Dr. August de Oliveira shares how he routinely uses CBCT for endodontic diagnosis, implant treatment planning and surgical stent fabrication. Learn about Dr. de Oliveira's books 'Implants Made Easy' and 'Guided Implantology Made Easy.' Dr. de Oliveira shares how he changes his surgical treatment plan based on the density of the bone and how a new dentist can get started placing implants in a predictable, controlled way.
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Audio HSP #35 with August de Oliveira
References and Links From the Show
Video HSP #35 with August de Oliveira
ImplantsMadeEasy.com - Dr. de Oliveira's website and books on Implantology
DigitalEnamel.com - Dr. de Oliveira and Dr. Todd Ehrlich's magazine for digital dentistry, Digital Enamel
MolarMechanic.com - Dr. de Oliveira's practice website
ImplantSeminars.com - Dr. Arun Garg's CE website
Dr. August de Oliveira's Bio:
Dr. August de Oliveira is the author of two implant surgery books, "Implants Made Easy" and "Guided Implantology Made Easy". He has been a CEREC Basic and Advanced trainer since 2004, and lectures nationally on 3D CBCT imaging and guided surgery. August serves as a lead clinician and developer for multiple guided implant programs nationwide. A graduate of the University of Washington School of Dentistry, he completed his GPR in dental implants at the VA Sepulveda and enjoys a thriving private practice in Encino, CA. Dr de Oliveira Co-Owns the website www.digitalenamel.com with Dr Todd Ehrlich
Howard Farran: Hey, it is always fun to be interviewing, I feel like you are my brother. I mean, I have known you on DentalTown. How long have you been a townie on DentalTown?
August de Oliveira: Since the year 2000.
Howard Farran: 2000, now it is 2014. How many posts do you have?
August de Oliveira: I didn’t check. I don’t know, 6,000 or 7,000.
Howard Farran: I know.
August de Oliveira: Yeah.
Howard Farran: I mean, it is a few guys like you that just make DentalTown a must go to site, so I want to thank you for all of the sharing you have done.
August de Oliveira: Oh, thanks for putting it on.
Howard Farran: You have been a huge pioneer in implantology. You put up that course on DentalTown, Implants Made Easy. You have had two books on implants, Implants Made Easy and Guided Implantology Made Easy. I have to tell you, we were just on the same lecture format. Where was that at? Nashville, weren’t we?
August de Oliveira: That was at Nashville, yeah.
Howard Farran: Yeah, just a couple of weeks ago. But I would say if you are inside a football stadium, you know everybody is looking at the football. And the football right now, the hottest topic in dentistry is basically we have gone from a 2D x-ray machine to a 3D and the law of unintended consequences, this is massively changing everything, especially implants. And some of those threads on DentalTown about CBCTs and guided implants, it is where the football is.
August de Oliveira: Right.
Howard Farran: And that is why I am so glad to have the master himself. No you are, you have been pioneering this stuff for a decade. I have your book right here. I wish I could pan the camera over. But tell us, what has happened to dentistry going from 2D to 3D radiographs?
August de Oliveira: Well, I mean, in the past we have had to really extrapolate a lot from 2D. We had to almost guess sometimes. You know, the biggest thing that I love having a cone beam in my office for is not even implants, it is endo. How many times have we taken angled x-rays to try to figure out where extra canals are? Or my biggest pet peeve is trying to diagnose any sort of problem on an upper molar. I am looking for a radiolucency in a giant radiolucency, the maxillary sinus. So the biggest thing I think that 3D has given us is the ability to see more things rather than having to kind of guess.
Howard Farran: And I don’t know anybody who went 3D who wants to go back to 2D.
August de Oliveira: Oh no.
Howard Farran: It is like I don’t know anybody who lost their vision and is glad. You know what I mean? So let’s start with the basics. There are a lot of machines out there and I am sure a lot of our viewers are saying, “August, come on. Those things are like $100,000.”
August de Oliveira: Yeah.
Howard Farran: First of all, what machine did you go with and what is your short list of recommendations if some dentist is going to go 2D to 3D?
August de Oliveira: Oh, definitely. Well, I went with Sirona and I have the Galileos Comfort Plus, which is their large field of view machine. You know, it depends on what you really want to do with it. I think the biggest requirement if you want to use it for endo is making sure that it has a very small, what they call a voxel size, or resolution. And I would say 150 microns or below. And the way that K-files are set up, the ISO standardization system is that if you have a ten file, the tip of the ten file a millimeter back is 100 microns. So if you have 100 micron machine versus a 200 micron machine, the 200 micron machine will only show a canal big enough to stick a 20 file in, whereas 100 micron machine, you will be able to see a canal small enough for a ten file. So I would say the big thing is really resolution. But also, if you want to do guided surgery and if you have a CERAC machine, it is imperative I think that you go with a Sirona cone beam, because the benefits between the two are really huge as far as being able to make your own surgical guides and just have that crown down accuracy that you can get.
Howard Farran: So you are saying the general dentist is going to love this the most for endo? So if a dentist is out there saying, “Well, I don’t do implants,” but you are saying you like yours the most for endo. And then implants would be number two?
August de Oliveira: You know, yeah, I guess if I could backpedal a little bit, just overall diagnosis I think is where cone beams really shine, because we can diagnose endo problems, we can diagnose if the patient has enough bone. But yeah, number one use that I have it for in my office day in and day out is endo, number two use is implants.
Howard Farran: And what is the number one cause of endo failure? Missed anatomy, right?
August de Oliveira: Right, yeah.
Howard Farran: So when you are looking at these maxillary molars, what percent of the time – well, first of all – your best guesstimate of the 120,000 general dentists in America, if they all did a molar endo today on a maxillary first molar, what percent of them would just do three canals?
August de Oliveira: Like 90% of them.
Howard Farran: 90%. And what percent of those teeth do you think have more than three canals?
August de Oliveira: I don’t remember the actual research, but…
Howard Farran: No, in your observation.
August de Oliveira: I would say at least 60% of them have an extra canal.
Howard Farran: 60%?
August de Oliveira: Yeah.
Howard Farran: And how often do you see a fifth canal?
August de Oliveira: Oh, not very much.
Howard Farran: And where do you think the most missed canals are, maxillary first molar would be number one?
August de Oliveira: Oh yeah.
Howard Farran: And then would you say the distal canal on mandibular second molars?
August de Oliveira: Yes, yes, most definitely. And you know, it is even the more benign things, like you are going through a crown on an upper second premolar, and usually the upper second premolars only have one canal, but a lot of them have two canals. So just being able to look at that before you even start the endo and say, “Okay, well look, if I have to go through this crown, I have really got to make my access a little more palatial and find that extra canal.” So it is good and bad, because you know sometimes in the past I would just give up looking for a canal. If I would trough for a while and I didn’t find a canal, I would say, “Oh, it is not there,” because I was only using 2D. But now it is 3D and I know that canal is there, so I really have to work hard to make sure that I find that extra canal.
Howard Farran: And what percent of your molars are you doing in one appointment? What is your thing? What makes August go two appointments versus one?
August de Oliveira: Really the only, I probably do about 95% of them one appointment. The 5% would just be the inability to dry the canals. So if blood is just shooting out of it or pus is just shooting out of it, I put calcium hydroxide in there and let them go away for about two weeks and then come back in.
Howard Farran: And it doesn’t matter to you if there is a periapical radiolucency to one-step it?
August de Oliveira: You know, there has been a lot of research out there, and I am sure there are a lot of people, especially on DentalTown, that will not do one appointment with a radiolucency. When I have someone with a radiolucency, I just really soak that tooth in sodium hydrochloride for a solid half an hour. But I fill at the end and I think my success rate is good.
Howard Farran: What do you think about going out the apex with like a very small six file to, you know, kind of stir up that periapical lucency or get some bleeding in there to kind of break that down? Do you think that is a little too aggressive?
August de Oliveira: Oh no, I always make sure all of my canals are patent. So I am always going out the end of my canals with at least an eight or a ten file, depending on how big the canal is. So I always want to make sure that I have patency.
Howard Farran: Okay, so let’s leave endo and go into implantology.
August de Oliveira: Okay.
Howard Farran: What percent of your implants do you place with guided?
August de Oliveira: Probably about 95%.
Howard Farran: 95%. And back to all of the dentists in America, what percent of the implants placed do you think are done with guided technology?
August de Oliveira: Probably less than 10%. I think most are done free hand.
Howard Farran: And that is where I am telling you the football is right now in dentistry, you know? So August, talk to these dentists. What are the advantages of using guided implantology versus just laying a big flap and looking at it with your eyes and just doing it free-handed? What is non-guided called? What do you call that?
August de Oliveira: Just non-guided, just free hand.
Howard Farran: Yeah, free hand. So what are you thinking? I mean, we have oral surgeons on DentalTown like Jay Resnick that will only use guided, and then you have oral surgeons that I have never used a guided. So walk us through that.
August de Oliveira: Okay, well there are a lot of things. One, you know, not disrupting the periosteum means that we don’t disrupt blood supply to the bone. So the bone always has a blood supply if you can either do a punch, which sometimes you can’t do a punch, or at least lay a really, really small flap. That is one thing. Postop pain, just it goes without saying that making an itty-bitty four millimeter hole in the gum is less painful than a big old flap. But the biggest thing for me is accuracy and safety. You know, I am worried about nerves and I am worried about adjacent teeth and I am worried about sinuses. I can see all of that ahead of time, make sure I plan my implant where it should be and avoid those things. The other thing is crown down implantology. That is the big buzz word in dentistry. I am doing more and more screw retained final restorations. And one drawback of the screw retained restoration is that screw hole has to be in a very exact position. It can’t be on a cusp, or you are going to break porcelain around it. It can’t be coming out the buccal or the lingual, or it will be ugly. I don’t like my implants to be shoved to one side or the other causing you to have mesial or distal cantilever to the crown. I like it dead center. In the anterior, I want my implants coming out of the singular of the teeth, not the incisal edge obviously. So being able to get that accuracy for me, I could not do it non-guided. I have to do it guided.
Howard Farran: So let me stop you there. So why do you want a screw retained implant versus a cemented?
August de Oliveira: Well, cemented restorations, of course I have always done those in the past, because that is just what I am used to. I have my little nub and I glue my crown on top of the nub and that is what I have always done as a dentist. What we are just finding is just that, you know, it is hard to sometimes get subgingival cement out, and that cement is causing problems. Sometimes abutment screws loosen up and if you have a non-screw retained restoration, sometimes it’s tough to get back into the screw access. The other thing is just for repair-ability. Sometimes people break porcelain or, you know, things change and it is really easy to unscrew a screw retained versus having to cut off a conventional cemented restoration.
Howard Farran: So it is the same argument with endodontists when they talk about obturating a tooth with a carrier, right Thermofill.
August de Oliveira: Right.
Howard Farran: That is all great, everything is fine, but it makes it more difficult to take out and re-treat. So you like the retreat-ability of this?
August de Oliveira: Absolutely, yeah.
Howard Farran: Absolutely. Okay, so you have a CERAC CAD/CAM, which is made by Sirona. And Sirona also makes a 3D x-ray Galileos.
August de Oliveira: Right.
Howard Farran: Walk us through more specifically. To someone who has never seen a surgical guide, they don’t have the first idea. The first question I want to ask you is, to someone who has never placed an implant, does this make it easier?
August de Oliveira: Oh yeah.
Howard Farran: Like how much easier? Is there any way to quantify that? I mean, has this lowered the bar?
August de Oliveira: Yeah.
Howard Farran: I mean, I remember back in the day when I got out of school, I got out ten years before you did. That is why you look like a Calvin Klein model and I look like I just fell out of a car. You know, I went through Carl Misch, got my fellowship at the Misch Institute, my diplomat from the International College of Implantology. You had a 2D pano. You would lay these big flaps. You would think you had an inch of bone and it would be paper. It was just, you really had to be a surgeon to place implants in the 80s.
August de Oliveira: Right.
Howard Farran: But now, not so much. Would you say that?
August de Oliveira: I say that, yeah, the integration between CERAC and Galileos has done quite a bit to make it easier. You know, again if we look at CERAC and Galileos, we call it CERAC and Galileos integration, the most basic form is that we get a crown form in CERAC, we put it in the Galileos, we move our implant around underneath it into the right position and then send away to Germany, a lab in Germany called C-CAT. And they make us a surgical guide. That is the most basic form. And that works out great. Another aspect of CERAC and Galileos integration is what is called CERAC guide, and CERAC guide is a way of milling your own surgical guide in your office, which I think is really powerful, especially if you do a lot of immediate implants. Immediate implants, you pull a tooth, you stick an implant in, but the problem is that you have to drill a hole in the tooth socket, which is usually in the wrong position. So I use CERAC guide a lot on immediates, and I think that is a great, great thing.
Howard Farran: Now is that the standard milling unit, or do you have to get the lab milling unit?
August de Oliveira: It is the MCXL, but it is not the lab MCXL. If you have the newer milling unit since 2008.
Howard Farran: Do you have a surgical guide at your desk or do you have one that you could hold up?
August de Oliveira: Yeah, I think I could probably dig one up…. Hang on a second. So yeah, so this is a standard surgical guide.
Howard Farran: And you can mill that out in your office?
August de Oliveira: Oh no, no. That is _____ 14:31 surgical guide. This is CERAC guide, and CERAC guide is made up of two components, thermoplastic tray material makes up the body and the whole and the height of the guide and the angulation of the guide, it is hard to see, is this clear piece that CERAC mills out.
Howard Farran: And does that limit your depth, too, with that surgical guide?
August de Oliveira: It does, depth, angulation and yeah. Depth and angulation.
Howard Farran: And so how would you compare, what type of surgical skills could you compare that to? If this dentist is doing extractions, I mean, do you have to be good at pulling wisdom teeth or impacted wisdom teeth? Compare the surgical skills of extractions versus placing implants with a surgical guide.
August de Oliveira: Well first off, I don’t do impacted wisdom teeth. And so that is scary for me. So I think implants are quite a bit less scary and less surgically intensive I think than surgical extractions, that is for sure. If you are placing an implant guided, I always tell people, really the motions and the parts and pieces are no different than doing a stainless steel post on tooth number three. You know, there is tooth number three, let’s say you are going to put the post in the palatal canal. That palatal canal is going to guide your drills and you are going to start with some round burr, maybe some piezos and maybe a post drill. When you are doing guided implantology, you do about the same thing. You use something to enter into the bone like a lance bur or a round bur, then you can go through your series of drills, maybe about two or three drills and then you put your implant in. So the actual surgical skills of guided implantology are almost operative, like doing a filling or doing a post. It is very nonsurgical, if you are doing punches, which of course we can’t do punches on every case. A lot of the times the bone needs to be recontoured or there is not enough good attached tissue. Then you just can’t do it that way.
Howard Farran: And what percent, talk about whether you can immediately load this. What percent of the time do you mill out the CERAC crown after you place the implant and place the final restoration?
August de Oliveira: Well, there is kind of a difference there. There is wanting to put on a temporary and then going for it and going for the final restoration. I think everything really boils down to how much torque you get on the implant. So you can’t immediately load or temporize an implant unless you have at least 35 newton centimeters of torque.
Howard Farran: And what percent of the time would you achieve that?
August de Oliveira: I don’t know, on a healed site, almost 100% of the time, maybe 90% of the time. On an immediate extraction, that is tougher, because the implant is really only being held in the bone by about three or four millimeters of bone. So that is maybe 50/50. And I think a real point to tell a patient if they broke a number eight off of the gum line, you know, I am going to do my best to put an implant in and get it in tight enough so we can put a temporary on you, but you know, if we can’t, then you are going to have to wear a flipper. And so the important part with immediates is never to promise the patient that they are going to get a tooth that day.
Howard Farran: Yeah, and I also want to tell my fellow dentists out there, is that is one of the reasons I think warranting your work five years is intense, because so many dentists when a patient snaps a number eight at the gum line will do a heroic root canal, a heroic post build up, place the crown and think they did a good job and take $2,500 from the patient, and they back in with their hand a year later and they are just like, “Well, you know, I tried. I tried.” It is like, well trying isn’t good enough. You are a doctor. And if you can’t guarantee your work for five years, you have got to diagnose a little more aggressive. And I always diagnose aggressively enough to where I have no problems warrantying what I did for five years.
August de Oliveira: That is great advice. Yeah, I heard you say that back in your, you know, 30 Day Dental MBA days and I have done that, too. And one of the great things about being a general dentist that places implants is we have that option. You know, even if you don’t, you can always send the patient out, but I mean having that in your option, I try not to do heroics. I mean, I sometimes do and it still bites me in the ass, but I try not to do heroics.
Howard Farran: And it also makes me leery of the endodontists who can’t place an implant, because I see it in Phoenix all of the time. The endodontists who don’t place implants, no matter what you send them, they will say, “Well, I will try,” and they re-treat the tooth, they do the root canal. But if they have CBCT, they see the mesial buccal root is fractured, they can still make money. You know, they will extract the tooth, place an implant, do whatever. But if your only tool is a root canal and you are an endodontist, that might not be the best guy to refer to. You might look at referring to someone who has got a CBCT and can make money saying, “You know what, I don’t think we should do a root canal here. I think we should pull this tooth and place an implant.” So about your books, what year did your books Implant Made Easy and Guided Implantology Made Easy, what year did those come out?
August de Oliveira: I think Implants Made Easy came out in 2010 and Guided Implantology Made Easy was 2013.
Howard Farran: 2013. So for someone out there, one of these listeners, they have never placed an implant, they don’t have a CBCT, walk us through those two books and how can they order those and how would these books help their journey to 3D and guided implantology?
August de Oliveira: Sure, well Implants Made Easy is actually on the thread on DentalTown, Implants for Dummies. And in Implants for Dummies, what I did is I started placing implants and I wanted to just post a bunch of stuff that I thought was important to learn along the way and kind of post my cases and get critiques from guys that have been doing it for a lot longer. So Implants Made Easy is basic, lay a flap implantology. It is just how to do simple single units. There is some stuff on, you know, a little bit on the restorative aspect of it, but it is mostly just garden-variety implants and anatomy. The second book, Guided Implantology Made Easy focuses much more on guided surgery and more specifically how CERAC and Galileos talk nice to each other and how to mill out your own surgical guides or to use, you know, do an edentulous case and how to integrate a CERAC scan of a patient’s denture into the plan.
Howard Farran: And how would these viewers purchase these books? Where would they go to?
August de Oliveira: Implantsmadeeasy.com.
Howard Farran: Implantsmadeeasy.com. Implants, plural, made easy.com.
August de Oliveira: Yeah.
Howard Farran: Okay, now on this Guided Implantology Made Easy, does this book only apply if you went with Sirona’s Galileos? What if they bought a Carestream or another CBCT?
August de Oliveira: Yeah, well there is definitely some cool stuff in there. One thing, and I know you know this. You have been placing implants longer than I have, so you know this more. But teeth have certain angulations. So you have the Curve of Wilson and you have the Curve of Spee and what I did was I have a little atlas in there that has tooth diameters and what size implants to use and what the average angulation buccal-lingually of number eight is. So although the book is geared more towards CERAC and Galileos, even if you are using an _____ 22:36 or you are using Noble Guide or whatever, I think they could benefit from it.
Howard Farran: And what makes you decide if you are going to send a surgical guide to Germany and have them made versus mill out your own? What are your thoughts there?
August de Oliveira: Yeah, multiple units. So I use CERAC guide for single units, but if I have multiple units, I send it out to Germany. The CERAC guide, you can do multiple units with CERAC guide, but it is really hard.
Howard Farran: And what about the fully edentulous, if you are talking about putting fully edentulous?
August de Oliveira: Yeah, definitely you want to send that out. You can’t mill that in CERAC guide.
Howard Farran: And what do you do on a full edentulous, because you know, the bottom line is men die on average 74, it is women who almost go to 80. So most of these older ladies with dentures problems, you know, most of them are females. Do you have a low cost, like two implants, medium cost, like four and a Hader, the high cost six implants and bridge? Do you do those or do you have more of just a standard four on the floor? Talk about the…
August de Oliveira: The different options for the patients?
Howard Farran: Yeah, the 80-year-old. Tell me about that, it is an 80-year-old, full denture. She is having a hard time chewing.
August de Oliveira: Yeah, if someone, you know, just wants something to nail the denture down, I typically do two implants with, I call them GPS attachments or locater attachments, and just retrofit their denture. You know, I have to be honest with you. I don’t have little packages. I probably should. We diagnose individual implants and we have a charge for an implant, the attachments and stuff like that.
Howard Farran: And you getting success with two implants, retrofitting a lower mandibular denture?
August de Oliveira: Oh yeah. Well I mean, the important thing is talk to your patient and see what your patient wants and how much they can afford. But you are always going to get more retention on a lower than without implants. So yeah, that has been greatly successful. Patient’s love it.
Howard Farran: Is that your go-to, two implants with locator attachments or is it more four implants or hybrids? What is your go-to?
August de Oliveira: Hybrids. I love hybrids.
Howard Farran: What if it was your mom, 80 years old, full denture. August’s mom, full denture, 80 years old. August, I can’t really chew. My molars are flopping around.
August de Oliveira: Yeah, you know, I mean this is going to sound cruel, but I would still try to talk them into a hybrid. I mean, when you are 80, it is not my job to determine how long you are going to live, but I just know that you are going to really like to eat during the years that you are around. So I tell them, “Hey, the best thing is a hybrid.” They can’t always do it.
Howard Farran: Explain what a hybrid is to our viewers.
August de Oliveira: Oh, I am sorry. A hybrid is a screw retained denture. It is a screw retained bridge. You know, I personally can get away with four implants on the lower and doing a hybrid if we have something called the AP spread, and the AP spread is the distance between the most anterior implant to the most posterior implant and we can cantilever back 1.5 times that. So if I have enough AP spread to not do removable, I try to talk them into a hybrid if they can afford.
Howard Farran: So a hybrid is a fixed that doesn’t touch the tissue, but you can remove it.
August de Oliveira: Yes, I can unscrew it, but the patient can’t.
Howard Farran: And what I really like about this is one of my pet peeves with our profession, it seems like dentists are more engineers. They are always talking about adhesive rates, wear rates, you know, micron fits.
August de Oliveira: Right.
Howard Farran: And it seems like almost all of the dentistry I do gets destroyed by gram-negative anaerobes. I mean, it is Streptococcus mutans and P. gingivalis. So I see dentistry as a biological problem, not an engineering problem. And what I love about implants is when I go into these nursing homes, in my area, I have a dozen nursing homes in my zip code.
August de Oliveira: Oh wow.
Howard Farran: And when I go in there, August, I mean those ladies aren’t in there for a year and root surface decay has just bombed out their entire mouth.
August de Oliveira: Oh yeah.
Howard Farran: And those ladies that got titanium, they don’t get cavities.
August de Oliveira: No.
Howard Farran: And they are perio, I don’t even like calling it periodontal disease around implants, because it is totally different. You know, irritated gums is not periodontal disease.
August de Oliveira: Right.
Howard Farran: Would you say periodontal disease is massively different around implants versus teeth?
August de Oliveira: It is. It is weird. You know, it is interesting. If you have a real deep pocket on a tooth, a lot of the times there is pus and stuff like that. Sometimes you can have bone loss around an implant and have, you know, a ten millimeter pocket and there is no pus. There is no infection. And you know, you sit there and think, “What do I do? Is this implant going away, or what do I do?” I tend to watch things like that. But it is amazing how there is no redness, pain or any signs of infection around these areas where you have peri-implantitis.
Howard Farran: Yeah, and I mean first of all if a person has got full-mouth gum disease, you extract all of the teeth and the gums look all firm and pink in two weeks. I mean, they look perfect. There is something, the tooth has something to do with the entire disease. And irritation around a titanium implant, August, walk me through this. I am having an ethical problem in my own mind and my own practice.
August de Oliveira: Okay.
Howard Farran: You know, men, they all worry about prostate cancer and all of these different things and they all die of a heart attack. It is just kind of like the public, they all worry about dying in an airplane and they all end up dying in their car. Men aren’t an issue with me. But these women, you go into these nursing homes and it is 99% women. And they live so long and so many times I am seeing dentistry I did over the last 25 to 26 years doesn’t even last a year in a nursing home. And then I start wondering, you know, that lady was 65 and I took $2,500 for her and saved a badly broken down molar with a root canal build up and crown. Gosh, if I would have extracted that and done an implant and a crown, it would have been immune to root surface decay, Streptococcus mutans. And then if they have a history of like Alzheimer’s or dementia, are you starting to look at a 65-year-old lady with a broken down molar saying, “You know, I am more concerned about this lady when she is 80 than at 65. And maybe I shouldn’t be doing endo on ladies over 65.” I mean, does that cross your mind or does that play with your thinking?
August de Oliveira: It doesn’t, you know, from the time frame that you are talking about. But I will say that, you know, if I look at a tooth that has had endo and it is a perfect endo and there are still PA lesions, I am much less likely to re-treat. If I can get my cone beam and go in there and know that I found all of the canals, I still got to the apex, I am more likely to offer the patient either going to an endodontist to have it re-treated, because I don’t want to re-treat it, because I don’t think it is going to work, or talking it out and doing an implant. So my gutsiness is much less now that I have implants and I know how well they work. But yeah, I understand your point. I mean, but should we give up on endo? I don’t think so. I mean, who knows if the tooth that you did at 65 would be around at 90? I hope it would.
Howard Farran: Yeah, you know when people say the golden age of dentistry is over, I say, “Absolutely. Now it is the titanium age.” And what I love about titanium is its immunity to gram-negative anaerobes, because that is what we do.
August de Oliveira: Yeah.
Howard Farran: So I want to switch gears here. We are halfway through this. Pretend I am a 30-year-old woman dentist who just graduated five years ago from the dental school up the street and I am like, “August, I have never placed an implant. I have got a 2D pano. Really? Should I spend $100,000 and buy a CBCT and get into guided implants?” This is a huge decision. And I notice on DentalTown, I look at their search results. You know, I look at what people are searching for every month. And I guarantee you, as a decision starts costing six figures, like CAD/CAM or CBCT, I mean, that is all the searches. And you are the man in this area and they are searching and reading your threads. Talk to this 30-year-old woman dentist. Should she really commit this kind of money? And the first thing she is going to say to you is this, “I have still got $300,000 of student loans and I bought a practice that cost $400,000. I am already $700,000 in debt and now August is telling me to go deeper.”
August de Oliveira: Right, well it is a really tough decision to be honest with you. I mean, whenever you buy a piece of dental equipment, you need to say to yourself, you know, is it going to make money? Is it going to generate enough net income, not gross income, net income to make the payment? And cone beams are expensive, no doubt about it. If this person is not, let’s say they are not doing endo, they just want to buy it just for implants. I would say on the first, I don’t know, 10 or 20 cases send the patient out to a scanning center and see the scans and do the implant off of that. But what I found very early on was that, you know, the more scans I did, the more I found I was doing a lot more implants and I was seeing cases that I could tackle. So it is a tough call. When you have a lot of debt, obviously you don’t want to throw more money on it. But the other thing is diagnosing. I mean, I diagnose so much more endo than I ever did in re-treats and things like that, because now I can see everything. So if you are a GP doing endo and doing implants, I would say, yeah. I would say go for it. If you are buying it just for implants and you have never placed an implant before, I would say wait until you get to a point where you are doing more implants to justify the cost.
Howard Farran: Okay, and what would you say to this dentist if she said to you, “Well, shouldn’t I take an implant course first?”
August de Oliveira: Yeah.
Howard Farran: What course would you recommend? What would you recommend to get educated making this decision?
August de Oliveira: That is a great question, and it has, I think, more to do with your personality. I mean, you did Misch, which was great. It was a pretty big time commitment. I, I don’t know if I have adult onset ADHD, but I can’t pay attention for more than 20 minutes. Yeah, there are lots of courses out there that you can kind of do ala carte. Like I know Garg has some great courses. I have got a buddy, Todd Engle from the Engle Institute where you can take these ala carte four day classes where they will teach you, you know, how to do a basic implant with a flap. You will get a live patient and then you will do it.
Howard Farran: Can you drop some contact information? How do they contact Garg or Engle? Do you know their wwws?
August de Oliveira: Garg, I think his website is called implantseminars.com.
Howard Farran: Okay.
August de Oliveira: And I think the Engle Institute is engelinstitute.com, and that is spelled E-N-G-L-E, Engle.
Howard Farran: And where is he from?
August de Oliveira: He is in North Carolina.
Howard Farran: North Carolina.
August de Oliveira: Charlotte. But I would definitely, definitely say that if you are going to learn how to do implants, you need to do a course with some live patients. You have got to do it on a live body. And, you know, again I know Garg his this thing in the Dominican Republic where people go and they place, like, some God awful amount, like 30 or 60 implants over a weekend and it is all on patients and they are doing sinus lifts and all sorts of crazy stuff. So if you take a course where all you do is learn on a model, I don’t think that is going to cut it. I think you need to make sure that you do a course with live bodies.
Howard Farran: And I want to throw one answer to that in too, that was excellent advice. Garg is tearing it up out there. All of my friends have gone to the Dominican Republic and they loved it. But I want to say another thing, is if you don’t have any money, if you call your local oral surgeon and periodontist, I mean, they all want a friend. And you are thinking, well he is not going to teach me how to place an implant, because then he is going to lose business. So why would he teach me to lose business, because I am sending him all? And that is just not the way 90% of them think. I mean, same thing with ortho. Every orthodontist has told me that every general dentist that wants to do ortho, they are all afraid of telling him or whatever. And they gladly help any one of them and usually after two or three or four years, the dentist is done with that phase in his life and he gets all of the referrals.
August de Oliveira: Yeah.
Howard Farran: In fact, I know several orthodontists who a general dentist gets into ortho and a year later says, “Oh my gosh, will you take all of my cases?” And they go, “Absolutely.” So yeah, call your periodontist, call your oral surgeon right across the street. They are going to help you.
August de Oliveira: Yeah, for sure.
Howard Farran: So looking at failed root canals, is the CBCT helping you that is just missed anatomy, or are you also seeing root fractures? Like on a maxillary molar, are you seeing that the mesial buccal root is fractured and if they were using 2D x-ray and did a re-treat it wouldn’t have healed up anyway because it was fractured? Are you seeing root fractures causing failures or is it mostly missed anatomy?
August de Oliveira: Mostly missed anatomy. As far as root fractures go, remember we are limited by the resolution of the machines. So if I have 100 micron voxel sized machine, that crack has to be at least 100 microns thick to show up. That is a pretty big crack. I mean, you could definitely see that on an x-ray. So what we are seeing more is the sequela of a root fracture, so a deep vertical pocket, you know, a lateral PA lesion, stuff like that. That tells us more of fractures. But I would say most of the endo failures are due to missed anatomy.
Howard Farran: Okay, but describe that more for the person listening to this on a podcast. Describe more of what this would look like on a CBCT. You are not seeing the fracture, but you are seeing the pathology around it. You are seeing vertical pockets, you are seeing…
August de Oliveira: Yeah, it is a big huge bunch of bone loss on the side of the tooth ending mid-root. You know, if you have a PA lesion or an abscess that is blown out, you will see the sinus tract going from the end of the apex all the way up. But if you see a lucency just kind of go all the way down the root and stop mid-root, you know, you have got a horizontal fracture at least there or a vertical root fracture. So it is easy to see that. It is hard to see the actual fracture itself.
Howard Farran: Okay, and August, what about surgical guides, there are other threads about surgical guides, Blue Sky, Armen is doing surgical guides. Any commentary on those methods?
August de Oliveira: Yeah, you know, they are all good. I think it depends on really how much hand-holding you want. I know Anatomage makes some great surgical guides, Roe Dental Labs I know works with Blue Sky to do it as well. My thing with Sirona and Galileos is that they are so anal. They reject scans on me left and right. They tell me, “August, do you really want to get that close to the nerve?” You know, so there is always someone reading my scans and kind of getting my back. And I don’t know if it is true with other companies, but I know Sirona will give you a certificate of accuracy where they will actually test the accuracy of your surgical guide versus your plan. I don’t know if they do that on a model, I don’t know exactly how they do that. So there are lots of guide companies out, it is all good. There are lots of good guides. I can’t say that one company is better than the other, but for me, I like Sirona because I like that hand-holding that I get from them.
Howard Farran: Okay, and then I want to talk about another area. So, you know, we generally think of four types of bone in the jaw, that the lower anterior mandible is hard as oak, back is more like balsa and the front is more like styrofoam.
August de Oliveira: Yeah.
Howard Farran: For a newbie getting into implants, you know, their first hundred implants they are going to place over the first couple of years. Are there any areas of the jaw where you would say start here and avoid here? I mean, you know, are you telling them to avoid mandibular posteriors because of the inferior alveolar nerve or the sinuses? Does that play into your mind for newbies?
August de Oliveira: Yeah, yeah. I mean, for newbies you want to stick to maybe D1 or D3 bone, or even D1 bone. D1 done is kind of hard.
Howard Farran: Explain that terminology to our viewers.
August de Oliveira: Yeah, so the anterior mandible is mostly cortical bone and in dentistry, we are always used to drilling holes and sticking things in holes that are smaller than the hole. So if I do an inlay prep, my inlay prep is bigger than my inlay. If I do my post prep, it is bigger than my stainless steel or zirconium post. It is the opposite in implantology. We make small holes and we put in big screws. So if I am in D4 bone and I drill a hole that is slightly smaller than my implant, I am going to have a spinner and the implant is not going to have any retention.
Howard Farran: Explain D4 bone to someone who doesn’t know D1, D2, D3…
August de Oliveira: Yeah, so D4 bone is made mostly of trabecular bone. The trabecular spaces are very wide and there is very little cortical bone. So when we want osseointegration, we want bone laid down on our implant and there is just not a lot of bone in there. And so when you are dealing with D4 bone, I might put a six millimeter implant, but the diameter of my osteotomy may be three millimeters. And I am going to rely on my implant to somehow compress the bone into a denser bone. That is kind of tough to manage. And D1 bone on the other hand doesn’t expand at all. And so when you are drilling into D1 bone, you really have to make your hole almost the same size as your implant. D2 bone can be tough sometimes. D2 bone has a thick cortical plate, but it has trabecular bone in it. And then D3 bone is nice. It is kind of spongy bone and you make your hole and your implant expands it. So I don’t really tell people to stay away from different types of bone. But yeah, definitely stay away from upper and lower second molars. You can tackle first molars, but make sure that you have got tons and tons of bone, you know, 18 millimeters, 16 millimeters of bone and stick in a 10 millimeter implant. I also tell a lot of people to stay away from the omental foramen, because that can get kind of tricky, too.
Howard Farran: Now where were you in your career when you became a member of DentalTown? You were a dental student, weren’t you?
August de Oliveira: No, I just got out of my GPR and I bought your 30 Day Dental MBA and I loved it so much, I watched it over and over and over again. And so I think I was an associate when I bought it and when I got into DentalTown.
Howard Farran: An associate. Because I want to ask you a question, but I want to say something first. To me, it seems like if I could sum up your career, because I have watched your career for a long time. To sum up your success is because the number one trait I see in the most successful dentists is humility. They listen, they learn, they take a lot of CE. They listen to their staff, they listen to their patients. And you do two traits that you don’t see in dentistry. You are so humble and you have always been transparent. You know, you have been posting everything that you do on DentalTown. And I think that it is so counterintuitive, because most humans don’t want to post any case they have done on DentalTown because they are afraid someone is going to say, “Well, it is not perfect.”
August de Oliveira: Right.
Howard Farran: And then if someone says, “Well, I think you could have done it better if you did this,” and they are traumatized. And our personalities are the opposite. We want to hear the feedback to be better. But August, I am going to throw this question in. What do you see, you know, to the 5,000 dentists who just walked out of dental school. They are $300,000 in debt and they are thinking, “August, well it was good when you got out of school. But I am getting screwed. This is horrible.” And some of these dental graduates have been out five years, since the great 2008 economic collapse, Lehman Brothers and all of that stuff. And for five years they have just kind of been shell shocked. So I am going to ask you this, is the golden age of dentistry behind us? Should those students have graduated when you did and not now? And what advice would you tell the graduates and the ones that have been out five, six, seven years? What could they do so that when they are 45 like you, they would be sitting there with all of these clinical skills and a great practice and crushing it?
August de Oliveira: Yeah, you know, the funny thing is that it is always a shitty time in dentistry. When I got out, everyone was telling me the same thing. The golden age is over and then you are just going to have a sucky life. So you know, I tried to work at any associateship I could get. The way it works in L.A. is usually someone is not busy enough to give you five days a week, so you work a day here and a day here and a day here. First off, I would tell graduates don’t be stuck up. You know, when I went to dental school, it was just very ivory tower kind of stuff. And I worked in HMO clinics, I worked in inter-city clinics. I worked in boutique practices. I worked everywhere and I saw all sorts of different things that I wanted to emulate and also some traits that I didn’t want to emulate. So that would be number one. But number two, and I learned this from you, you can’t sell what is on your menu. So if you don’t know how to do endo, take endo courses. You know, don’t waste all of your time with TMJ and occlusion and all of that stuff, which is good to know, but your bread and butter stuff is what you are going to need to do. So take classes on extractions, take classes on how to do a good crown prep. Be a jack of all trades. Be able to treat whatever can walk into your door.
Howard Farran: And you know, one of the greatest endodontists in the state of Arizona, if not one of the greatest endodontists in the world, is Brad Gettleman, just an endodontist up the street. And you young dentists don’t realize that a lot of those guys have open door policies. I mean, if you don’t know how to do a perio program, you can just go spend the day with your periodontist up the street. If you don’t know how to do endo, go sit there and just sit on the assistant’s stool at your endodontist. I mean, I sat for countless hours just watching Brad knocking out molar endo after molar endo, just perfect endo in under an hour. But yeah, so how many hours of CE would you recommend that they take when they get out of school?
August de Oliveira: Oh wow, I don’t know to be honest with you. I mean, I know the state requirement in California is 25 hours per year. I think you should do more, at least 50. I mean, get out there and just get into these classes. It is easier now that there is so much great stuff online on DentalTown and stuff like that. And I would also go back to DentalTown and back to posting. I learned a lot more by just posting my stuff and getting, sometimes getting a new one ripped by an endodontist saying, “I can’t believe you did such a shitty endo.” You know, and that hurts, but the same regard that criticism stays in the back of my head. And I think posting or taking pictures of your work and posting it online, you will see the good, the bad, and the ugly. And you will get some people that honestly do want to help you and that helps a lot.
Howard Farran: And that is the counter intuitiveness of success, the being transparent when everybody else won’t show what is in their closet and that is how you get better, is showing it. So you have talked a lot of about endo. You have talked a lot about implants and CERAC. Anything else in your office that you are passionate about? Describe your practice, first of all, what city are you in? You are in Encino?
August de Oliveira: I am in Encino, California. It is outside of Los Angeles. It is a fairly affluent area, so I don’t take any HMOs or PPOs. I am not a Dental dentist, but we do accept _____ 47:37 benefits. I think another exciting area which I don’t know a lot about, but I want to learn more, is medical billing. I think that what we are finding out is there are certain things in dentistry that medical cover, such as night guards and stuff that we do a lot. And so one aspect of my practice that I am trying to do more and trying to learn more about is medical billing and I think that is an exciting area.
Howard Farran: Because night guards, because you seeing a lot of TMJ or is this sleep apnea? Is an affluent area more stressed out grinding their teeth?
August de Oliveira: Probably, yeah. No, you know, I mean I am not an expert at all. I see two things. Nocturnal bruxism without TMJ symptoms, and in those cases we do a flat plane splint. But then sometimes we do have patients that do have TMJ symptoms that are clenching or grinding and we will do an occlusal orthotic or we will do a Michigan appliance on those types of patients. So I am certainly not educated enough to talk about all of the aspects of grinding, but what we are finding is dental insurance wouldn’t cover them, but sometimes medical would if you play by the rules. So that is kind of an exciting aspect that we are looking more into.
Howard Farran: I had my mind blown on a CBCT on a case that for the last 27 years I just would have made a surgical flat plane splint, but I had the CBCT and it crossed my mind, you know, well look at the joints. And there was a piece of bone. And I sent it to Dale Miles, the TMJ guy, and he was like, “That needs to be removed. That is a huge problem.” And without a CBCT, how could you have seen that?
August de Oliveira: You can’t see it.
Howard Farran: I mean, I don’t know anybody. So besides TMJ and medical billing, what else has got you excited in Encino?
August de Oliveira: Oh, good question. I mean, just working more on my practice. You know, I have gotten to a point, and I do this all of the time on DentalTown. I lecture so much, and I know you do, too. It is currently right now where just getting back into marketing our practice, getting more stuff with Facebook. The staff has really taken over and are really kind of reworking my practice and making it more efficient and better. So practice management I guess is what has got me excited lately.
Howard Farran: I have got to give you a Facebook tip, I don’t know if you know this. But we are talking the day before Halloween, but I have 60,000 friends on my Facebook page. So I get so much stuff, I can’t even repost what everyone is sending me. So every single day, I repost like the greatest hits. So you if are building your Facebook page, follow me at facebook.com/howardfarran and just steal my stuff. You know, I didn’t make any of that stuff, I am just sharing it all. But it is a repository of…
August de Oliveira: You have got some great stuff.
Howard Farran: Oh yeah, and it comes from everywhere. Czechoslovakia, Germany, Brazil, just all over. So I have only got you for nine more minutes. So what do you say to that dentist, he is in Parsons, Kansas? The last five years, his town is not going anywhere. And he is sitting there thinking, I know what he is thinking. He is saying, “Oh, come on, August. You are out in California. You are out in Encino. I am stuck in Parsons, Kansas.” And he wants to live in Parsons, Kansas. He was born and raised there, his family is there and all of his friends are there.
August de Oliveira: Sure.
Howard Farran: What advice would you give that guy in the middle of the small town, rural America?
August de Oliveira: Well, you know, you have got to work with your market. So don’t price yourself out of your market. I mean, although all patients think we are expensive anyway. But just again be the jack of all trades. Be able to do everything in-house. I love having CERAC, and so being able to do crowns in-house saves my lab bill and I can bust things out in one appointment. Learn implants, learn extractions, learn dentures. You know, just treat your patients. It is these people that are cosmetic dentists or subspecialties of some aspect of dentistry that are doing fine for a while and then the economy goes to crap and they lose everything. So just be able to treat everything.
Howard Farran: And that is great advice, because this last recession in here in Phoenix, that 2008 Lehman Brothers, we saw about 85 practices go under in Phoenix. And the cosmetic ones were the first to go and the reason I always had a bone to pick with those guys is I don’t remember applying to dental school telling them I wanted to do plastic surgery and tummy tucks and veneers and bleaching. I thought we were doctors at first. I always identified more with the public health dentist and you said when you got out, you worked in HMO clinics and public health clinics. And that is the way I look at it. I am a fireman. I don’t care if the fire is in an apartment, a trailer or a mansion. I am a fireman. I put out fires. You know what I mean?
August de Oliveira: That is great, yeah.
Howard Farran: And I love doing the extraction on the kid who doesn’t speak English and just snuck into Phoenix a year ago paying with 20 dollar bills or doing an elaborate cosmetic case. I always feel the public health dentist is what we are supposed to do, but it is also the best business model.
August de Oliveira: Yeah, definitely. There is always a patient with a toothache, and I don’t care who it is.
Howard Farran: Yeah. So in your last five minutes, take it away. Again, go back to that person five years out of school who is looking for direction. You are saying online CE, learning to do root canals…
August de Oliveira: Just yeah, I mean, get on DentalTown. That is the thing, too, is that we are so loners. We are little weird hermits in our little offices. We don’t get out and talk to people. And sometimes it is hard and sometimes you don’t want to. I mean, I am as grumpy as the next guy. But get online and read everything you can and if you are a lurker, that is cool. Don’t worry about it. But if you have a question, post it on DentalTown and there is someone who had the same problem you had who can help you with it. You know, patient management is hard when you are a newbie. And saying, “Gosh, you know, I have this patient. She is a total pain in the ass and she is saying this and she is saying that. What do I do? What can I say?” Sometimes there are phrases we use, or your know, let’s say you just do a crown on a tooth and it wasn’t hurting before, but now all of a sudden the crown hurts. How do you explain that to a patient? And so all of that stuff is on DentalTown, so just get on DentalTown.
Howard Farran: Oh, and thank you for that, but you also have a website. But you also have a medium, digitalenamel.com. Tell them about that.
August de Oliveira: Yeah, it actually was started by Todd Erlick.
Howard Farran: He is out of Texas. Whereabouts?
August de Oliveira: He is in Austin.
Howard Farran: Austin, Texas.
August de Oliveira: Yeah, it is not a message board. It is just us showing cool stuff. And so as he likes to call it, dental porn. So we take pictures and pre-pictures of stuff that we do. Actually, we like to show the good, the bad and the ugly. We show just pictures of digital dentistry. So it is a magazine of digital dentistry.
Howard Farran: Yeah, and Todd Erlick, like you, also has an online CE course on DentalTown. You guys are just huge in dentistry and I like everything you guys have done for dentistry. I mean, you really have.
August de Oliveira: We owe it all to you, Howard.
Howard Farran: No, I am just the long-distance phone carrier. I am not doing any of the conversations. It is guys like you and Todd Erlick that have just made DentalTown a must-go-to place and home. So what website, if I want to get ahold of your books?
August de Oliveira: Implantsmadeeasy.com.
Howard Farran: And that is your main, for the dentists out there listening, that is the main website to go to, implantsmadeeasy.com?
August de Oliveira: Yeah.
Howard Farran: And if they are interested to switching to dental porn, it would be digitalenamel.com. And you post some amazing stuff. But August, I just want to tell you seriously man, how many posts do you have on DentalTown? Thousands.
August de Oliveira: Thousands, yeah.
Howard Farran: Thousands of posts for 15 years.
August de Oliveira: Yeah.
Howard Farran: Yeah, so I just want to thank you so much for all that you have done for dentistry. I want to thank you so much for all that you have done for DentalTown and I want to thank you for giving me an hour of your valuable time.
August de Oliveira: Thank you, Howard.
Howard Farran: Alright buddy, I hope that you have a Happy Halloween. What are you going to dress up as?
August de Oliveira: I was thinking about going as a dentist.
Howard Farran: I am going to go as a short, fat, bald, grandpa dentist.
August de Oliveira: Okay, see you later.
Howard Farran: Okay, have a good day. Okay, bye.
August de Oliveira: Okay, thank you.