Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Dr. Daniel Butterman is a general and cosmetic dentist with a practice emphasis on implant placement and restoration. In his capacity as an Advanced CEREC Trainer, Mentor, and Visiting Faculty for CEREC Doctors, Dr. Butterman has trained other dentists worldwide. In 1994, he graduated with honors form the University of Maryland School of Dentistry. Dr. Butterman also is a graduate of the Misch International Implant Institute, and was awarded the Mastership Certification by the International Dental Implant Association and the Fellowship Certification by the International Congress of Oral Implantologists. He also is a member of the American Dental Association, the Colorado Dental Association, and the Metropolitan Denver Dental Society.

www.buttermandental.com

Howard: It is just a huge honor to be sitting in my home on a Friday afternoon and have Daniel Butterman stop by for a podcast. You are a legend in my mind and after this show, you're going to be a legend in many other people's minds. He's a general and cosmetic dentist with a practice emphasis on implant placement and restoration. In his capacity as an Advanced CEREC Trainer, Mentor, and Visiting Faculty for CEREC Doctors, Dr. Butterman has trained other dentists worldwide. In 1994, he graduated with honors from the University of Maryland Dental School, which was the first dental school in the world, in 1856, which I think is interesting because G.V. Black's the father of modern dentistry and he was born in 1836. He was ... most people don't realize that before, like G.V. Black, everybody was learned by an apprentice. You learned dentistry because you worked for the dentist.

Daniel: Never met the guy when I was there.

Howard: You never met him?! And Dr. Butterman was awarded the Mastership Certification by the International Dental Implant Association and the Fellowship Certification by the International Congress of Oral Implantology. He's also a member of the American Dental Association, the Colorado Dental Association, and the Metropolitan Denver Dental Society. So, you teach CEREC in the most elite CEREC deal, which is CEREC doctors with Sameer Puri, who has been on the show, and also you place implants.

Daniel: Yes, yes.

Howard: And, so, which do you love more, which do you like to teach more?

Daniel: Oh, I have to say, I started with implants years ago and I kind of ... the whole idea of the implant placement just kind of blew me away where we can take nothing and create a tooth from it. But things sort of evolved and things changed for me with the advent of CEREC and being able to incorporate all these pieces together just sort of ... which do I like better? I like the combination of both. I like teaching both of them together because they mix so well together.

Howard: Well, right here in Phoenix Valley, we've got two dental schools, one out in Mesa, A.T. Still; one out in Glendale, Midwestern; and every one of those graduates walks out of school and says, “Darn it, they ... I didn't learn how to place one implant.” How do you ... what would you tell a graduate ... how do you go from zero to one?

Daniel: Yeah, that's a great question, and I think that there's sort of a push for people to learn it quickly and I can tell you, drilling a hole in bone and putting an implant in, you can learn that in a weekend course, but that's really not implant dentistry. And I think that we need to be a little bit careful that we step back and maybe do a larger program, something that can more teach the biology, teach the construction, the everything that's happening with the entire implant process. So, we really understand the treatment planning part. Because I can tell you from my perspective, when I place implants, the hardest part I ever do is not drilling the hole in the bone. It's doing the treatment planning and figuring things out beforehand and that's where the education comes in.

Howard: Yeah, and, I mean, just little things, like, some people are worried about putting an implant in someone who's a smoker. I'd be ten times more worried about a [00:03:09] bruxer. [0.6]

Daniel: Sure, sure.

Howard: You know, the United States, a lot of the implant training is tied to the manufacturer.

Daniel: Yes.

Howard: So, a lot of these dental students, they almost feel like, Well, I need to pick the implant first because ... it's just like in the Phoenix Valley...

Daniel: Sure.

Howard: I mean, almost all the courses are manufacturer courses. What do you say about that? Do you think you shouldn't learn the manufacturer courses? Some people say, “Well, it's like driver's ed. You didn't end up buying the car that you used in driver's ed school.” Is the system a big part of your implant journey or is that a little part of it?

Daniel: Yeah, I would say that certainly taking a course from an implant manufacturer, it's great in that you get to play, you get to dabble a little bit, you get to see, is this for me, is that something I'm interested in or not? But, I think if you decide that, I'm excited about this, this is great, then taking a course ... because really titanium is titanium to a certain degree. And, yes, there are nuances and differences between manufacturers, but the biggest part of the education is the biology, healing, treatment planning and those are parts that aren't necessarily going to be covered and taught in a manufacturer course. So, I think they both have a place. And certainly, taking a larger course - and there are many, and I did my training through Carl Misch, who we recently lost ...

Howard: That's a buddy of mine.

Daniel: ... and his whole premise was, it really doesn't matter, it doesn't matter what brand, and I think a lot of the courses that teach more on a generic approach, just principles, will let you be able to ask the right questions because...

Howard: Ryan, will you go get Carl's book.

Daniel: But the technology is constantly changing, and sales people come into my office all the time with the latest surface and the latest implant, latest and greatest, but if you haven't learnt the basic principles and understand what you're really looking for in an implant - what works, what doesn't work - then it's hard to make a decision.

Howard: By the way, I just made a post on Dentaltown, this recurring thread, you know, it seems like the Millennials are always whining about their student loan debts and then right now on Dentaltown, a big thread today is this guy just got accepted to dental school, he hasn't even started, it's - this is August - and he's getting ready to get started in the fall, but he's realized that he's going to borrow so much money, he's going to graduate with $500000 in student loans. And, I just don't buy it because, number one I didn't have a car in undergrad, I didn't have a car the first three years of dental school, I didn't have ... get a car until senior year. For us, Spring Break meant going back home with Mom and Dad, and hanging out with Dad drinking Busch beer out of a can.

Daniel: You say that like it's a bad thing.

Howard: Yeah, these guys hop on airplanes and fly to the Caribbean and that whole ... both those schools look like new car lots for Japan. And, you know, when I talk about implant training, you know, they'll want to ... when I learnt, took Misch, I mean, I bought his book and read it twice, like a novel, before I ever took a lecture. Like, here's the last read I did, Misch's 'Avoiding Complications in Oral Implantology', but, see, the Millennials, they don't want to buy ... they don't want to sit down and read a eight-hundred page textbook which would give you all the answers to the universe. They always want to get in an airplane, fly to Beverly Hills, stay in some resort, but it seems like they find the most expensive way to do anything. And, by the way, let me tell you something about those student loan debts - I've never met a dentist in my life whose divorce didn't cost at least five times more than their student loans. So, your little whiny $350000, yeah, go write some chick a check for $2 million some day, and then tell me how expensive your stupid student loan is.

Daniel: I'm happy to say I know nothing about that.

Howard: Well, you better keep treating Irene because I'm looking at Irene over there.

Irene: Don't give him any ideas.

Daniel: No ideas.

Howard: And she's ... I see a $2 million bill sitting there.

Irene: [00:06:58] [DANIEL AND IRENE TALKING OVER EACH OTHER.] [1.4]

Howard: She already knows what the number will be. She's already ... her girlfriends of her, they've got a calculator app where they can...

Daniel: If we could change the subject, that would be awesome.

Howard: So, my deal is on the implant training is, you know, old farts like me - and if you think I'm bad, you ought to see the boy's grandfather, he's ninety, so, he grew up in the Depression. Oh, my g*d, he is ... he has millions of Dollars in a bank account and he won't go to a steakhouse.

Daniel: Yeah.

Howard: So, it seems like, though, that generation, my g*d, they could squeeze twenty-five cents out of a radish, you know, and then our generation loosened up a little bit, but the Millennials are loose as a goose. I mean, you know, they just spend money hand over fist. They start having babies in dental school. Some of these guys graduating dental school, they've already got two kids and it's like, don't ... that's not student loan money, that's just living high on the hog. I mean, I graduated in '87 and I didn't make Eric till '89. You know, I already had my house and the baby room set up.

Daniel: Sure.

Howard: So, my first deal ... and then on endo, [00:08:05] Pathways of the Pulp just came [1.2] out with their eleventh edition. Well, g*d, after you've read that, if you still have a question on endo, you're Stevie Wonder and you didn't see any of the words, you know, so.

Daniel: Yeah, you know, and in fairness...

Howard: Where would you tell them to get training? If someone said...

Daniel: Sure.

Howard: ... I want to get trained from A to Z. I want to know what you know, where would you send them? You can't send them to Misch, he's gone.

Daniel: Well, they still have the program going and I think the curriculum is still good there and there are many other comprehensive programs out there. I think Garg has a fantastic program that he's doing as well.

Howard: Arun Garg?

Daniel: And, but, basically in defense of the Millennials, which I'm not obviously...

Howard: Well, you're...

Daniel: Thanks for laughing at that! I appreciate that.

Howard: Well, Millennials are 1980 and after. What year were you born?

Daniel: I was born a little before that. I was born '68.

Howard: '68?

Daniel: Yes.

Howard: Damn, you're looking good, man!

Daniel: Hey, thanks, appreciate it.

Howard: Irene must be feeding you well and not stressing you out.

Irene: He runs a lot.

Howard: He runs around a lot.

Daniel: I do run a lot. But, really, what they've done is they've embraced technology. And I think that people, guys my age and guys that have been doing the things that we're doing, implant dentistry for example, for a long time, that doesn't come so easy for us and I think that spending money, if you're going to embrace technology, you got to do that. The stuff is ridiculously expensive. It all costs a lot of money. They're maybe a little bit less likely with the sticker shock than a guy my age would be. And I think the ... embracing that technology, lets them change workflows. And that's what I've learnt, the biggest ... when you asked me, which do I like to teach, that combination of the two, where we're placing implants but we're using the technology piece of it just to streamline things and we've changed our workflows entirely with implant planning and implant placement and especially with implant restoration now. We've taken implant restoration down to one or two appointments now. And I think Millennials can embrace that, I think they can sort of grab onto that because...

Howard: So, what technology are you talking about? Are you talking about the CBCT?

Daniel: Absolutely, absolutely.

Howard: For implant placement?

Daniel: I think...

Howard: And which CBCT did you go with?

Daniel: So, I have an XG 3D Galileo's system.

Howard: So, that's the Dentsply Sirona.

Daniel: That's correct.

Howard: And it's the Galileos what?

Daniel: It's the XG 3D.

Howard: XG 3D. And what's the X? I know what 3D is. What's the XG?

Daniel: So, I have no idea.

Howard: I still don't know what P90X stands for, either. I [00:10:27] [INDISTINCT]. [0.1]

Daniel: I know. That I do know.

Howard: Well, what is it?

Daniel: The...

Howard: What is P90X?

Daniel: I know what the...

Howard: Well, the '90' is a ninety day program.

Daniel: I know the car.

Howard: The car? No, the workout program.

Daniel: Oh, P90X.

Howard: P90X. I know the '90' is the day. I mean, it's a ninety ... anyway.

Daniel: I have done a lot of it, but I have no idea what it stands for, yeah.

Howard: So, you like Dentsply Sirona's Galileos XG 3D.

Daniel: Yes.

Howard: And why did you like that one as opposed to Carestream or iTero or all the others?

Daniel: Sure. You know, for me, they all take great images, that if we're looking ... especially for looking at bone and we're looking at implant position. What I want to be able to do is workflow. I want something that's going to be streamlined, something that I can go from A to Z with it. And, again, it's little different for me because I'm placing my implants and planning them and I'm doing it in front of my patients now. So, when I have a patient that walks into the treatment room and they're missing a tooth, and I say to them, “Have you ever thought about putting a tooth there?” And they say, “Well, I don't know. What can I do there?” My answer is, “I don't know either. Let's take a look. Let's see.”

Howard: Nice.

Daniel: So, my workflow is, we'll do a CBCT.

Howard: Co-discovery.

Daniel: Yeah. And we'll say, “Well, let's take a look at the bone.” And then, while that's processing, I'll take my CEREC and I'll do a scan of the edentulous space and I'll design the crown, and we'll sit down, and we'll say, “Well, that's what your crown is going to look like when we're finished. What do you think of that?” And it might be a crown that's really low because the upper tooth has super erupted into position and we get to have a conversation. We get to say, “Well, look how short that is. Is that okay for you? Or maybe should we think about doing some ortho on the opposing tooth, or maybe we should crown the opposing tooth? What would you like to do there?” And then when we see if the crown looks great, then we pull up our scan, we can combine our design of our crown into our cone beam scan and we can say, “Well, we should probably line up that implant so it comes right through the center of your crown. What do you think?” “Yeah, yeah, it'd be great.”

Howard: And you're not in a mega-rich area, I mean. Where is Centennial, Colorado?

Daniel: Centennial is a relatively affluent area.

Howard: But where? Is it a suburb?

Daniel: It's southeast of Denver and...

Howard: Like a stand-alone city or a suburb?

Daniel: No, it's a suburb. A suburb, it's ...

Howard: So, is there good money there?

Daniel: Yeah, it's pretty decent money there.

Howard: And what percent of your patients are stoned? Right, we've heard about your medical marijuana is now legal. It's not even medical marijuana.

Daniel: I can say that the decision-making process has become easier in my office. I don't know why but all of a sudden it has. And all of my patients are far more relaxed, so, it all works out in the end for me.

Howard: So, how long has it been legal there?

Daniel: How long has it been legal? A couple of years now.

Howard: Has the State gone to hell in a handbasket or has it been uneventful?

Daniel: I can honestly tell you that people that live there, from my perspective, other than the fact that there may be more dispensaries than Starbucks in certain towns, it's not something that we notice day to day, it really isn't.

Howard: So, it's been uneventful?

Daniel: I mean it's totally, totally under the radar when you're living there.

Howard: Yeah. So, you ... do you mostly like the Galileos because it is integrated with your CAD/CAM machines or, I mean, you said that they they'll give a great image.

Daniel: They all give a great image.

Howard: So, then why did you pick Galileos?

Daniel: Again, because I want to be able to design my crown. For me it's important.

Howard: The integration?

Daniel: Well, it's important for me to design my restoration first. It's important for me to see what the final crown is going to be able to look like, not just a simulation of the two, but the actual crown, the opposing occlusion, the contacts, everything about it, and then be able to take that seamlessly and throw it in my cone beam software and then be able to plan my implant position based on where that crown is. And I don't know that there is as easy and seamless a workflow with any of the other systems right now.

Howard: Yeah, though, you know, the big debate is always the open system versus the closed system.

Daniel: Sure.

Howard: And the open system, the advantage is you can mix all the scanners and millers and mix all the pieces and parts.

Daniel: Sure, sure.

Howard: But the downside of that is, you'd better be tech savvy. Your office better be tech savvy. Because you go into so many offices and a patient will just throw a curveball and say, “Can you ... can I have a copy of that x-ray or that CBCT?” And the staff doesn't even know how to do it or they're like, “Do I get a ... burn it onto a disk or this or that?”

Daniel: Well, I admit, that's part of it. The other problem is what happens when things don't turn out the way you want it. What happens ... I have a 3D printer, for example. And those are great, and I think there's just a ton of cool things that we can do with them, but the software is still evolving, and you've got to run things through lots of different ... if I want to print a surgical guide, I've got to run things through a couple of different software platforms. What if it doesn't turn out the way you want it? Which one of those pieces is the problem? And I think, when you say 'an open system', that's fine until something happens.

Howard: Right, so, if you're tech savvy and you don't ever need a I.T. guy, and you can figure out all your firewalls and downloads, and if you're that guy, then you could probably have an open system.

Daniel: Yeah, you know...

Howard: But if you're not that guy and you're always having to call up your kids from college and say, “Hey, come help the old man figure out this printer”, or this, or that, or this, or that. It's just not going to get it done.

Daniel: I buy it for easier, faster, better. And if it's not going to be that way, I'm not interested. I don't buy it for the sake of technology. I want it to make my life better and if it complicates it, I'm not in that. That's not for me.

Howard: Okay, now is this Galileos ... would you would you call it a large fill, medium fill?

Daniel: No, my particular ... if I were to do it again, and again things have changed, I've had mine for about four years now and the technology has evolved from there, things have changed from there. Mine's an eight by eight field of view, so, I can see third molar to third molar, basically. I can see about about halfway to two thirds up into the sinus.

Howard: And would you ... would an endodontist be able to use this one?

Daniel: Oh, for sure, for sure.

Howard: Yeah, you know what? You know what's really interesting about me is, one of the pet peeves I have about implantologists is they have a religious mindset of, you know, they got a ... you know, when you look at the one to thirty-two teeth, and you look at a hundred million insurance claims processed, it's pretty much all flat, then on the six-year molars, it's these huge spikes. So, it's like four huge spikes. So, which tooth is most likely to get a filling? Six-year molars. Which one is most likely to be root canal? That one. Crown? Six-year molars. Extracted? Six-year molars. Replaced with an implant? Six-year molars. If a hundred crowns went to Glidewell, which is the most likely tooth to be crowned? Six-year molars.

Daniel: So, there's a prejudice against second molars!

Howard: Well, I mean, the difference between ... well, how old ... you have three boys?

Daniel: Yeah.

Howard: How old are your three boys?

Daniel: One is turning twenty-one, twenty and a sixteen year old.

Howard: Well, yes, so just remember the difference how they took care of their teeth between six and twelve. I mean, at six, you brush their teeth; and at twelve, they brush. I mean, it's just ... it's a humongous deal and I wish dentists would be far more aggressive on that six-year molar when it pops through. I mean, I don't even like sealants. I mean, I think the pits and fissures, your air abrasion, blow them all out or drill them all out, seal that thing as soon as it erupts because that tooth is going down the drain. But, when they do these sinus lifts, I mean, there's a ton of rhinologists and ENTs in the Valley that, you know, some lady will come in and says, “Well, I've had allergies for the last twenty years”, and then you find out it's a failing root canal...

Daniel: For sure.

Howard: ... leaking into the sinus and ... or an implant ... a sinus lift that's gone south, and they go up there with cameras they show me these pictures of all this white fungus and candidiasis and you see like that the implant sticking into the sinus. It's just disaster. And the rhinologists are like, “Well, you had a virgin second bicuspid and a second molar. Why didn't you just do a damn bridge?” But the point is this, the point is since dentists worship odontologist god and they don't, you know, the sinus, they'll blow it up with a hand grenade, stick titanium, cow bone, dead cow bone, crap in there, all the stuff like that, but you need ... it's standard to care that if someone comes in with a second bicuspid, first, second molar, and I say, “Well, how's your sinus? Do you ever have sinus problems?” And someone says, “Well, yeah, I have sinus issues, I have allergies.” You got to get a 3D x-ray of those root canals that go around the sinus because a lot of them...

Daniel: A lot of them are failing, and I do...

Howard: ... are failing and just leaking sludge into the sinus.

Daniel: I do a lot of endodontics in my office and I can tell you that having a CBCT also before you do the root canal is unbelievable, to know in advance is there an MB2 canal and how far is it from the MB1, or to see that doesn't exist. I mean, knowing that before you come in. But I can tell you that when my staff takes a CBCT on a patient that I've done the root canal a couple of years ago, I get all nervous because we don't ever want to see our failures. But it's amazing how many asymptomatic molars, maxillary molars are sitting in the sinus just blown up.

Howard: Well, you know why I've never had a failure, an endodontic failure? Is ... what I do is I take the x-ray and I Photoshop it.

Daniel: That's a good idea.

Howard: Yeah, I mean, and I do some of the best work ever. I lectured in Florida last year to a dental insurance association meeting and there were like three hundred dentists there that all worked for the dental insurance companies, and I was sitting there talking them, you know, you saw them at lunch or hanging out with them in - I think it was in Disney World - for a couple days. You wouldn't believe it, the ... everyone was saying the same thing. Guess how many ... what percent of the PA's they get on a root canal of a maxillary first molar only have three [00:20:12] gutta-percha [0.6] points in them?

Daniel: Yeah, yeah, I would say the majority probably have only three.

Howard: All of them.

Daniel: Yeah.

Howard: And they're like, Okay, I do this full time. I see a four ... I see an MB2 opturated about every time I see a blue moon.

Daniel: But that's a Millennial thing. I don't think MB2s existed when I went to dental school. I think they're a new invention.

Howard: Yeah, I think the only...

Daniel: But you're right.

Howard: ... and then what's funny is you ask any dentist, Well, what percent of your endos fail? They go, “You know, knock on wood, I've never had one fail.” But the insurance data and talking to these guys, seeing their data, when you're talking about millions and millions and millions of root canals done every year, if a general dentist does a molar root canal in sixty months, ten percent have been extracted. If an endodontist does it, it's five percent. So, you're telling me, you've never had a root canal fail, but the data is showing that ten percent are extracted, because there's a big difference between failing and extraction.

Daniel: Sure.

Howard: I mean, failing might ... maybe it didn't heal up, maybe it's still symptomatic, maybe it's still ... no, we're talking about somebody pulled the tooth and billed the insurance company. So, that's a pretty significant mortality. And then when you figure on that there's four thousand endodontists working forty hours a week and they say that two thirds of their business is re-treats.

Daniel: Right.

Howard: And then you figure all the dentists that have never had a root ...endodontic failure - that's a lot of immigrants coming into America...

Daniel: That's a good point.

Howard: ... with a lot of failed endo done in Romania, you know.

Daniel: Yes, that's ... that ...

Howard: I love inconvenient facts and what dentists hate is, you know, they hate facts. I mean, like, they'll tell you their composites last as long as amalgam. I mean, okay, well, the worst study I can find on amalgams, they last fifteen years; the average studies that they're lasting about thirty-eight years; and the normative study on [00:22:02] posterior [0.5] composites is six and a half years.

Daniel: Yeah. Well, you know ...

Howard: So, how does every dentist I meet say, “Well, they don't do it right. I do it right.”

Daniel: I have to say, look at implants even. And I think when I first started placing implants, the common wisdom was that that's going to be there forever. Ninety whatever percent of every implant we place is going to be successful.

Howard: Ninety-nine point two.

Daniel: Right.

Howard: Ninety-eight point nine.

Daniel: There's this thing called peri-implantitis now. I don't know if you've heard of it, but our patients sure have because there's a lot of things going on with implants that are failing or are just not successful in the first place. And I think part of that has to do with planning, part of that has to do with biology for sure, but it's not necessarily as successful as we were originally led to believe.

Howard: And a lot of it, it still blows my mind about how much the mind is closed, like, below the belt. You know, if some patient came into your office every six months with chlamydia, you know, or every three months, you'd finally say, “You know, are you sleeping with someone with chlamydia?” And when we look at implants, in sixty months twenty percent have peri-implantitis, and you go in these doctors’ offices, they've seen Grandma every three months for ten years and they've never seen Grandpa. It's like, do you not know that she goes home and kisses him goodnight and the routine average Grandma kiss transmits eighty million micro-organisms, fungi, parasites and viruses, and these people have all these perio programs with Mom and they've never seen Dad. Then you finally see Dad, and he's got like a bombed-out cavity, he's got gum disease, he's got like ... it's like, you know, I mean, we haven't even got to a point in dentistry where they realize periodontal disease is a communicable disease.

Daniel: Yeah, well, and I think a lot of that we see is monitored negligence from dentists, where we're just kind of watching it and I hate that, even in my office I hate the word.

Howard: Supervised neglect.

Daniel: Yes.

Howard: We'll just see you every three months and you'll always have gum disease. Well, in the end we'll just see every three months until...

Daniel: I had a guy in dental school and every time we talked about a watch, he'd say, “What are you going to watch it do?” I mean, what does that mean exactly? If something's going wrong, it's going wrong.

Howard: Imagine going to a farmer in Kansas and saying, “Well, you know, we just inspected your barn and there's a little hole with termites in there but we're just going to watch it. We'll come back every six months and watch it.” I mean, if you tell a farmer he's got one little termite hole in that barn, they will cut out a section of that wood...

Daniel: Sure.

Howard: ... the size of this table, and the dentist will say, “We'll just watch it.”

Daniel: Yeah, no, well, but, and I think part of that might be that there's sometimes not a proper process as far as knowing what to do. Just because you've got an implant and after a year or two now you see twenty percent bone loss, I don't know that we've necessarily developed the proper workflow, the proper protocol for a lot of dentists to be able to jump in and say, “Well, here's what we need to do - A, B and C.”

Howard: Well, it doesn't exist in 2017.

Daniel: Yeah.

Howard: So, as of this recording, there is not a standard protocol for peri-implantitis.

Daniel: And I think there needs to be. I think everybody needs to be on the same page, “Hey, when we see this, it's not okay for puss to be draining around an implant. That's just not a good thing.”

Howard: Is that a Colorado thing?

Daniel: Just saying! We sometimes see that.

Howard: I mean, I don't know, I think that might be a Colorado thing.

Daniel: Maybe, maybe.

Howard: But, yeah, it's true. And then the other thing is, what's tough is you know on an implant, on a removable, [00:25:40] on the fix, [0.8] where Grandma can pop out that denture and go in there, she can clean it much better and everything, but the market doesn't want that.

Daniel: No.

Howard: Psychologically they want it fixed and then, are you going to go in there like, you know, how are they going to clean underneath that and then some of this stuff, like the dentist will say, “You really need to think it through”, like on the floss, I mean, unlike the water pick. They're not going to brush underneath those deals.

Daniel: We've pre-selected for - generally, not always - but we've generally pre-selected for patients that have demonstrated they have poor hygiene. Most of them, that's why they lost their teeth, that's why they're in this situation.

Howard: Yeah, these aren't vegan yoga instructors that lose all their teeth, right.

Daniel: Well, that's normally the case and I think, but I think you're right, the day of the high-water bridges, where it was super-cleansable, our patients would shoot us if we ever did something like that for them today. That's how we used to do it, but not today. Now it needs to be form fitting, they don't want to see anything that doesn't look like their natural tissue.

Howard: Yeah. And then you set them up and you say, “Well, you need to irrigate this out of the water pick.” But then it makes a mess in the kitchen or the bathroom, so, they put it below the sink and that's why a lot of these companies are now going to ... my favorite's still the shower floss. I mean, you know, you get that in your patient's hand, they unscrew the shower deal, and they hook up the shower floss, so, it's just hanging there. Because when you're in the shower, you don't care if you're blowing lettuce and bacon and tomato all over the walls because you're in the shower. But if their husband, if Grandpa uses that in the bathroom and makes a mess, Grandma will throw the damn thing in the trashcan.

Daniel: He'll do that once and that'll be it.

Howard: And water pick just now came out with a water pick where it's rechargeable. You fill it with water, then you can take it into the shower. And so, it's these little things about, you know, is this getting done, is this getting cleaned? And it would be really nice if you weren't making out every night with somebody with nine millimeter pockets, that, you know, that would be nice too. I tell all my periodontal ... I tell ... first of all, where I freak out is when the little girl's pregnant. I say, “Look, this kid will not be born with Herpes Simplex 1, canker sores, streptococcus [00:27:53] mutans and [0.3] get decay, [00:27:54] pregingivitis, [1.0] she won't have any of these diseases.” And then the herd is going to infect her the minute she slides out. I mean, you'll take your baby and you'll hand it to your grandpa, who's got upper and lower partials, hasn't had a dental cleaning in five years and he'll kiss it right on the mouth. And you need to start ... I want to see every single person that's going to babysit or kiss or whatever, and you need to start coaching them that you don't kiss apes on the mouth. You can kiss their hand, you know, you ... but I ...

Daniel: I don't know that Grandpa is going to appreciate being called an ape, though. Just saying.

Howard: He is a monkey without a tail. Is that better?

Daniel: That's fine.

Howard: Is that better? But when you start ... you know, the people in the lead on this are the ... the only place I've seen it in the lead is in Austria and Liechtenstein where they're ... where you'll go to a dentist and say, “Well, what kind of practice to you have?” And they'll say, “Well, you know” - you know Germans – “I have eighteen hundred and twelve patients and six hundred of them are under twenty-one.” And, but, they're culturing for streptococcus mutans. They'll say, “You know, I'm very proud - I still have four hundred of my six hundred children under eighteen still do not test positive ...”

Daniel: Interesting.

Howard: “... to streptococcus mutans.”

Daniel: Interesting.

Howard: And in America, I mean, they [00:29:09] don't prevent, [0.4] like look at ortho. Talk to any anthropologist. There was no malocclusion from two hundred years ago to one and a half million years ago, and now every kid has got a malocclusion. Why? Because for the last two million years, where a hundred billion humans have come and gone, they nursed for several years and you fed them, you know, a woolly mammoth bone and they're chewing cartilage off a dead animal. And now when you nurse, the first time the child has any difficulty with this, you know, force spreading his palate, you switch him to a bottle and a sippy cup and then start feeding him applesauce out of a jar. The kid has never had any force, nothing spreading his palate or his jaws, and then they've got these high arches and they got all these malocclusions and the dentists aren't even the ones talking about it. The ones who's talking about it, and all the research papers, are anthropologists. They're the ones publishing all these papers that say, “Why is this?” And it's like, why are the anthropologists figuring this out? Shouldn't the ten thousand orthodontists...

Daniel: Yeah, it's quite interesting.

Howard: ... be having classes, saying, “Hey, are you pregnant? Come over to my orthodontic office on the first Thursday of every month when we want all the pregnant ladies in our zip code. Let me show you how your daughter is not going to need ... how your baby's not going to need ortho. And, just because it's squirming while it's nursing, it, you know, it [00:30:29] should after, you know, for a million years, take a lot of effort to eat. [3.6] Now you're feeding it, gosh, darn, you know, applesauce and squash and all this crap out of a jar.” They've never chewed, they've never ... you know, it's just amazing. But, yeah, so, prevention of these peri-implantitis. It's so much. It's who they're sharing tablespoons with, who they're living with, they're sharing toothbrushes with them, they're kissing each other, and we're not treating the herd, you know, we're treating, you know, here's Mrs. Jones. Well, Mrs. Jones is a herd animal and she lives in a house with three other people - I need to treat this house. You know, it's like a farmer in Kansas. If you got fifty head of cattle, you can't treat one. And if one of your head of cattle gets some infection, you know it could pass through the whole herd.

Daniel: You know, and I feel your passion about this and I don't disagree with you, but I think getting that message out there is a long time away. I just think that the social acceptance of that is going to be a tough sell.

Howard: Yeah. Well, it took AIDS for the planet to get religion on STDs. Before AIDS, it was like, “Well, it's just going to be a baby, or you might need a shot.” And then after AIDS, the whole planet's like, “Whoa, you know, this is a very ... STDs are very serious.” And I think what's going to be the AIDS for communicable diseases is this HPV and oral cancer. I mean, these kids are all going to college and think that if they wear a condom or ... they're all good. They're realizing, No, you put a condom on downstairs and then stick your tongue in some person's mouth...

Daniel: Right.

Howard: ... and now you've got HPV.

Daniel: Well, and fortunately, I think, the vaccinations for HPV is getting more commonplace now, and I think that's really being pushed by pediatricians to...

Howard: Well, Australia made it mandatory for all their kids and ... Australians are brutal, man. Not only is that a mandated vaccine, if you go to school and your kids aren't vaccinated and you don't want to get vaccinated, they ask you to leave the country. They're like, “Get vaccinated or where do you want to be deported to?” And when Texas tried to mandate the HPV vaccine - remember the backlash of that? Oh, my g*d, they went crazy. So, I don't ... I think America is ... yeah, it would be nice if they got the HPV vaccine.

Daniel: Yeah, and I mean, certainly in my area, I know personally with our kids, that was pushed pretty heavily to us, and I think that's a good thing.

Howard: Oh, yeah, it's a very good thing. These, you know, this is 19 ... this is 2017, and a lot of people think the sky is falling, but go back just one century. By 1917, you already had a world war going and the Spanish influenza that dropped five percent of the entire planet died during the 'flu season. And today you're worried about, you know, Putin hacking the elections and, I mean, and you got all these people against vaccines. It's like, this century is a gift compared to the first seventeen years of the last century. So, what implant system did you end up going with?

Daniel: I've tried many of them. I've gone down a lot of different pathways and I can say that I've had success with a lot of different ones.

Howard: Pathways. Was one of the pathways [00:33:43] Pathways? [0.1]

Daniel: Maybe that's where the word came from.

Howard: You went down Pathways to the Pulp.

Daniel: That may be where the where word came from. But, again, it falls down when I'm looking for an implant I'm looking for specific things. I'm looking for - and I'll answer your question, but really it comes down to what is the shape of the implant going to be, what's the connection of the implant because these are all important things. And then is it going to integrate with the way that I want to restore it and in the way that I want to plan it. And now I'm primarily focused on ASTRA. I like that system...

Howard: ASTRA?

Daniel: I like the ASTRA [00:34:15] [...]. [0.0]

Howard: That's a Dentsply Sirona system?

Daniel: It is. It is. And I just think that the workflow works nicely with the way that I do it. But there are many systems. There are many that work out beautifully.

Howard: And where's ASTRA headquartered?

Daniel: Where are they headquartered? I don't know.

Howard: I'm sure Dentsply just bought it.

Daniel: Yeah, yeah.

Howard: I wonder where they started.

Daniel: That I couldn't tell you.

Howard: You don't remember the founding father of that or ...?

Daniel: I don't know.

Howard: If you do, email me, tell me. I'm curious.

Daniel: I'll definitely do that.

Howard: I'm curious. Because usually behind any implant system there is dentist somewhere that designed it, started it.

Daniel: Yeah.

Howard: But that is one of the top three systems. I mean, Sweden has Nobel Biocare, Switzerland has Straumann, and the Americans have ASTRA. And it's just called ASTRA?

Daniel: ASTRA, and their newest connection that they've used is the EV connection.

Howard: And what does the EV stand for?

Daniel: I have no idea, just like I have no idea where the company was founded.

Howard: You don't even know what P90X stands for and you're in rocking good shape.

Daniel: Power. How about Power Ninety...

Howard: Power Ninety? Is that what it is?

Daniel: Power Ninety, yeah. P. P for power, wouldn't that be?

Howard: P for power?

Daniel: Let's go with that.

Howard: Okay. Well, I'll take ...

Daniel: Look, if Tony Horton calls into your show and tells you that it's different, that's fine, but otherwise I'm sticking with it.

Howard: Oh, my gosh, I have a whole [00:35:26] P90X [...] in [0.7] my garage. It's so...

Daniel: I've done them too. I love the program.

Howard: Yeah. So, you like the EV Connect?

Daniel: The connection, that is that particular connection between the two. Because that's important and I think that...

Howard: So, you're in a suburb of Denver.

Daniel: Yes.

Howard: Here's ... tell me if this is true or not. It seems like ... okay, so, I have a firm belief that if you're not doing the procedure once a week, you're never doing it good and fast enough to be good and profitable.

Daniel: Sure.

Howard: Every time some dentist, you find out he does like an Invisalign case every other month or a snore guard every other month or a sleep apnea or hernia implant every other month. They never reach critical mass.

Daniel: Sure, sure.

Howard: And you take the cost of all their continuing education, their systems and all this stuff, and it just would have been smarter to refer it out.

Daniel: Yeah.

Howard: So, you got to do it once a week. But the other pattern ... you've got to do it once a week, but the other pattern I see is they always have a human - the ones who get it done and they reach critical mass and they place an implant every week - they always have a human rep in their field, in their city, that comes by ... it just seems like there's not a human...

Daniel: Sure.

Howard: ... that knocks on your door, you never get it done.

Daniel: And yet, I think ...

Howard: True or false?

Daniel: I think that it's partly, for sure that's an important part. Having a relationship with a company that's going to be there to back you up, that's going to be able to help you, that might walk you through some complicated cases or even just to grab a part for you that you forgot to order, is very convenient. I think that's nice to have ...

Howard: Are they fixing you up with other dentists that place implants?

Daniel: Well, maybe to a certain degree. But I think that the whole process and the whole ... it more comes down to belief. Yes, the rep is important, absolutely is important, but it's what do you believe, and do you honestly believe that the best treatment you're doing for your patient is placing an implant there. And if the answer is yes, then the question is, how many bridges do you do, how many partial dentures, how many full dentures do you do, how many endodontic teeth are failing, so when people say to me, “Well, they just don't walk into my office.” Well, not a lot of people are necessarily going to walk in that have a pristine site for an implant that has been missing this tooth forever and knock on your door and say, “Hey, would you please put an implant in for me.” But you've got this entire range of other patients that, if in your belief system that patient that's been wearing a partial denture for a lot of years and is getting a lot of bone loss, maybe that's somebody you should have a conversation with about implants. That full denture patient that came in for a realign, maybe that's somebody you should have a conversation with, and maybe before you grind the adjacent teeth down for a bridge, you might want to have a conversation about placing an implant. So, those cases are in your practice every week.

Howard: I notice you said ‘grind down those teeth’, you didn't say ‘grind out that sinus’.

Daniel: Well...

Howard: Are you from the church of odontology...

Daniel: I'm very careful.

Howard: ...or are you from the church of ENT?

Daniel: I am very careful. And, you know, but I respect the sinuses and I'm careful around them.

Howard: Because that's why the R14 got popular.

Daniel: Of course, because you're angling away from the sinus...

Howard: Absolutely.

Daniel: ... because then you wouldn't go into it. But, and the thing that I'd like, and the trend that I've seen that I do like, are the shorter implants. I think that the ability...

Howard: The shorter, fatter implants?

Daniel: The shorter, fatter implants.

Howard: And I'm short, fat and bald. I'm a strong promoter of shorter and fatter implants.

Daniel: So, you bought a lot of their implants. I know, and I get that.

Howard: When I see a tall, skinny implant...

Daniel: It freaks you out. It's not natural.

Howard: I think, That's not nice.

Daniel: No.

Howard: It's not natural.

Daniel: It's not natural, but if we can use different systems to be able to avoid going into these structures, why not?

Howard: How fat would I have to get to have an implant named after me?

Daniel: I think you're all there. I think you've got it.

Howard: I think there should be a Howard implant. They'd be the shortest, fattest one from Dentsply.

Daniel: I think we're going straight to P90X after this.

Howard: I want you to call ASTRA and say, “Let's make one so short and fat that we'll call it the Howard implant.” So, I really love the ... what I love the most about the Galileos system and the CAD/CAM, is that it's seamlessly integrated. You can go into offices and it just seems like again, they get it done. You know, if you have a rep that comes in, they're more likely to get it done. If the system is all integrated from the manufacturer, it seems like it's a lot less training for the staff...

Daniel: Sure.

Howard: ... to teach, to coach, to just get it done.

Daniel: Well, and once you get the workflow and once you understand that ... my crown appointment is the same now in a single visit as what it used to be when I was doing multiple visits, and it just comes down to understanding the technology and having the pieces and the parts talk together, having the workflow be easier, to do the same thing.

Howard: And now, I want to ask you a controversial question. This is Dentistry Uncensored. We can talk ... we only talk ...

Daniel: And I'll lie to you if I feel like it's the right response to go with, so ...

Howard: Okay, but this measures the tone of your voice, this can tell if you're lying.

Daniel: No, no, no.

Howard: I got it from Russia. Putin sent it to me.

Daniel: And, well, I've got a better system. My wife is sitting right across here. So, she'll like clue you in.

Howard: She'll be over here going, “Push it, push it!” Okay, so this is a obvious source of confusion for kids in dental school, Millennials. It seems like all the old guys like me, older the guys from fifty to seventy who have placed a thousand implants or more, none of them use surgical guides. I would go to say that anyone who's placed ten thousand implants has never used a surgical guide. Except for like, you know, you know what I mean, the majority.

Daniel: Okay.

Howard: Standard deviation two.

Daniel: Okay.

Howard: Far more than standard deviation one, sixteen ampersand. We're talking standard deviation two. All the Millennials, they swear by surgical guides. So, how can you have these two polar opposite groups: never use a surgical guide - always use a surgical guide?

Daniel: That's easy. I don't even have to lie to you for this one. So, the guys that place ten thousand implants, generally these are the surgeons. These are the ones that are [00:41:23] clinically ... [0.0]

Howard: Oral surgeons?

Daniel: ... not restoring them.

Howard: Oral surgeons?

Daniel: So, I've got a great picture, I've got a beautiful implant position number nine...

Howard: Please send it to me.

Daniel: It was dead-center in the bone, tissue's pristine around it, gingiva's pristine around it, happens to be sticking right through the patient's lip, if you were to angle a crown through it, but there's great bone around it. So, what's the goal of the surgeon? The goal...

Howard: Well, first of all, I mean, was the patient Tennessee? This could be...

Daniel: Well...

Howard: She could be the hottest chick in the trailer park!

Daniel: Yeah, you're right, you're right. But, the point is, if my goal is looking at it from getting an implant in the right position in bone and treatment planning based on the bone, that's a totally different approach as ... my patients - and Carl Misch used to say this all the time, our patients don't want implants, they want teeth. So, if I start with the tooth first, and I say, "I really don't want to have a cement retained restoration, I don't want to mess with cement. I want it to be a screw retained crown." If I start with that end in mind and then I say, “Okay, well, if I want a screw retained crown, it sure would be nice if I could have that screw access right through the central faucet, that'd be a great thing.” So, starting with those two pieces and we say, “Well, it also would be really nice if we can have the ... go right along the long axis of the implant.” If you don't have those pieces in mind first, then your results are not predictable. So, if we do that though, and if we say that we're going to go with a screw-retained crown and you have a surgeon that places his implant five or ten degrees off and now that's changed, things have changed, and maybe you're still going have a great restoration that's going to work really well but the lab might call you and say, “It's coming through the marginal ridge. Are you okay with that?” Or “It's coming through the buckle cusp. Are you ...?” So, it just becomes less predictable. And I would say that I have placed many implants non-guided, the reason that I've leaned more towards doing guided, is because it lets it ... it makes it easier for me when I go to restore the tooth. It's more predictable.

Howard: And what percent of the general dentists do you think, if they weren't placing implants, would prefer to send it to a periodontist instead of an oral surgeon because they think the placement would be better?

Daniel: I'm not going to answer that question. I think that's a loaded question.

Howard: But what percentage?

Daniel: And I'm going to either piss off my periodontist or my oral surgeon!

Howard: Because Jay Resnick is one of the greatest oral surgeons that ever lived, and he uses all guided implant placements, because he always tells me, he says, “Howard”, he says, “I'm a surgeon. I can eyeball this and get it right ninety nine percent of the time. But I do all guided a hundred percent of the time, because that one percent, if I'm off one at one percent”, he goes, “that's one ...”

Daniel: That's a lot of restorations. That's a lot of restorations.

Howard: He's placing a hundred a month.

Daniel: Right.

Howard: So, he doesn't want one referring dentist in L.A. once a month to get this case you're talking about.

Daniel: Now, to play devil's advocate just a little bit, as much as I do believe in guided surgery, I think one of the trends that we're seeing that I don't love is that some dentists are only learning guided surgery and...

Howard: And they're not a surgeon.

Daniel: Well, they're not a surgeon, and what happens when you go to place that implant and there was a mistake, or something doesn't feel right or the bone isn't as dense as you thought, and now your implant's spinning. You don't know what to do. You don't know what to do and I don't want people to feel like, if I learn to do guided surgery, I can close my eyes and drill through that wall and think about what I'm having for dinner because it's not that easy. I think everybody should know how to place an implant freehand and know what it feels like and know what they're shooting for, and the guide is just a tool to get you a better, more accurate result when it comes to the restoration.

Howard: So, that's a good point. You need to be a surgeon.

Daniel: Yes.

Howard: You need to learn how to lay a flap.

Daniel: You're not just punching a hole through a guy to get your implant in there.

Howard: Yeah.

Daniel: Some of them go that way. But again, it's that one percent.

Howard: So, if you were born in ... you said you were born in sixty what?

Daniel: '68.

Howard: '68, so, you're an old fart, you just look good.

Daniel: Thanks.

Howard: So, he's on steroids and human growth hormones. His best friend is Lance Armstrong.

Daniel: That's why I'm so bulked out, right?

Howard: He's hanging out with Lance Armstrong. But, I can still remember the greatest thing on the radiology is when the pano upgraded, a software upgrade, and they put the R on one side and the L on the other.

Daniel: Yeah.

Howard: I thought that was the greatest invention, but I just think of these people who own the CBCTs, and I think how many millions of implants were placed with a 2D planner...

Daniel: Sure.

Howard: ... and ...

Daniel: But there were tricks. I mean, there were ... the guys that were good, the Misch that could sound bone and kind of figure all that out.

Howard: Well, he had a 2D pano, but you were flap ... you were opening the flap.

Daniel: For sure.

Howard: So, now if you're going to punch the gingiva, you have to have a 3D CBCT. But it's nice to be able to have the skills where you could use just a pano because you can flap and see what you're working with.

Daniel: Sure. Sure.

Howard: And, but again, the healing is a lot easier when you don't flap.

Daniel: It is, I think. I think, for sure, the morbidity is less and, but still, it's a necessary evil.

Howard: You need to know.

Daniel: You need to be able to do both.

Howard: You need to be able to do both, is what you're saying.

Daniel: Yeah.

Howard: You should be able to place an implant with a pano and a P.A., and you should be able to place an implant with a CBCT.

Daniel: Right, but that's where the programs we were talking about come in, because it's that whole education part. The education isn't for ... when you take a weekend class - and again, nothing against those classes - but when you do that, and you learn how to drill a hole in bone and torque an implant and to know what the parts and pieces are, that's great for when everything goes great. The education is that ten or fifteen or twenty percent of the time when something's off, something's not quite right. That's where the education comes in.

Howard: So, you went out of your way to talk about screwing versus cementing.

Daniel: I don't want to talk about screwing. My wife is sitting across...

Howard: It's Dentistry Uncensored. We're going to talk about that ...

Daniel: I'm not talking about screwing.

Howard: Let's talk about screwing.

Daniel: Okay, alright, you got me. You got me. Let's do it.

Howard: Do you think it's very important to be able to screw retain your crowns as opposed to cement.

Daniel: I'm afraid of cement still. I really am. And I think cements are getting better, to where they're are more radio opaque, and we can we can see them better on our images. But my goal, I always shoot for screw retained. Now, I can't always get there. The situations are going to be there where we're going to have to be cement retained, but, you know, I just think if we can shoot for that, we're going to be less likely, it'll be one more thing, one less possibility that's going to cause a problem with our implant down the road.

Howard: And when something goes south, it'll be a lot cheaper to unscrew it ...

Daniel: For sure.

Howard: ... than to cut it off.

Daniel: For sure.

Howard: And do you have very good luck tapping out? I mean ...

Daniel: No, I would never do it that way.

Howard: You know, I'm to the point now, I never even try to tap out anything.

Daniel: You turn your cement retained crown into a screw retained crown. You do endo access on it and then you unscrew it as one complex. So, it becomes a screw retained crown that you should have possibly done in the first place.

Howard: Yeah. Yeah. It's too much. So, are you ... so, on your surgical guides, if you placed one hundred implants ... in your last one hundred implants placed, single units I'm talking about, not ... because multiple units on edentulous arch, I mean, you know, what percent of your edentulous patients, multiple units on edentulous arch, would you use a surgical guide on?

Daniel: I'd say by far the majority.

Howard: By far the majority?

Daniel: By far.

Howard: What percent of your first molars, just the first molar, where they had a second bicuspid and a second molar, would you use a surgical guide?

Daniel: Part of the answer, now it's close to a hundred percent and it's not because I feel like I have to, but the technology has made it so easy for me. I'm going to plan my implant in cone beam anyway. I'm going to design my restoration anyway. So, it's just one more step to design the surgical guide in my software and I hit no.

Howard: One?

Daniel: Why not?

Howard: And is it milled out or is it ...?

Daniel: Both. I do both.

Howard: Do you do 3D printing?

Daniel: I will either ... I will do one or the other. I'll do one or the other. If I need it quicker ... 3D printing ... there are some printers that can do it relatively quickly but the one that I have, the Form 2, takes about ...

Howard: The Form 2?

Daniel: Yes, it's made by Formlabs.

Howard: Formlabs. Ryan, can you send me that? Why did you pick Form 2? I mean, I never even heard of that, so, what ...?

Daniel: Oh, you will hear of it, I promise you. A couple of main reasons for it, it is incredibly accurate. There are a lot of dental specific resins that you can use for it, so you can choose a resin that can be [00:49:42] auto-clicked, [0.5] that you can make the surgical guide with. I can tell you one of their competitors, SprintRay, which makes probably the next up-and-coming printer, MoonRay. They're based out of California. Great company! I think the CEO ...

Howard: SprintRay?

Daniel: I think the CEO is like twenty-six years old. Just an incredibly brilliant guy. And they're making a slightly different version of the printer, but same idea.

Howard: And what percent of that business is for dental?

Daniel: It's become incredibly popular with dental. I think ... I know SprintRay, in particular, has shifted most of their business ...

Howard: Did you find SprintRay, Ryan, out of California?

Ryan: Sorry, what was that?

Howard: Did you find SprintRay?

Ryan: SprintRay?

Howard: CBCT, out of California.

Daniel: No, they're a printer. They're a 3D printer.

Howard: 3D printer.

Daniel: And their printer's called the MoonRay.

Howard: The MoonRay?

Daniel: So, they have a MoonRay D now, which - D is for dental.

Howard: MoonRay D. Nice.

Daniel: And they're jumping in on that market because there are so many things: What if you could print your night guards? What if you could print your surgical guides? What if you could print clear aligner retainers for patients? What if you could print permanent restorations? So, that's the direction we'll see. I think, milling now is still much more efficient. We have a vast array ...

Howard: You got to think bigger though, because I've been thinking about printing $20 bills.

Daniel: I haven't found the resin for that yet.

Howard: You haven't found a resin for that?

Daniel: I haven't found a resin for that yet.

Howard: That's all I want to print, is $20 bills. And, so, but, do you think ... go out in the future, I mean, nobody predicts future, I mean, I tell these people that, you know, when you're [00:51:19] [...] [0.3] no-one predicted the fall of the Berlin Wall, no-one predicted the Arab Uprising, no-one predicted 9/11. So, it seems like ... and then after the event, everybody knew it was going to happen.

Daniel: Right.

Howard: But no one knew an hour before. But to me you're pulling this three-rooted tooth and then you're going back and you're drilling a singular hole for your implant.

Daniel: For sure.

Howard: And then you look at 3D printing, I mean, do you think we're around the corner from, I'll extract the tooth, I'll scan the tooth, it will print out a replacement tooth in titanium or bio-ceramic and I'll just replace? Remember that movie when we were little, the Six Million Dollar Man?

Daniel: Yeah, yeah.

Howard: We have the money, we have the technology, we have the know-how. Do you think we'll be ...?

Daniel: You invent it and, I promise, I'll buy it.

Howard: Do you think we'll be doing bio-identical?

Daniel: Why not? Why not?

Howard: Because then you wouldn't have to even drill a hole.

Daniel: Why not have biocompatible materials that you can print out and design and, like you said, I mean, it's so easy now to be able to get an accurate 3D scan of something, whether it's with a CBCT or some of the digital imaging systems out there, and then incorporate that into a printer. Why not?

Howard: Because ... so, you agree it makes sense that ...

Daniel: Of course it does.

Howard: If I extract ... because when you look at, you know, I always think about when people say, “What is the average American?” Can you imagine if the UFO just swooped down on earth and took one person back to whatever planet they're from and said, “This is a human.” I mean, what if it was a little five foot two Irish girl with red hair? What if it was a six foot eight Cardinals football player that weighed two hundred and eighty pounds? And to me, it ... when I look at these implant selections, I just think the ultimate implant selection would just be to scan your extracted tooth, hell, the CBCT could just scan the empty socket after the extraction, because if, you know, and then you just mill ...

Daniel: Yeah.

Howard: ... a bio-identical ...

Daniel: Yeah, now, if you can also print out the PDL, then you'd be in business. Then you'd be ... that'd be ...

Howard: I wanted to ask about that. You know, there's ... so much is cosmetics. You know, I've always said that in dentistry, especially for women, oral health is done for mental health. I mean, if you pulled Irene's ... and I got to ask Irene. Irene, how much money would I have to pay you to extract your front tooth?

Irene: [00:53:27] They're all implanted. [0.0]

Daniel: No, she's kidding. She's kidding.

Howard: But, really, how much money would I have to pay you to pull your front tooth?

Irene: If he were placing the implant?

Howard: No, no. You just had to pull the front tooth and go without your front tooth for the rest of your life.

Irene: Oh, well, I wouldn't buy that.

Howard: Would you do it for a million Dollars?

Irene: No.

Howard: So, when people will not pull their front tooth for a million Dollars, I mean, if I was married, I'd make my wife pull her front tooth for a million Dollars. I'd say, “Honey, get over there and pull that tooth.”

Daniel: You'd pull the damn tooth.

Howard: I'd pull it myself for a million Dollars. But, the bottom line is, you know, the dental health, oral health, is done for their mental health. And, so, a lot of people, you know ... the cost ... I still think the hardest implant case in the world is a single incisor.

Daniel: Hundred percent.

Howard: And the last one I did, after, you know, playing with this thing forever, I sent her to my buddy, a prosthodontist, and had him re-do the whole damn thing and gladly wrote a check, I mean, because her expectation, you know, it was front tooth, high lip line ...

Daniel: Right.

Howard: ... and so, some people are talking about there should maybe be ceramic, so, you don't have the dark metal. Do you think ASTRA ... do you think Dentsply Sirona ASTRA ... do see them coming out with a porcelain glass implant in the future or do you not think so?

Daniel: I can tell you that that is actually becoming fairly popular in Europe. I know Straumann has a full ceramic implant. I'm not really in favor of that, and it was funny because it brings up a lecture with Carl Misch years and years ago, because that's not new. That's not new. They used to have, and they tried ceramic implants many, many years ago. And the problem was the modulus of elasticity was so stiff, so rigid with it that they were seeing lots of failures. Now, it sounds great in principle to have something that's white and not gray to show through, but I don't know. I'm concerned about that.

Howard: Well, Carl even said that when one of those fracture, remove ...

Daniel: What are you going to do, right?

Howard: I mean, removing one was a crazy ...

Daniel: Right, what do you do, and then what are you going to do if the implant is slightly off angle? Having parts and pieces that join together, I don't love that idea. So, I think, right now, most of the workflow has been on one-piece ceramic implants, but are you going to prep that, are you going to cause micro-fractures in that?

Howard: What do you think Carl will be most remembered for?

Daniel: I think he was the most ... as far as his teaching skill, being able to call bullshit when it was bullshit, being able to sit there and say, “Here's my belief and I don't really care what you believe, and here is the research to back it up.” That part of the education has changed now, and I think we see a lot of people talking about things. Maybe there are different incentives that they have and there are different reasons for saying what they say but he was a no-bullshit kind of guy.

Howard: Yeah. And who was the prosthodontist that used to lecture with him and he finished out in Green Laboratories in Arkansas? Do you remember that guy?

Daniel: Yeah, I don't know that ... he wasn't part of the ... when I did it years and years ago, I don't know that he was part of that.

Howard: Who was ... but do you remember the prosthodontist that used to work at Green Laboratories?

Daniel: Yeah, I know who you're talking about.

Howard: Prosthodontist, Green Laboratories. Who was ... I wonder if his name will come up. Gosh, I can't believe he died of cancer five or ten years ago. But, I'll tell you what my favorite instructors are. You know so many of the lecture circuit, you know, they did, you know, five hundred cases and they show you. They just come show you the best of the best of the best and they just sit there and basically, it's just a low self-esteem convention where he's trying to validate himself that he's great or whatever. And what I loved the most about Carl is how he could put up six carousels of slides and go through every dental abortion mistake he'd have ever done and even this book, I mean, think about this, it's so cool. 'Avoiding Complications' and he's showing you every failure that he ever saw, found or did, and who was that guy who ... that prosthodontist. But, anyway, I loved the lectures that are, you know, like, who cares about veneers, show me the veneer case that failed.

Daniel: Right.

Howard: How do you fix the failed one?

Daniel: Right.

Howard: Don't show me how to do a root canal. Show me how to do a re-treat. Why ... you know, I love the doctors that have so much self-esteem they can get out there and say, “Let me show you every time I ever struck out in my life.” Whereas most of the lectures are, “Today's going to show you every grand slam I hit since, you know, preschool and Little League and here's me hitting a home run in high school.”

Daniel: It's a great point. I mean, wouldn't it be cool to do a lecture and you say, “I'm just going to take my next ten cases and those are going to be the cases that I'm going to show, good or bad. It's going to be those ten cases and that's what we're going to talk about.” That's not easy though.

Howard: Because a failure is just ... if you learn something from a failure, it's just an expensive lesson. And it seems like in the last, you know, like these Millennials that get out of school, my g*d, the first three or four years out of school, you're the best dentist that ever lived, because you haven't practiced long enough to see anything fail.

Daniel: Nothing's come back through your door yet.

Howard: Yeah. And then at five years out you're like, well, maybe they should take away my license and I should no longer practice anymore. And these, just, I've always learned the most from a failure. I remember, I changed my hygiene pay from paying them thirty five percent of production to an hourly wage because I didn't understand variance and I didn't realize that a dentist could have the whole morning fall apart. But then you could come in the afternoon and have a root canal build-up, two different root canal build-ups and crowns. So, the variance in what I can do for hours is so huge but when you're a hygienist and you lose two patients in the morning, how do you really make that up just to ...

Daniel: For sure.

Howard: And I didn't understand the variance and it wasn't until I lost one of my favorite hygienists in the world and she gave notice and she took a job somewhere else and she said, “It's because I'm not working on commission”, and that's what made me ... the pain of that is what made me rethink the whole deal and realize she's actually right. But I had to lose, I think her name was Donna Moore - if you're still out there watching. But, yeah, her name was Donna Moore, but it was ... so, I've learned ... it seems like the most dentistry I have ever learned was only from the failures.

Daniel: Yeah. It's my favorite saying, ‘Experience is what you get when you didn't get what you wanted’. And I think that's ...

Howard: Experience is what you get ...

Daniel: Experience is what you get when you didn't get what you wanted.

Howard: Nice.

Daniel: You can steal that - that's yours.

Howard: Nice.

Daniel: I stole it from somebody else.

Howard: Now, were you smoking legal marijuana when you thought of that?

Daniel: That has nothing to do with it. That doesn't enter into the fact at all.

Howard: You know they voted it down in Arizona, and I'll tell you what, if you ever have a patient come in and it's the governor or the mayor or whatever, if I was advising Colorado, you know what I'd tell him? When Vegas got legalized gambling, or I'd say the Mafia got legalized gambling in Las Vegas, as he started making bank, they spent a good chunk of that money keeping gambling illegal in the other forty-nine States. And, my gosh, if you look at the amount of weed that Colorado is selling and how it's had an impact on pricing of the houses and all that stuff, it's because in the States that it's not legal ... I mean, think about this bet, here's the reality the bet, if I asked you, Leave Phoenix, drive three hours south of border, cross into Mexico, pick up some marijuana and drive back, and I'll pay you a thousand Dollars.

Daniel: See you later.

Howard: You'd say ...

Daniel: Oh, sorry.

Howard: You'd say, “That's high risk. I wouldn't do that.” Ninety nine percent of Americans wouldn't do that.

Daniel: Of course.

Howard: But if I said, “Get in the car and drive to Denver, Colorado.” Well, I mean, I'm fifty-four years old. I've never once had a police officer say, “Pop the trunk.” I mean, if I get pulled over for speeding it's your license, registration, so, it's a very low risk driving to Colorado, Denver, and back. So, if I was Colorado, I would spend all your money fighting it in all the other States, and they just lost it in the election here.

Daniel: But there were a couple of States that passed it in this last elections.

Howard: I know, and you need to keep that ...

Daniel: We should step on that?

Howard: Yeah, yeah, you don't want that legal. Same thing with casinos, as these casinos rolled across United States, it hurt Vegas so much. You know where they're putting all their money now at? Keeping gambling illegal off the Internet.

Daniel: Now, if I can make implant placement illegal in every other State, now that would be cool. I'd be all in on that.

Howard: But Vegas thinks their downfall is going to be when everybody can just play the slots on their iPhone. So, they're fighting that tooth and nail. But, so, gosh, I can't believe we've gone an hour, that we've already gone over an hour. What ... is there anything I've missed that you're still passionate about? Oh, I know what I wanted to talk about. What percent, on a singular crown, what percent are milling out? Are you sending any to the lab?

Daniel: Very, very rarely.

Howard: Very rarely to the lab.

Daniel: Very rarely. There's just not a reason for it. We've got so many different materials for really any indication that you would do. There's just not a reason anymore to do that.

Howard: And are you just ... and what is your ... for your standard bread-and-butter six-year molar, what block are you using?

Daniel: It's going to be probably a lithium disilicate material or lithium silicate, they're relatively similar.

Howard: Lithium disilicate?

Daniel: Which would be e.max, or the relatively similar equivalent would be CELTRA DUO. So, one of those ...

Howard: And how do you spell that? That's a Dentsply one?

Daniel: That's a Dentsply one.

Howard: And what's it called?

Daniel: CELTRA DUO.

Howard: Spell it.

Daniel: C-E-L-T-R-A-D-U-O.

Howard: C-E-L-T.

Daniel: R-A.

Howard: R-A.

Daniel: Second word D-U-O.

Howard: D-U-O?

Daniel: DUO, as in two, as in two purposes.

Howard: DUO means two in what? What language is that? Italian?

Daniel: Well, just go with it. Just go with it.

Howard: CELTRA DUO - and 'DUO' means 'two'. Ryan, what language does 'duo' mean 'two' in.

Ryan: Ah, Latin, duh!

Howard: Is it Latin?

Ryan: Sure.

Howard: Is it Latin?

Daniel: Let's go with it.

Ryan: It sounds Latin.

Howard: Okay, what's the difference on the price of the block. What's an e.max block from Ivoclar and a CELTRA DUO from Dentsply Sirona cost?

Daniel: Yeah, probably similar. Probably in the $30 range.

Howard: $30? So, no-one's trying to get your business by having the [01:04:02] cost leader, [0.7] the Ikea, Walmart, Costco, Southwest Airlines?

Daniel: Well, if you think about $150 lab bill versus a block, which is going to be in the upper twenties to low thirties, a couple of boxes are going to make a difference. Probably not. I choose it more for workflow and what I'm looking for in the result.

Howard: But if you did a hundred first molars, what percent would be e.max and what percent would be CELTRA DUO?

Daniel: You know, it's changing. It's changing. And I'd say that it totally depends on the indication, what I'm looking for, and the result I'm looking for.

Howard: Okay, what about ... that's lithium disilicate. What about the zirconium?

Daniel: Yeah. I ... when zirconium first came out for chairside restorations and chairside milling and single visit dentistry ...

Howard: In the CEREC machine.

Daniel: So, when it first came out in the CEREC machine, I thought, What the heck do I need this for? I am totally fine with the other materials I'm using, but I bought it just because I like buying toys and I thought, Why not?

Howard: Oh, so, it's a separate milling machine?

Daniel: Well, so, right now the current version ... so, people that were to buy CEREC technology today would have a milling machine that would be able to dry mill it. And that's important because you can ... in the older machines you could wet mill it, but the sintering, or the firing process, of it takes longer, it takes an extra ten minutes, and, you know, for a dentist ten minutes is ten years. I mean, we just can't wait for anything. So, when it first came out, I invested in that technology without really appreciating what advantage it was going to bring to me. But it's been huge. It's been a big difference because the fit, the accuracy, when you take the material and you grind it and it starts out twenty five percent larger, you have a limitation with the size of the burs that can mill that restoration. But number one, the burs are smaller for milling zirconia, and then it mills out twenty five percent larger. So, once that condenses and shrinks back down, the anatomy, the fit is unbelievable.

Howard: But, on your standard first molar, do you ... would you prefer zirconia? If I came into you ...

Daniel: Yeah.

Howard: ... and I broke my first molar, I have seven inlays, onlays, crowns. Mine are all gold.

Daniel: Right.

Howard: Because when you're short, fat and bald, you know, you're not going for looks, you're just going for ... for I don't know, I just wanted all gold with ...

Daniel: Sure.

Howard: Oh, my g*d, what's the cement? I can't believe ...

Daniel: Is it zinc phosphate?

Howard: Zinc phosphate, yeah. I mean that's just ... to me that's still the gold standard. Would you ... if I came in, broken first molar, would you do zirconium, or would you do lithium disilicate?

Daniel: So, right now in my office, I probably wouldn't do zirconium, because the material for being able to get it done quickly right now is, it's fairly opaque and I'd say the cosmetics is higher. So, if I don't need that sort of strength - and that always comes back to what's strong enough? Is four hundred megapascals strong enough? Is a thousand? What do you need to get the job done? So, if you look in Europe and you see how many people are doing zirconium crowns in Europe, it's not big there. It's not big there. It's not like here. We're all in because we want the strongest. We don't want our patients to ever knock on our door. We don't want any possibility ...

Howard: You know what the red flag I see on zirconium is. You just said it with, when you were talking about the implants versus porcelain. You know, you say porcelain is stronger than Tupperware because you can put porcelain on a runway and have an elephant stand on it.

Daniel: Yeah.

Howard: But if I drop porcelain, it shatters.

Daniel: Right.

Howard: And then you say Tupperware is weak because I have an elephant stand on it, it'll smash it, but I can drop Tupperware and it bounces.

Daniel: Sure.

Howard: And when that implant was titanium, the fracture rate was lower than when it was all porcelain.

Daniel: Right.

Howard: Because with all porcelain, there's no give. And I'm already seeing some red flags from endodontists on this show who think that, since zirconium is so damn hard, that you're going to fracture more roots because now the weakest thing on that root canal build-up and crown, it ain't the zirconium. Now it's the root.

Daniel: Well, look at the implant too, because if you think about it from before when we used to place implants in and we'd screw in our abutment, the screw always got loose. That was the weak link and implant companies didn't like that and we didn't like it. So, now that's not a problem anymore. We really don't see screw loosening, screw fracture very often. So, the weak link became, we had a PFM crown. We'd have our feldspathic porcelain that would delaminate from the metal and that would fracture. So, that was ... our patient would overload the implant, that fails. Now we've got an implant that's really strong. We've got a screw that's strong. We've got an abutment that's strong. And now we're putting zirconium on top of it. We've sort of eliminated the weak link in that equation. So, our patients are still going to overload our implants. What has now become the weak link? And my thinking is that it might be the bone. Are we going to start seeing more cupping around implants? Are we going to see patients overloading our implants because we really haven't built in anything that's going to have any give to it?

Howard: Did you like that show? You are the weakest link! You remember that one, that British ...?

Daniel: No, because it's normally me that's the weakest link so it kind of hits a ...

Howard: Hey, what is the chance we could get some online CE from the master?

Daniel: Love it. Love it.

Howard: Really.

Daniel: You tell me what you're looking for, we'll set it up.

Howard: I would love it, man.

Daniel: No, I'd love to do it.

Howard: Huge fan of you. Huge fan of your work. It is so ... it doesn't surprise me that here you are, you fly into Phoenix, you're going to lecture tomorrow, you're with your wife and what do you do before? I mean, it's Friday night, and you decided to stop by my house and talk to my homies.

Daniel: I am a huge fan. I'm a huge fan and it's an honor for me to be here and I truly appreciate you inviting me over to do this.

Howard: No, Buddy, the honor is all mine.

Daniel: Oh, thank you, thank you.

Howard: All right.

Daniel: Appreciate it.

Howard: Thank you. Good luck with it. Now, how old's your boys again? You said they're ...

Daniel: Sixteen, nineteen ... or sixteen, twenty and twenty-one.

Howard: So, you're right in the crazy zone right now.

Daniel: I know, I'm good.

Howard: These are not good years for you.

Daniel: Oh, they're expensive years but they're good years.

Howard: Yeah, from sixteen to twenty-five is a little crazy.

Daniel: Yeah, they sure can be.

Howard: But just remember this, when they start turning twenty-five, twenty-six, they'll be normal again. They were ... I say all my boys were perfect till I gave them car keys, and then they were crazy till they turned twenty-five.

Daniel: Oh, that's funny.

Howard: But, alright, thanks so much for coming by.

Daniel: Thanks for having me. I really appreciate it.

Howard: Right, thank you, buddy.