosphoric acid but Ivoclean works. If it's not zirconia at all, I would use phosphoric acid. Then we'd wash it out, put a new screw in, torque it to 30 to 35 Newton centimeters, re-cork it, send them home.
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Howard Farran:
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This is Dentistry Uncensored and so I'd like to talk about the controversial things. One of the biggest controversial things in implant dentistry is to use a surgical guide or not to use a surgical guide.
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Gordon J. C.:
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No. Wow. Yes. Very, very, true. I made a video, by the way, a little hype for our educational programs, if listeners were to go to the website, very simple, P, like Paul, C like Charlie, pccdental.com, you would see enumerable educational possibilities for you. Among them, are many, many videos. We change videos as soon as they're out of date. We change courses. Every course I give, half of it's new every time I give it. The-
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Howard Farran:
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And I just want to say one thing about your websites. What I do for my guests, because my guests are listening right now, driving to work, I read ... those two websites you gave, I just re-tweeted your CR Foundation. So you follow @HowardFarran, about 20,000 do, I just tweeted your @cr_foundation and that has a link to your Clinicians Report, and then I re-tweeted Gordon Christensen which is @GoJChristensen, and that has a website. So if you're driving to work, don't worry, just go see my last two tweets and the last three were all Gordon's tweets.
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Gordon J. C.:
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You and Trump are tweeting all the time. Yup. Did you learn that from him?
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Howard Farran:
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No, what I like about Twitter is ... When you post something on Facebook, it doesn't go to everyone who likes your page. But Twitter, if you [inaudible 00:35:06] out 20,000 Twitter followers, you make a tweet, all 20,000 get it. So Facebook says, "We'll build up this huge following and then when you make a post, if you want everyone that follows you to see it, give us money and boosts your posts to all of your members."
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So I still don't know that Twitter makes any money because I've never given them a dollar in my life.
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Gordon J. C.:
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Yes.
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Howard Farran:
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How do they stay in business? I've never given them a dime.
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Gordon J. C.:
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I have no idea. I think they're selling marijuana and cocaine on the side, I think that's probably what it is.
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Hey, by the way, let's go back to this guided versus non guided. If we go back 30 plus years, when [inaudible 00:35:43] implants were introduced by [inaudible 00:35:44], out came his original All-on-6 orientation. And, everything was hooked together. In other words, some of them even put a bar across connecting the six implants together. There was no anti rotation feature, there was nothing there, and it was all by guessing the [inaudible 00:36:04], you felt it with your fingers, you palpated it, you used a ridged calipers.
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And, by the way, there's something your listeners really need to know. Numerous companies make ridge calipers. That's where it's like an ice pick, you put the thing on the ridge and go facial angle, facial angle, facial angle, facial angle, moving up. And you find out, "Oh, I've got eight millimeters there but there's one millimeter of gums on the front, one millimeter on the back. That means I really got six and that's enough to put a four millimeter diameter implant in." So, that was done routinely way back. That was the only way we had of judging.
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Subsequently, about 20 years ago along came tomographic radiographs. I did those for years with Instrumentarium, that's where you're putting in two implants, one in each canine area, you do one image, and one image. That was great, that was all I really needed. I don't need 750,000 slices of the head to know where I'm going. But, that satisfied me for about 15 years. I've had [inaudible 00:37:11] now 17 years, and I don't know how I got along without it. I guess we may want to talk about it in a minute.
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But the question is, how many of those thousands, millions, of implants were placed free hand? And the answer is, I don't have the answer. The answer is more than 95% of the placed implants freehand. I teach three implant courses in our course series. The first course is Simple Single Implants in Healthy People with Good Bone. What's good bone? Good bone would be six millimeters facial angle. It would be upwards of 10 millimeters in size of coronal apical, and if they've got that, any village idiot ought to put an implant in there. I think you would agree with me on that.
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Now, the second course gets into socket graphing, sinus lift, and some of this stuff that many dentists do not want to do. They would rather refer those.
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And the third one is, how do you restore all these things? So we got three levels of courses and I've had a hard time teaching not knowing whether to teach guided, which is all the hype now, or whether to teach free hand first. So I called a significant number of so called implant specialists. You would know every name if I were to mention them to you. I said, "Okay. What would you suggest if you were deciding in your elementary course, are you going to teach free hand or are you going to teach guided?" And, what do you think? Give me your opinion, because there is no right opinion, and what do you feel, Howard?
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Howard Farran:
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Well, I mean, every single person I know that's placed over a thousand, or 5,000, or 10,000 never used a surgical guide. And, you know, you got most of them are replacing the first molar. I mean, when you look at the insurance data, and you print out one to 32 teeth, it's the six year molars where us just got four huge spikes for all these crowns and implants. And you got a second bicuspid in front of me, you got a second molar behind it. You can put their head right in your lap. And you need to be a surgeon. Because if something goes wrong with that surgical guide, or where you punch into the tissue, you need to learn how to be a surgeon. You need to know how to lay a flap, check out the bone, repair, I mean, it's just ... if you're going to be an implantologist and you're going to use guides and just punch the tissue, I don't think you're ever going to be an implant surgeon.
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Gordon J. C.:
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Well, you agree with me completely. And with the majority of the people that I call. There is the fairly logical question, would it [inaudible 00:40:02] me if I was even afraid of blood? Well, they probably ought to not be doing it much anyway, but take that person who's really not done a lot of surgery, not extracted a lot of teeth, and all of a sudden they want to screw in the bone. That person is going to trust the guide.
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Can we trust the guide? If I'm putting an implant between canine and a central incisor, we have a lot of those in Utah's congenital defect, as you know, and usually, they've had some orthodontic treatment to move ... to make a little more space, and often, they tip the teeth this way instead of moving them bodily. So I wound up with an average of five millimeters between central incisor and canine. Five millimeters. I need six to really be comfortable. There's plenty of bone up to the nose holes and you can even approach them through the nose if you want to. But, say I've got five millimeters. Can I spare one millimeter, which is the average inaccuracy of a guide? No way. No way.
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Matter of fact, I did a video a while ago ... that's got me talking about videos. I did a video a while ago where I picked a case like that, one missing, one missing here lateral, and I did guided on one side, and free hand on the other. And recorded every step of both procedures. It was pretty interesting. Because, pretty obviously, the guided on one has the cost patient significantly more because I've got to send in a cast, or a scan. The implant ... well one of the companies we use is Implant Concierge in Dallas, and they're telling me only about 10% of their casts come in scan. In other words, 90% are sending an inaccurate, [inaudible 00:41:56] impression, poured in an expanding stone, you following all that? And expecting that to be accurate. Good luck.
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Even the scan will be slightly inaccurate for a full arch, but the typical scan, much of the research shows is off at least one millimeter with the guide. And the drill for a guided placement is 25 millimeters long or more, where the drill that you're using is standard for an implant would be half that. So how about that long lever arm? You're starting to drill the hole and if the lever arm is even off slightly, the tip of the drill is way off. So, I did that video, and it was really very interesting.
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To do it guided, I have to get on the phone, talk to the company, they then send me a prototype of three or four different alternatives, I correct one of those, and they send me the guide, and so, if I'm doing a rehab and I have to jerk a tooth and put an implant in that day, I can't do that. There are quite a few disadvantages. If I wanted to a lateral one incisor, if I wanted to go in and make an incision and push the soft tissue forward, it makes it a lot harder when I'm doing guided.
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When I'm doing unguided, make the slit angle, move it forward, put a typical temporary restoration on it, and create the [inaudible 00:43:27]. I see, right now, after thousands of implants that I've placed, there's a secret. Here's a tooth. Here's a tooth. Go down the middle. There's the secret. Put your fingers on the facial and lingual, when you're starting the drill. If the drill has vibration toward the facial move lingual. If the drill has vibration toward the lingual, which it won't usually there's the palate there, then you would go facial.
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So what was my decision in my elementary course? Do free hand because they learn more free hand. Then when they're starting to do multiples, three, four, five in a row, that's another story to help you with the parallelism. But even that, I can put one in, put a paralleling pin in it, parallel it with the next one, the next one, the next one, the next one. It's a moot point, but with the 90 some odd percent with having been done freehand, it's like trying to tell somebody they need some guidance to drive their car now. After they've driven the car a million miles. I'm obviously biased, I fully admit it.
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Howard Farran:
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I try to help ... I always do a transcript of the podcast so they're driving to work, all this will be on the transcript. Are we up to date on all the transcripts? That's good. And you mentioned Implant Concierge, so I just retweeted that for them. Implant Concierge, for everyone who's never heard of it, doesn't know anything ... Who's the CEO of that?
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Gordon J. C.:
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Implant Concierge?
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Howard Farran:
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Yeah.
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Gordon J. C.:
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I don't know.
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Howard Farran:
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Why do you use Implant Concierge? What is it? And what do they do for you?
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Gordon J. C.:
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Oh, okay. Implant Concierge, is one of many, many labs that will make a guided ... a printed guide, for you. A lot of dentists, in fact our next big research project next year, [inaudible 00:45:22] is to try to get printing into dental offices. I don't mean printing paper, which some dentists still feel what printing is. I ask often in a course, "Do you got a printer?" All the hands go up. They're thinking of a paper printer and I'm talking about a printer for occlusal splints, guided placement, the whole business.
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Implant Concierge is one of many ... The reason we use that is because one of the brands we use quite often is Implant Direct. Which, as you remember, Implant Direct, in the $200 range, has the implant, the cover screw, the abutment, the transfer coping. Whereas, you could pay $700 to some of the other companies for the same group of pieces.
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Howard Farran:
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We just podcasted the founder Gerald Niznick, a couple of weeks ago. It was a great podcast.
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Gordon J. C.:
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Yes.
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Howard Farran:
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He was a mover and shaker in implant dentistry, wasn't he?
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Gordon J. C.:
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Oh, no question. I worked with him ever since we were both in puberty, you know.
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Howard Farran:
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I thought he said ... I didn't want to laugh because I just loved Carl Misch, but whenever he didn't like anything Carl Misch would say, he always says, "Yeah, Carl keeps spreading Mish-information."
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Gordon J. C.:
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Mish-information. Well, we all had a lot of respect for Carl and I'm sorry he's in the grave right now. We're all going there shortly. It's a great opportunity to help people with implants. As I look back over in my career, there's several things that stick out. Very strongly is being highly prominent, one is the air rotor, of course. And everybody had it, as I said earlier, within six months. As implants came on, it frightened dentists, but one thing a lot of general dentists don't understand, the whole root form implant concept, and blades, and [inaudible 00:47:20], the whole business originated, not with surgeons. It originated with general dentists.
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The Alabama Implant Dental Study Club, people like Hilt Tatum, and many others who were general dentists. Hilt Tatum looked like an oral surgeon because he was a general dentist turned oral surgeon. But in the mean time, a lot of general dentists think, "Oh, this is way too hard. I have to be a surgeon to do this." Well, our grandparents are general dentists. They're not surgeons.
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Howard Farran:
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Well, what happened to Hilt Tatum, he was in Florida forever, then I guess he packed up and went to Europe. What'd he do? Find some little hollow-
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Gordon J. C.:
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By clear chance, I sat by him on an airplane recently. And I've got sitting right by my side a bunch of little ridge splitters that he gave me. He's older than the hills. He's older than I am and that's really old. And, he's still there. He's still doing surgery.
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Howard Farran:
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Do you have his email or anything? He's one of the legends. I want to podcast him so bad.
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Gordon J. C.:
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You should. He was one of the real movers and shakers in implant dentistry.
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Howard Farran:
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Do you remember how he used to teach sinus lifts?
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Gordon J. C.:
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Yeah. Yeah.
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Howard Farran:
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With an egg.
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Gordon J. C.:
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I know.
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Howard Farran:
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You would perforate the egg, and oh my God, he was just a legend. Where did he move to, France?
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Gordon J. C.:
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Yeah, France. Hilt Tatum. I'm just looking him up right now. Here it is. You ready? Hilttatum@yahoo.com. I'll repeat it. Hilt, his name, Tatum, all together, no dot there, at yahoo.com.
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Howard Farran:
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Yeah, just amazing. Where was he at? Was it St. Petersburg, Florida? Was that where he was at forever?
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Gordon J. C.:
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Yeah, yeah. He was with Dawson for a while.
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Howard Farran:
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Yeah, that guy's amazing. Alright, I know I don't got you for very much time because you got to run. But, next week, 6,000 kids are going to graduate from dental school. You know, they got a lot of student loan debt. And, there's a lot of high priced equipment. What're your views on lasers?
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Gordon J. C.:
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On lasers? I have been using lasers for 50 years. The first one I used was as big as a car. We were trying to fuse-
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Howard Farran:
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$50,000. I bought it, too. That was an expensive toy.
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Gordon J. C.:
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We were trying to fuse calcium carbonate onto tooth surfaces to seal the grooves. I mean, it seemed logical to me. And we melted the calcium carbonate. Fortunately, it was on extracted teeth, because all of the enamel bit off. That was my first adventure. And subsequently, I've had many, many, many encounters with lasers.
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There's some 20,000 of them in the US right now, give or take. Many of them had been made by one of our ex employees. There's a guy you ought to podcam, that's Densen Cao. He's an engineer, now has hundreds of employees in China. He's made most of the lasers in America.
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Howard Farran:
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Can you email me and him. Me, howard@dentaltown.com, and then him and introduce us?
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Gordon J. C.:
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Yeah, yeah.
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Howard Farran:
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To come on the show?
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Gordon J. C.:
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I'll give you his address. And, most of them are diodes. Of the 20,000 I'm sure Densen can give you better information than I can on the quantity right now.
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Howard Farran:
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Denson? D-E-N-S-O-N?
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Gordon J. C.:
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D-E-N-S-E-N.
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Howard Farran:
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S-E-N?
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Gordon J. C.:
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D-E-N-S-E-N.
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Howard Farran:
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And then Cao is?
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Gordon J. C.:
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C-A-O.
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Howard Farran:
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C-S-O?
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Gordon J. C.:
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C-A-O.
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Howard Farran:
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Oh, C-A-O. Okay.
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Gordon J. C.:
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Yeah. Okay. Now, this particular orientation of diode, is basically in the 800, 900 nanometer range and it basically is light going through that wavelength through a fiber optic bundle, and the light would do nothing. Nothing. Until, you put, as you know, a black piece of burnt cork or articulating color on the tip. So if you send light through this fiber optic bundle and it hits this black thing, what would it turn to? Heat.
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The diode laser's, basically, a large electrosurgery. A slow, large, electrosurgery. Making a cut, give or take, three quarters of a millimeter to a millimeter wide. Other lasers, not diode, but let's say CO2 as an example. One of the very significant brands that's now in that range for soft tissue only, is called LightScalpel. And it's in Seattle. I'm going to be off a little bit, 25 to $35,000 and that will cut a cut a half millimeter, quarter of a millimeter. Looks like a cold steel blade cut. That's the CO2 with a fiber optic bundle. Light, does in fact, cut. It's not just some large electrosurgery thing.
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There are three lasers now, three brand names, that will cut hard tissue undoubtedly more, but there are three well known ones: Fotona, Biolase, and Solea. We're just testing the Solea, the last one here, and this is a CO2 laser that, surprisingly, quite well cuts tooth. I have usually been quite frustrated with the length of time it takes to cut a tooth structure but just recently, on pigs in one of our courses, I was able to take this Solea laser and make incisions to lay a flap in seconds. And then changed the setting, and trimmed bone to do a crown lengthening. And then changed the setting, and cut a class five prep. All with the same laser with different settings.
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In about, I'd say that whole thing was, four minutes. So it's really changed. I can remember when we first were doing cutting of two structures with laser. My gosh, it was just a joke. Now, it's starting to look like it's somewhat viable. It doesn't cut a prep, it cuts a hole. You're used to a prep that would be relatively smooth, that would have a distinct cavosurface margin, that's identifiable easily. And now, it looks like a porcupine when you cut it, as you know, with a laser. There's little [inaudible 00:54:22] sticking out every where. There's no way, absolutely no way, the restoration can fall out because there's so many irregularities.
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We've looked very seriously at what happens to the melted enamel, which is what it looks like around the margins. Around the class two adjacent surface of the tooth, adjacent to a class two. Well, Rella, my wife, did some evaluation there, electro microscopically, and found we could bond to that just as well as we bond to enamel prisms. And maybe, maybe, I don't know this, maybe it's even more [inaudible 00:54:55] resistant to have that enamel all fused together. I don't know that. But, it's an interesting question.
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Now, at this point, should a dentist have a laser or not? Like I said, there are only some 20,000 out of 141,000 general dentists. Should everybody have a laser?
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Howard Farran:
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So, twice as many dentists have a laser than a CAD/CAM?
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Gordon J. C.:
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Yeah, yeah. CAD/CAM are about 13, 14, 15,000 devices, I'm going to be off a little bit, but many of them aren't being used. As you know, you go to Ebay or Dentaltown, or somewhere, and you're going to find some for sale. So, some have got one and decided, "I love it!" And they become a zealot and they join all the clubs, and they become one of the boys or girls. And then there are others who got it and thought, "For crying out loud, I did a conventional technique faster." So you got both ends of that spectrum. That's why in 30 years, it has not captured everybody, it's captured some, as you know.
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Many dentists hate lab work, you know that, and others [inaudible 00:56:05] lab work. But, back to the laser, the laser yes, I think a typical general dentist needs a laser, and an electrosurgery. The electrosurgery cuts up to 10 times faster, it will cut at a narrower cut, it heals faster. This is all contrary to the hype, it heals faster in our dog studies. It leaves less scaring than a laser. And, basically, it's over the healing period, can be more painless because you barbecued all the nerves when you cut it with it.
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I'm not negative about laser, here's the major positive thing. It has less heat. That's another bad thing in the hype, the heat created by an electrosurgery is more than a laser. But, some of the hype for laser says, "You don't have any heat." Heck, you don't. We put thermal couplers in meat and tested the heat produced by a laser compared to the heat produced by an electrosurgery. Obviously, electrosurgery creates more.
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And the electrosurgery, if you hit metal ... here's another very good advantage of laser, with most lasers, you hit a, of course infused with a metal crown, and a metal crown in your mouth, and anything that's metal, a bar, and you got sparks flying, your hair is sticking straight up. If you hit it with the laser, big deal, not much happens. So, there is this singular, major advantage of the laser. Well, I won't say that. There's another major advantage but it's not biologic, it's psychologic. If a laser is good for [inaudible 00:57:46], it must be good for teeth. That's a patient conception. And you know, everywhere you go, there's some laser ad for vision. So, we're riding kind of on that crest with laser.
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If laser was really a, now I'm going to be kind of negative right now ... If laser was really as important as some think, everybody would have one. So, why do only, whatever one out of six have one, one out of five or six ... It's obvious, there are other ways to go.
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Howard Farran:
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When you mention hard tissue, you said Fotona.
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Gordon J. C.:
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Fotona.
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Howard Farran:
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Biolase.
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Gordon J. C.:
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Solea.
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Howard Farran:
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And Solea.
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Gordon J. C.:
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Yeah.
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Howard Farran:
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But, AMD, Alan Miller Dental lasers just came out with their Lite Touch. You didn't include Lite Touch. Why was that?
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Gordon J. C.:
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Well, only because we haven't evaluated it yet, yeah. We'll get on it.
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Howard Farran:
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[crosstalk 00:58:48]
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Gordon J. C.:
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Last year ... Yeah. Last year, we evaluated a little over 700 new products.
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Howard Farran:
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Oh my gosh.
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Gordon J. C.:
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And, your listeners won't want to hear this, but only one out of five met their claims. One out of five of the 700 plus met their claims. We see it everyday I'm in these research labs. There-
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Howard Farran:
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How much more time do I get you because you told me you had to go an hour, it's exactly one hour. How long can I hold you for the chair before you have to run for your car?
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Gordon J. C.:
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[crosstalk 00:59:22] I can still make it. Give another ten minutes, okay?
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Howard Farran:
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Ten minutes. You're so sweet. Tell me if this is true or false. Since you and I have been ... When we got out of dental school, there weren't cell phones, I mean first we had that little Motorola flip phone, then Nokia, and iPhone. Some people think, "Why would I want to buy a $100,000 CBCT, cone beam technology, when in five years, the new one's going to be twice as nice?" I mean, if you told me I had to have my same smartphone for the rest of my life, I'd be sad. I'd rather rent it or lease it. So, is that true, or false? Is buying a CBCT going to be last as long as your iPhone before it's outdated? Or is that not true?
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Gordon J. C.:
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You really got a good point. There are three major areas of dentistry that will drive most dentists to cone beam, I've been on it, as I said, 17 years. I started with Planmeca and we've now graduated a half dozen brands. I originally bought the Planmeca piecemeal not even knowing if this concept would turn into anything, which it definitely has. Endo is the main thing that's going to drive people to cone beam. Why? Because let's say a general dentist, or anybody, does an endo, it looks perfect ... this actually happened to my son in Canada, their practice is up there.
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Howard Farran:
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Mikey?
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Gordon J. C.:
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Yeah, Mikey boy.
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Howard Farran:
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Mikey, the hunter.
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Gordon J. C.:
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Mike will do everything from brain surgery to circumcision. He [inaudible 01:01:01] as a general dentist. They drag bodies up on his porch in the middle of winter, of course, it's 40 below, and he's supposed to identify them by their teeth. It's an interesting little kind of practice.
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But anyway, with the cone beam ... Let's say somebody does a root canal, it looks perfect. It's a three rooter, it looks like it's a three rooter, and they get upset because it's still paining, paining, paining, they hear about endodontist, which most people don't even know the word. They go to an endodontist. The endodontists got a cone beam and John Wes and I, well he created the survey and I assisted him a little bit. John Wes, being a well known endodontist in Washington, did a survey and about 70% of endodontists have now got a cone beam. And it's only a couple of percentage of general dentists.
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So, they go down the street, they find an endodontist, the endodontist does a cone beam, lo and behold, there's another root. Usually, it's disguised by the fact there are three there and there's one right behind it, and you can't see it. [inaudible 01:02:05] You flip it 90 degrees [inaudible 01:02:07] and sees another root there. There's a lawsuit just waiting to happen, and there are now lawsuits about endo. Endo being semi witchcraft. 20% of endo, according to certain surveys, one out of New York U, are failing in some way by just a few years. The patient still knows something's screwed up with that tooth.
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Our recent survey which was empirical, granted it was about a thousand dentists, said about 10% of their endo is in someway, failing. It's either the patient knows that there's something wrong with the tooth, or it's literally failed by five years. So, that area of dentistry done by typical general dentists doing ... we just finished the survey on it, the general dentist is doing between zero and four endos per week. However, some will go as high as 20. But the average was very low. I was surprised.
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As you know, the net revenue of a dentist, the major portion, is [inaudible 01:03:17] pros, but the second portion in volume is endo. They ought to be looking seriously at finding access to cone beam, for legal purposes as well as physiologic purposes. The next one is going to demand it, it's already demanded it for me, I had half my implant career without cone beam, I look back and I could've killed a dozen people. You know, because I'm now seeing things I've never seen before. So, implant ... If they're doing implants, they need to either buy one or go in with another dentist and share one, or find a radiographic lab in their community who could do the radiographs for them and hopefully help them until they learn how to do it.
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We have an implant ... Pardon me. We have a cone beam course right here. In fact, we've got one coming up in a couple of weeks. Where I use Dale Miles oral maxillofacial radiologist, and me, and we actually do cone beams on some of the participants and let them see in their own head. They're a lot more attentive when it's their head than some-
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Howard Farran:
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So if you were an endodontist or a general dentist, would you want a different brand of CBCT than, say, if you're an orthodontist who wanted both jaws and a [inaudible 01:04:32].
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Gordon J. C.:
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Right now, the major brands ... The major brand right now is Sirona and that's because of the Cerec interaction, that you know. The second most major brand is the i-CAT from [inaudible 01:04:45]. And the third most popular is-
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Howard Farran:
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Who makes i-CAT, is it iTero?
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Gordon J. C.:
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i-CAT. I-C-A-T. Yeah.
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Howard Farran:
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Is that made by iTero or is iTero completely different?
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Gordon J. C.:
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No, no, it isn't.
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Then the third most popular is Planmeca, which is the grandfather of [inaudible 01:05:03]. Early on, all of those were in the $150,000 range, now we've got quite a few coming on that are in the $60,000 range. And that's where I suggest general dentists go. They should be looking at brands like Carestream, the 8100 model, which is around, I'm going to be off somewhat, mid 60's. And another one that's going to really make a significant impact on America is Vatech, coming from South Korea, and just like Hyundai and Kia, those automobiles have made such an impact now. It seems like every third or fourth car I see is a Hyundai or a Kia.
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Similarly, there Vatech brand, which is the most popular one in the world, but not in America because they just came in here, they're in the mid 60's. There are two brands, of course, there's a general dentist, and it's in limited field. If I do six teeth, I don't need the whole head, I just need that, and therefore, you're only responsible legally for that. You're not responsible for the whole head. Now, if you do the whole head, you're responsible for the head. If there's a tumor in there you missed, you could be sued on that very nicely.
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I do see cone beam right now ... Access to cone beam, when you asked me, "Did they need to get it?" I'd say, "No." But they need access to it. Since so few have found access to it, in my observation in courses, I would say I'm seeing, 30% with access to cone beam and that's-
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Howard Farran:
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Okay. I only got you for three more minutes so I got to have your rant on the three most topical areas I see going crazy. Sealants. I mean, Gordon, with you's like all the research says half fail in the first year, half fail in the second year, and then a lot of people say, "No, that's not true." Rant on sealants. How long does a sealant last?
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Gordon J. C.:
|
Okay. Rella, my wife, has done obviously a microbiologist and physiologist, she's done a lot of research on that way back, and she continues to do it on carriage. In about a year, she'll blow the whole caries theories apart. Most of the things you and I learned in dental school, and even currently, comes from the 1800's. W. D. Miller and others theorize and did some micro ... Now, not really. We're doing another one, micro we're doing DNA analysis on it, we're identifying genus and species on the organisms in caries and we're finding organisms that are not even in text books. They've never been identified. And then they're different as you go down inside the tooth.
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When you disinfect the miserable cavity preps ... because what we're calling recurrent caries is really continuing caries. It has nothing to do with recurring. It continues if you don't kill the bugs. We've been promoting now, for some time, the use of the glutaraldehyde containing solutions, two minutes of which ... Two, one minute applications, will literally kill everything to the pulp. That would be Gluma, or one of the more popular less expensive brands, MicroPrime from Danville.
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You probably know Danville was just bought out by Zest and a lot of their products are absolutely excellent. But back to your question. Yes, sealants are falling off. The international data says about 50% within five years. And, a lot of the dentists are using old products from literally the 60's that were partially filled. They ought to be going in to products like Filtek Supreme Ultra Flowable. Filtek Supreme Ultra is well known, the flowable is not as well known. And that wears about the same as Filtek Supreme. The Ultra, the restorative product. They should get off these partially filled things that have been around forever.
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They should also be using a air story polisher, which only not even 20% of dentists have because it's such a freaking mess. But if they would use an air story polisher to clean out the plaque out of the grooves, there's no reason for the sealant to fall out. It won't come off. If they leave the plaque in there ... Most hygienists would just scratch the occlusal surface with an explorer, thinking they cleaned the plaque out?
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Howard Farran:
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What air story polisher do you like?
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Gordon J. C.:
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Prophy-Jet, Cavijet, either one of those from Dentsply are the most popular brands by far.
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Howard Farran:
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Prophy-Jet or what?
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Gordon J. C.:
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Cavijet. Cavijet or Prophy-Jet.
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Howard Farran:
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I use the one from Danville. The Danville-
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Gordon J. C.:
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Danville's fine. Danville's fine, yeah.
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Howard Farran:
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Cheap as heck, too.
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Gordon J. C.:
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Yeah.
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Howard Farran:
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Another question, amalgams last forever because when they set up, they expanded. The seal, the corrosion, the seal was incredible.
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Gordon J. C.:
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[inaudible 01:10:14] teeth, yeah.
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Howard Farran:
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All composites shrink.
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Gordon J. C.:
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Right.
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Howard Farran:
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But now there's a move instead of putting in a layer, cure, a layer, cure, a layer, cure. Now it's bulk fill. Do you think that's a good idea or a bad idea? Which composites going to be lasting longer? Incremental cures or a bulk fill?
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Gordon J. C.:
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I just published a paper on that, or will publish. It's in press right now. It will come out in Dental Economics shortly. Basically, right now, what we're seeing is the materials for bulk fill are excellent. SonicFill, wonderful material. It turned out to be very high in our evaluations. However, the way some of these are being used, is really defective. If you aim the light ... Here's the surface of the resin. If you aim the light even 15 degrees from perpendicular, Tim Palmer, our physicist says, 80% of the energy is lost. And you're going down a nine millimeter box form, you're 15 degrees off, oh sheesh. The box form, the depth of that, is gel. We're seeing far more class two caries now that they stick four pounds in and try to cure through it. It doesn't work.
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If they're going to bulk fill, they ought to be doing a prep, doing a normal bonding, going in an putting in the most apical part of that, about a half millimeter of resin, curing that, and then put a large wad in. I still do incremental cure, and so do most people doing research. It's just too hard to get the light aimed correctly and get it down that far with adequacy. Even though they think I can put the explorer on and it's hard, it may be hard but that's a ... It could be hard at 40% conversion, we need 60% conversion to make it adequate over the long term.
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Howard Farran:
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Final question because I know you got to run. Final question. Huge controversy, especially around the world. Of what lasts longer, an amalgam or direct resin?
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Gordon J. C.:
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I can say it in one sentence. Amalgam lasts twice as long as composite.
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Howard Farran:
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So, if it was your ... Do you have any grandchildren yet?
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Gordon J. C.:
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Yup. I got great grandchildren.
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Howard Farran:
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So, if your six year old grandson needed an occlusal on a six year molar, he's a boy, no one would ever see it. I've been talking to you for an hour. I've only seen your front bicuspid to bicuspid. I have not seen your molar the whole time. Would you go with an occlusal amalgam or occlusal direct composite?
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Gordon J. C.:
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This is going to sound really biased. People want white. You know it. The white's being done really poorly in America. The average big composite lasts six to seven years, according to international data. The average small composite, in our research, goes 15 years. I would want a well done composite by a meticulous dentist. It would be white. But on the other hand, if the dentist is hung over, or a pedestrian level of quality, then amalgam would be better. Period.
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Howard Farran:
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But Gordon, do you know how many times I've been in a poor third world country and [crosstalk 01:13:42] dental office, and they're watching the Americans and they're trying to do bonding. They'll acid etch and then they'll rinse with a Dixie cup and a pickle bucket. Then he'll put on the bonding agent and cure, then the lady will sit up and rinse. Then he'll put in an elemental composite and cure. Then she'll sit up and rinse and spit in a bucket. And you look at these techniques around the world, and there's two million dentists. One million of them don't have the facility to even do a direct resin.
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Gordon J. C.:
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No. They ought to be putting in amalgam in with absolutely no reservation in my mind.
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Howard Farran:
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All right. Thanks, man.
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Gordon J. C.:
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Good to talk to you.
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Howard Farran:
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Good to talk to you. Any legends that you think should come on this show, just tell them to email me. I respect you [crosstalk 01:14:25].
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Gordon J. C.:
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All right. I'll get the names.
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Howard Farran:
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Okay, buddy.
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Gordon J. C.:
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Thank you.
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