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AUDIO - Isaac Tawil - HSP #82
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VIDEO - Isaac Tawil - HSP #82
Dr. Isaac Tawil shares the inspiring words that remind him to always do great work.
Dr. Tawil received his Doctor of Dental Surgery Degree from New York University College of Dental Surgery and has a Masters degree in Biology. He also has a Bachelor's degree in Psychology.
Dr. Tawil has received his fellowship with the International Congress of Oral Implantology, and the Advanced Dental Implant Academy and recognition for Outstanding Achievement in dental implants from the Advanced Dental Implant Academy. He has also received an advanced periodontal training certificate from Harvard school of Dental Medicine, as well as, the President's Service Award for his volunteer work in places like Honduras, Tijuana, and Lima Peru. He volunteered his time along with several other dentists to provide dental care and implants to underprivileged recipients. Dr. Tawil is a member of the American Academy of Implant Dentistry, Academy of Osseointegration, American Dental Association and the New York State Dental Association.
During his free time Dr. Tawil enjoys hobbies such as skiing, mountain climbing and biking.
345 Kings Highway, Brooklyn, NY 11204
Howard: Live from New York, it's the eleventh annual mega jungle mention, and I'm so honored that you joined me. The reason I wanted to bring Isaac on ... Isaac Tower, Right? Is that Isaac you graduated in what,2003?
Isaac: That's correct.
Howard: And this is 2015 and right there on my podcast series there's maybe a thousand people will see this on their own town, maybe about three hundred on you tube, but twenty five hundred are listening to this on I tunes and they are drawing the work. My question to you is next month five thousand American kids are going to graduate from fifty six dental schools and you and I both know that in their entire career nine out of ten are never going to place a single implant, so what I want to capture with you is why did you ... Because you are not periodontist or oral surgeon, you are a general dentist like me. How did your journey start to where one day not only did you place them, but you placed thousands of implants and what advice would you give to that or even a dentist who has been out of school ten years, whose never placed one and spell out stair step. How could they someday be day like you?
Isaac: That's a great question. I have to say that when I was in dental school, I had a wonderful dean by the name Micheal Alfano and he drove in a message to us that stood in with me for the rest of my life. He said "You are not dentists, you are all physicians. You have to look at the mouth and treat it as a whole". So immediately when I graduated I started doing that, and I knew once I graduated I didn't have enough information. Whatever I learned in that school was a great foundation but it not take me to the level that I needed to treat people as a whole and become a true oral physician. So in my journeys I had found several patients that required much more than just composites, or root canals, or dentures.
I started with implants dentistry back then, replacing single teeth, multiple teeth and it grew from there. Education was paramount, taking lots of [inaudible 00:02:14] courses in various different fields. But the one that really interested me the most was implant dentistry, it was more involved and made me feel as if I was treating the body as a whole and not just treating just an isolated area. With implant dentistry comes a lot of systemic factors.
Howard: What is implant dentistry? You tell me about that a course, a magazine or?
Isaac: I mean implant dentistry as a whole.
Howard: As a whole ..
Isaac: Treating people, placing implants, diagnosing.
Howard: But how did you get the information to place your first one?
Isaac: Initially I was just taking local courses in the area of what I may like, maybe in a local oral surgeon was giving a class on implants and was really more driven to a restorative. But they showed some surgical slides, then that peaked my interests and I started looking for some local courses again, that would teach more of the surgical aspect. I started out with the Zimmer implants and they took me out all the way to Carlsberg, California and we were practicing on a mannequin.
Howard: There was never a mini implant?
Isaac: That was the full implant, the regular T.S.V [crosstalk 00:03:17] designed implant. We would be placing on the mannequin and everyone's mannequin, they wanted you to hit the nerve and I hit the nerve and mine didn't beep, everybody else's beep. So I said from there "okay I got to make mine beep" and I kept going to courses until I did make mine beep. So we went from one to another and to various educators like Aaron Garge and Samuel Lee and other courses that I've taken, cadaver courses, going through organizations such as I.C.O.Y and A.I.D and taking their courses, their seminars. For example, like being here today at the eleventh annual Mega'Gen symposium, I've been to a bunch of these now and every time I come you learn something new.
Howard: Okay. So you mention Aaron Garge, there's a hands on course.
Howard: Do you recommend a hands on course?
Isaac: I love hands on courses, I think the best way.
Howard: Now describe the hands on, you mean the hands on model because there is a hands on model, hands on tissue?
Isaac: I think the best way is to start with a model, just plain and simple. This is how we do it, this is where we drill, this is where your neighboring teeth are, this is where your implants should go. Once you have some of the didactic information even you can get reading the book, reading [inaudible 00:04:27] book you can get enough information to then go ahead and start doing model based dentistry. Then from there I think cadaver courses are generally the best courses, because again it's similar to a human being. It's not alive and they won't talk back to you, although some I think did. But for the most part you're now working on something that's live, that's real and then the next step from that is to go ahead and start doing them through actual live surgical courses.
We offer one in Mexico, where people can come and place implants on live people, there are several of them through out Vistara and New Jersey doctor Elian's course with the mentorship program. Where we hold your hand and teach you how to place them.
Howard: You do that yourself?
Howard: You do a hands on course?
Isaac: Correct. Well, through Doctor Elian, Nicholas Elian and Vistara.
Howard: How do I get information on that?
Isaac: Actually it's on the C.D.E website, I believe.
Isaac: You can find doctor Elian's mentorship program on there as well as other hands on courses that are offered.
Howard: Okay. So I want us to talk back, a lot of times we start giving instructions of like, how do you drive from LA to Phoenix, and a lot of people are thinking "well why the hell do I want to go to Phoenix?" I want you to first start with these nine out of ten dentists listening who have never placed implants, tell them why they should add placing an implant to their curriculum.
Isaac: I think at first you need to actually like to do surgery, if you are not into doing surgery you at least have to know how to diagnose it and refer it out to the right people who do. But once you have a feel for it and you like it, you are not afraid of blood, you are not afraid to go into the ... I guess the little nitty gritty areas of the mouth that some other people might not find. That might not like to do that, but once you are into that mode.
Howard: Wow. Let me stop you right there, so a lot of people think only 5% of general dentists place an implants, would you compare to what type of extract? You said you got to like blood, so then I want to ask you. What percentage of general dentists do you think like blood and pull teeth and how good of a situation of pulling activity do you have to be certain place implants? What is so intense? Yes, I'll pull incisors with gum disease for an immediate denture, but I won't pull a wisdom teeth? Tell them, what similar exodontia skills that would qualify you to place a single?
Isaac: That's a really good question, that's a really really good question. Because for the most part and those periodontal diseased anterior teeth, you can have your kids take those out so that's big discrepancy between that and doing impacted wisdom teeth. So I would say if you are the type of dentist that your orthodontist wants to do serial extraction of pull four premolars, whether you agree with that or not is totally different topic. But if you can take out those premolars you can certainly go into the field of implant dentistry.
Howard: And what percentage of general dentists you think can take out those four first?
Isaac: I would say if you're coming out of dental school, I would say at least 75% of dentists would be able to do that with ease.
Howard: Which really means 75% of dentists, three out of four dentists.
Isaac: Should be placing implants.
Howard: You know, I understand, I get it if you say you now, "I don't ever want to ever take an upper denture and place six implants in a bar and you know ... That's surgeon process." Honestly, I get that. But 95% of the crowns that go into the labs are just one unit at a time and 95% of the implants are just one tooth at a time.
Isaac: That's correct.
Howard: We agreed that three out of four dentists can do those?
Howard: So now that we got that I want just ask , in order to do that do I have to buy a hundred thousand dollars 3D X-ray machines? CBCT? Did you buy one? Is that kind of a prerequisite to be a quality placing single tooth?
Isaac: I think I'm a little wrong guy to ask that question because I'll have like an apple watch in just a couple of days. I'm that techi guy that loves to have all the toys, so for me I like to have that and I think there's no value in it to have it. But you don't necessary have one in your office but you can access to one. There so many centers all over and it's not just for implant dentistry, convene technology for endodontics, for general dentistry as a whole is becoming more necessary. We are looking at treating the whole mouth not just one area or we're looking to look inside without actually having to go inside the mouth.
Howard: Now do you do root canals too?
Howard: Because, do you agree or disagree with the saying that the number one cause of a failed root canal is not cleaning and shaving is that they missed a canal.
Howard: An MB2,and the macrifaced molar, the [inaudible 00:09:15] molar that disconnects two not one, lotelingual canal, and then[crosstalk 00:09:20] so do you use your CBCT for root canals and implantology or is the best CBCT for root canal not really the best one for implantology?
Isaac: So I think that's where skill set comes in. So if you are an accomplished general dentist or someone who has done, performed many many root canals and had great success over the years. Then I think your standard protocols would work fine because you would know when you might require a CBCT you'd say "that root looks funny" or " I see how that canal, it's really thick, but then all of a sudden it gets really really tiny, might diverge ". So that's the type of case I would say great! Go get the CBCT. But if you are young, up and coming dentist that is not really sure as to how many canals there are you want to treat in your office, I don't find it to be harmful, I think if anything you are saving your patient from possible infection down the road. To take a small little three by three or five by five scan of that tooth to make sure you're doing the right job.
I think we always say we don't want to do any harm to our patients. what's the better way of not doing harm than you being able to diagnose things correctly?
Howard: But I've heard some CBCT's can't get small enough to find an mb2.
Isaac: So I think as a young clinician you have to start out by buying the right type of machine, just like there's many different cars. You can drive a Hyundai, you can drive a Corvette, you know there are different level of cars and there are different levels of combine units, The most common combines now though are having various fields of view, multi fields of view, so the one I have has as it goes from seventeen by thirteen all the way down to a five by five.
Howard: What name brand is that?
Isaac: I have cash beam ninety three hundred.
Howard: So is it true that everyone says that men and boys are the price of their toys? This one was just a toy for you or is this a.
Isaac: It's my third one, so ... It's my third one so it's a third one I go through a lot of toys but I've found it not to be a toy, it's probably one the most important parts of my practice and if you're thinking you cant afford it you're wrong. Because you'll pay that monthly bill off very very easily just with the amount of work you are going through.
Howard: Are are you going to, will Delta cover a CBCT or [crosstalk 00:11:27]?
Isaac: We are starting to see more insurance companies start to pay for them, they are few and far between, but they are starting to come around. Some companies will pay for the reconstruction version as a panel, we are starting to see that they're getting, just like they're starting to get there with implants as well. They are starting to pay for not just the crowns but the body of the implant.
Howard: I want to tie you down on specifics again, when would you take a CBCT on a tooth before you hit a molar?
Isaac: For a root canal?
Howard: Because sometimes there's missed canals on incisors.
Isaac: I find for myself, upper molars, if I don't see a fourth canal, I'm going to take a combine because I know how often they're is a fourth canal and I missed some in the early days of my career and I don't want to miss another one. If I see that and I go inside and I don't see a canal, I would immediately get the patient up, do in the other room, have the scan done. Which is one of the great assets of having one in your office, you don't have to get a mobile van to come over, you can do it right then and there and continue the treatment.
Howard: Okay, let me flip this around. Lets say a patient came in and they had a filled root canal and the canals were found. It was a maxillary molar and there four, you could see four set of roots in there and it was done ten years ago and its failed. You could retrieve a root canal and you could do an implant, how is your mind looking at it? Are you looking at it saying, I bet the person who did this probably did a great job and it just didn't work, it's just easier to pull this thing and go with an implant. Or would you do the retreat?
Isaac: I always find that implants are a great backup, nothing beats a natural tooth in the mouth. If it was my mouth I would rather have my own natural tooth, if the crown ratio was favorable, if there's enough, meaning that a part of the tooth structure and the other parameters fall into the proper methodologies that we currently use to retreat. If we find that there isn't a J shape ratio [inaudible 00:13:36], symptomatic of a fracture.
Howard: Explain that again?
Isaac: There's lots of different ways to diagnose fractures of teeth and one obvious one where we see almost a J shaped black radial lucensy at the tip of the tooth, the effects of the tooth. When we see that J shape [inaudible 00:13:55] we immediately think fracture.
Howard: Why are you thinking it's a J shape and, why do you think that happens?
Isaac: Typical [inaudible 00:14:02] will be in a bowl shape at the end of the apex, however if it seems like it's extending from the root higher up along the root, in a similar fashion like a J going to the apex. That usually means that there's something there, it's either a lateral canal which would be quite rare to cause such a big pathology. Or it would be a fracture, because the fracture would be higher up along the root and then it would be extending down into that apex.
Howard: Any teeth more likely to be fractured?
Isaac: You see these teeth with really large posts in them or cast posts in them over the years, metal posts, [inaudible 00:14:37] posts that really don't bend or flex too much. Not like the modern ones we are using now, those tend to happen a lot or if you see a tooth that really didn't have a lot of crown above it left and it was really beaten down and those types of teeth with big large posts. You know that the post is doing most of the work, that's a red flag.
Howard: Okay, I am going to now say you are looking at that, it's tooth number 3, you determine it's a filled root canal it's from a fracture. How's your mind work now, would you pull that and immediately place an implant or would you pull the tooth and graft it and go back later? Talk about how, what you would do.
Isaac: You are full of great questions. That's a topic that you can go on for hours about, whether or not to extract and graft at the same time or to place the immediate implant, or even to put the crown on top of that same tooth. The technology has changed, the science has changed, the studies have proven that if we can place an implant at the same time, if the conditions are correct. Then we should place the implant at the same time and try to get that stability. Why? Because now the patient is not without teeth for that long, the longer a patient is without a tooth the more chance there is for shifting and if you're not putting the proper type of retention devices to stop shifting of the mouth. Then you inclusion is going to get off at some point and harmony in the body is very important.
If your back is not feeling so good and you're just a little bit off on one side and you start favoring the other leg, your leg is going to hurt you a lot. So if you are just chewing on the left side of your mouth because you are missing tooth number 3 on the right side of your mouth. Your left side can suffer a bit, so the sooner you can get a tooth back in the mouth the better and the sooner we can get them chewing on that tooth and back into the harmony of the body the better. As well as what it's shown, study wise, to preserve the gingital health, the gingital tissue, the inteproximal papilla, retaining those by placing the implant immediately. There have been a lot of benefits in placing at the same time, that being said, if you don't like the looks of the house get out of the house before it falls down on you.
There's times when you should say, look the architecture here is not ideal for me to place an implant at the same time. Let me graft this, come back when it's more solid and more good area when I can go ahead and then place an implant.
Howard: How many implants have you placed? Thousands.
Isaac: I've placed a few thousand.
Howard: Be more specific on what that house looks like that you don't want to put an implant in?
Isaac: The house is on fire right? Not a great place to run into, so if you see a lot of puss coming out and you can't control that. Then I wouldn't even feed it with a graft, I would say lets clean it up as best as we can, it's real messy in there. I can't really see what I'm doing lets close it up.
Howard: Do you put him on an antibiotics too?
Isaac: I like to place patients on antibiotics, better safe than sorry.
Howard: Which antibiotics?
Isaac: Amoxicillan seems to be the best antibiotic.
Howard: So if there's a lot of puss, what if there's a lot of blood, what if just a lot of bleeding?
Isaac: Then you want to look into the systemic history of the patient, even from before that you would have looked into their systemic history. You want that patient is not on a blood thinner or they're not taking a lot of aspirin. If they're not and it's just really messy and you can't see, then you can always control hemastasis with, vasoconstrict it, a little more epinephrine if we have to, if the patient can handle, not adverse to getting epinephrine in their body. But I think as a whole if you see a lot of granulation tissue and just completely blown out, there's no buckle plate, you can see the root of the next tooth net to it. Just doesn't look like a good area, you might be able to get an implant to hang onto one wall but, if I'm hanging off a building I don't want to be holding on with one hand I want two hands.
Howard: Okay, so if it was pussy and bloody and all that, you would get the tooth out, put them on amoxicillan and send them home?
Howard: When would they come back?
Isaac: Just a few weeks later I try to get them back.
Howard: Two weeks later?
Isaac: Usually it would be about 4 weeks I would say.
Howard: What would you do next? Would you do a bone graft and implant?
Isaac: I would try, if i can I would definitely try to, there's lots of different devices that we have. There's a really nice device upstairs called a [inaudible 00:18:40] membrane which is a titanium mesh membrane that locks onto an implant to rebuild the buckle plate. It gives you the ideal parameters, if you can build it the ideal way, the way you would want it in your mouth and you believe that you would do this on your own mouth. I would say that's a good option to go ahead and place an implant, if you feel that it's better to first re-architect the area. The construction area, foundation, proper, get your right walls then that might be a better time, then I would wait. I think that's really user dependent, if you're comfortable doing that then you should do it, if you're not comfortable and you really don't have a lot of experience rebuilding bone, then rebuild it first and come back and place it later.
But if you know you can rebuild that bone and get the implant in at the same time, then by all means lets get them teeth.
Howard: Bone grafting and placing implants, what percent of implants placed, and we're not talking about the complex, four, six in a jaw to do a big fix. I'm talking about the low hanging fruit, the 9 out of 10 implants, just like the 9 out of 10 crowns that go to the lab one crown at a time. The 9 out of 10 implants one tooth at a time, what's the low, I'm trying to locate 9 out of 10 dentists haven't placed an implant. What would be the low hanging fruit, first implant selection case to look at that would be a one implant without a bone grafting? Then talk about if you do a hundred implants, what percent of them are bone graft? I'm trying to explain how closely correlated is bone grafting to placing implants.
Isaac: I think they go hand in hand at this point.
Howard: Do all of your implants have bone grafting with it?
Isaac: When there's enough bone we obviously don't have to place more but, for most cases if people have been [inaudible 00:20:28] for a long period of time and they have been wearing a denture. Then it's usually that we're going to have to place some sort of bone grafting material in the area. If they recently had a tooth out and it was only 6 months ago and it was an emergency and they were in Cancun, Mexico and they got a tooth taken out as an emergency and they formed a good blood clot and the bone reformed on its own, we don't need to go ahead and place a bone graft.
Howard: Put bone grafts aside, key in on what would be a good entry level case to place your first implant, if you're not a bone grafter. What should this young dentist or a dentist maybe he's out there in the planes, this practice has been flat for 10 years and he wants to add another surgical procedure, go to the next level. I'm a big fan of it because I firmly believe, I'll tell you why I'm a fan of this, doing this for 20 I can tell you hands down that whenever you find dentists in group practice they're always happier than the solo guy. Whenever you find someone burned out, fried, drinking Listerine at work, eating Vicodin, he's always a solo practicing dentist, right.
You go into a group practice, in between patients you go back there and feed each other and so, group practice is better for mental health and that effects your patients. But another thing is when you're burned out and fried due to all you do is fillings and crowns, and you've been doing them for 8 gazillion years, learn something new. It seems like whenever I can motivate a kid to go in to implanting, like Dennis asked me, well should I get a laser and I'll say, you know a laser can stand for losing all savings equals reality and it can stand for light amplifications simulation emissions radiation. The determining factor to get a laser or not, if it makes you run 20 red lights on the way to work, by God you've got to buy one and you call it a toy. I want a lot of dentists to start dabbling because it just reignites their fire, so I'm asking you. Describe a case where the dentists say, I'm scared, I have fear. But describe a case, you talk about the orthodontic extraction, what would be the best first case to place your first implant?
Isaac: I think cases that have been either grafted in the past by somebody else and the patient maybe didn't want to place an implant or you've had a patient for awhile and they are just sitting there with that big parking lot worth of space. You are saying to yourself, wow that looks really easy to go ahead, the bone looks really good, maybe done some diagnostic workup, maybe took a cone beam. You can see that everything looks good there, there is no such thing as a simple-simple implant because there's always something to look for. Once you know your anatomy and you know where everything has to be, if you can find a nice block of bone that's 10 or 11 millimeters wide. To go place an implant in the molar region where no one is going to see it right away. That's one of those cherry picked cases, a lot of the cases where people have disiduous first molars still there, those are great cases because those are taking the space up. Maybe now [inaudible 00:23:47] and you can just extract it.
Howard: A baby tooth second molar.
Howard: If you can have a case like that, those are my favorites.
Isaac: So your mind went to the tooth that's been missing got awhile?
Isaac: What about a tooth you have to extract because it was a root canal, billet post crown, whatever. You had to pull that, is that not really an easy? I find those to be quite simple but, I think after you place a bunch of implants because drills can skip around in the mouth and if you're going to follow the same direction where that tooth was taken out. That might not be the right direction you might have to really redirect that implant, often. I would say almost 90 percent of the cases, you're not putting the implant right exactly where that previous tooth was. You're placing it either more lingual or more palatable to where that was, so even though those seem very simple could actually be a little bit tricky.
With that being said, I think if you can get yourself a surgical guide and you can get a nice area of bone and you can just drill through a hole and feel comfortable and know that you're doing the right thing. Do your checks, your basic x-ray checks, your pilot hole checks, you develop a comfort. You develop this excitement, it's something that's new inside and you say to yourself, wow, there's a whole world here for me and it starts with just one implant. But it may end up where you're placing, doing a whole mouth of bone grafting and sinus lifting and placing 8 to 10 implants. It starts out small but there's a whole new world that general dentist haven't been seeing and there's so many places to get the education on this, it's really foolish not to. If you enjoy even just a little bit, I'm sure once you got into it you'll enjoy it tenfold more and for me it was the best decision I ever made. I went from being one of those guys, I might have wanted to jump out of the building that you showed in you [crosstalk 00:25:41]. To falling absolutely, passionately in love with dentistry as a whole, I love doing a class 2 composite now, I used to hate it, but I live it. Why?
Because two patients before that I might have been placing 4 or 5 implants and now I come to that class 2 and I make that tooth look really good. It's about quality, it's about having fun and it just really can change your life and as a general dentist we are so lucky. The periodontist and the surgeons they're stuck doing the same thing all the time and its over and over again. We have this really bizarre way, we have a whole arsenal of materials, we have a book from Henry Shine or Patterson or Banko, this big that we can order form and we can do so many things. We can place posts, we can make crowns, we can scan the mouth, we can take cone beams and we place implants and if you really get comfortable with it, it becomes the most passionate part of your practice.
Howard: You said something I want you to elaborate on, you said surgical guide. When we're talking about a one tooth, do you need a surgical guide for one tooth? Do you use a surgical guide for one tooth?
Isaac: Personally for myself no, however if I was starting out and when I did start out, I did.
Howard: If you're just starting, would you say the first hundred implants you place you'd recommend a surgical guide?
Isaac: I think I did more than the first hundred were completely guided, completely guided. I couldn't let go I needed that person holding my hand and when there wasn't someone over my shoulder, like we have at Vistara, we are actually sitting there watching over your shoulder. When I didn't have that person with me I needed someone else to hold my hand so my surgical guide was that person holding my hand.
Howard: I just want to thank you for taking time out of your day and doing this Podcast, it's been an honor and a privilege to interview you and thank you so much for your time.
Isaac: Thank you.