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Perhaps the only thing more expensive than keeping up with new technology is not keeping up with new technology. Listen to Donald Roman, DMD explain why he loves all things laser.
Donald Roman, DMD:
Grad Fordham Universty in 1979, BS in Bio
Grad Fairleigh Dickinson University Dental School 1983
Commissioned Officer NHSC (PHS) 1983 - 1985 Acting director Camden Co Dental Services
Assoc Fellow AAID
Comprehensive private practice; Heavy in Cerec, 3D integration, Implant surgery and placement.
Howard: It is a huge honor for me today to be spending an hour with Donald Roman, who is all things laser. You are just one passionate man when it comes to lasers. Tell us how your journey started? Is it something that started in undergrad when you took physics, or did you get turned onto them in undergrad in physics lab?
Donald: You know, not one bit. When I went to dental school, lasers were, pretty much, non-existent back in the '80s. When I got out, I was in the service for a while, heard a little bit about lasers. Then just started doing a lot of research, I guess like most dentists, and researched the daylights out of it, and started with a Diode laser about 10 years ago, because I wasn't real happy with the ElectroSurges.
It just really took off from there, and the technology has been growing so darn fast, it's tough to keep up with it.
Howard: Explain to the kids what a Diode means, as opposed to ...
Donald: Okay. Obviously, really what's a laser? Really a laser is an instrument that produces a narrow, intense beam of light that that energy can be used to remove or shape tissues in the mouth, including soft tissue, gum, hard tissue, bone, and, of course, teeth.
There's different types of lasers. I guess the simplest is the soft tissue laser which is a Diode which uses a light-emitting Diode. Just like in a watch or an alarm clock or something like that, or like a display. That energy is focused on a certain wave length.
It's absorbed by tissue of a certain color for the energy to do something with. Basically, Diode lasers, they have a lot of use in them. It's not just an ElectroSurge type of technique where you can cut and shape tissue with very little bleeding.
We can do an enormous amount of things to stimulate collagen growth, and, of course, utilize them with a hard tissue laser to actually do periodontal surgery, but not in the conventional method where we used to lay big flaps, and really take away a lot of tissue and destroy tissue to make a contoured environment we could keep clean. Boy, that was a lot of talking.
Howard: You're doing great. Einstein said, "If you can't explain something to someone, you just don't understand it." You're just rolling off like poetry. Let's back up a tad and first go back to why did you not like ElectroSurge?
Donald: Okay, I used an ElectroSurge for years and they served well, but basically you're just using a hot knife, and you are burning tissue to get that implement to work. Obviously, much cleaner than a scalpel because you do get coagulation, but again, you're burning a lot of tissue, so it does have an effect on healing, how long it takes, and of course what is the tissue going to look like?
Are you going to get the same architecture that you sculpted when you were done? Take example just troughing around crown preparations. I haven't used packing cord, thank heavens, in more than 10 years. Started with the ElectroSurge and then switched over to the soft-tissue laser, and we get fabulous tissue control, great healing.
Many times, we can do it without using anything more than topical anesthesia on patients which, of course, I never could do with the ElectroSurge, so like amalgam, amalgam was great for 150 or more years, but now we have better right? We have posterior composites that we can bond to teeth. Amalgam is really something we don't really need, so it's just a simple progression of technology, and just being able to do better care for the patient, with better instruments.
Howard: Explain what ElectroSurge is because I always found it fascinating. It's technically a radio wave isn't it?
Donald: Correct. It's actually a radio wave. We're not using, like plugging a wire into a wall and just burning tissue. It actually is radio waves, and it does generate heat when it's in contact with tissue that's moist. It will literally cook or fry that tissue, depending upon how much energy you put into the tip. The more energy, the more cutting that the instrument's going to do. The lower the energy, the less cutting that the instrument is going to do.
Again, it's a good instrument, but I think it's time's past. I think technology has gone better where we can do the same thing, do more with less tissue damage, less bleeding problems, and healing is wonderful, especially when you trough around crowns. Pretty much where you place that margin, and use your soft-tissue laser to go around it, it cleans up the tissue, it does the retraction
I get very little change in [inaudible 00:05:23] height so that when my crown is in there, the margin's where I left it.
Howard: The ElectroSurge actually, in a round about way, was why I went paperless in 1999. That was because I would always keep coaching my front office staff that every single patient phone call, you have to pull a chart and you have to enter the conversation because sometimes people come back for a crown seat, and I had no idea that they were calling for pain meds because I used an ElectroSurge, and in fact a good dentist friend of my mine says, "He'd never had it any, any, any post officers come from an ElectroSurge."
I said, "Really?" We walked up front, and I asked his dental assistant I said, "Who've you used it on in the last week?" They called me, so I called the patient right there in front of everyone, and she says, "Oh my God. I've been eating Ibuprofen every 4 hours", is distraught. His eyes got real big, he had no idea.
I initially bought the receptionist like 15 foot long phone cords so they could stand up, and go pull a chart. It just turned out to be ... It just wasn't practical. You have thousands of charts, charts are lost. I thought the only way I can get them to enter this into the chart is to go paperless, so that when Donald Roman calls I can just type in his name, and then make an entry, "Yes, he says he's having a lot of post-operative discomfort, and he's wanting to know if he can have some pain meds or whatever.
That ElectroSurge, the people who say they get zero post-operative discomfort, I don't believe that. Do you believe that?
Donald: I'm going to have to agree with you, because I experience the same type of problem where people were sore, they were tender. Obviously, less that they would be jamming retraction cord down there and destroying the attachment. I never understood that, but that's the best we had 20 years ago.
Howard: Yeah. When you think of lasers, the first thing I think of is when the DVD came out it was $800 and it was lousy, and now they're down to like $30, they're amazing. I remember when I got out of school in 1987, they had that YAG laser. It was like $50,000. Now in 2015, I see lasers anywhere from $2,500 with Allen Miller's AMD laser, all the way up to like $75,000 with some of these lasers. I'm sure a lot of people are listening to this right now wondering, "What's the difference between a $2,500 laser and an $85,000 laser" and can you kind of just go over lasers and ...
Donald: Sure, sure.
Howard: It's kind of like going over a Chevy, a Pontiac, a Buick, you know?
Donald: The first thing you have to decide is what application do you want to use your laser for? If we're talking about ... Let's say you basically want to get in and you want to get easier, of course a Diode laser is certainly going to be on the lesser cost. You're going to run, as you say, anywhere from $2,000, $3,000 as your starting point, to probably about $9,000 on the high end.
What do I think the difference is? Number 1, you have to pick your wave length because the wave length determines where that energy is going to be absorbed. If you're doing a lot around implants and so forth, you've got to be careful because the implants will absorb certain Diode laser energy, so you've got to be careful because they do generate heat.
I think the big difference is probably consistency and reliability in terms of the unit. It's the difference between buying a Yugo, yeah, I guess it got you around, but it probably didn't last very long, to buying a reputable manufacturer where you know that the energy produced by that laser is going to be consistent, and also they all use fibers. They're all glass fibers, and the question is, how's the delivery system? What's going to be the cost to use that darn thing because some use a long fiber-optic cord that you just keep snipping off the end each time when you use it from patient to patient.
Other ones that actually use tips that go onto a hand piece where the fiber-optic is permanent to the hand piece, like a drill, and as a hand piece, and you switch your tips. That can also affect the daily cost of using your laser. My first one was a ... I probably shouldn't say names, but it was a 980 laser, and it used that long fiber-optic cord. I used that darn thing every day for probably close to 10 years, and I never changed the cord. Of course the Diode laser got closer and closer to the operating field as time went by until I finally said, "Okay, now it's time to get a cord because I can't have patients ...
Howard: I wish you would actually named names because my whole deal with Dental Town was that no dentist would ever have to practice solo again. You go into some of these conventions and let's say they got literally 50 different kinds of composites, and implants, and lasers. It's just so overwhelming, and that poor dentist has to wear so many hats, so when there's a guy like you on right now that knows the difference between 100 different car makers ...
Donald: My first one was a Hoya 980. The laser worked very, very well for probably 9 of those 10 years. I did start to notice that in the 9th year, I was having to turn power up a little bit more than I normally did, so maybe there was a loss of efficiency, and probably 9, 10 years for a small laser like that, it's probably about the life of the instrument. I started to look around and see what else is out there, and lucky enough, here in the northeast, there's easy access to all these units to get them demonstrated.
I started to think more about multi-tissue laser. Something that could do hard and soft tissue. Tooth, bone, as well as gum, and I got into the MD WaterLase, and it works beautifully when you use it correctly. It's fantastic for patients who are afraid of the drill, or afraid of having to have Novocain and so forth. We do a lot of our procedures just with topical anesthetic, and a lot of distraction for the patients.
Howard: WaterLase, is that part of Biolase?
Howard: Okay, so MD ... approximately what does something like ... You bought that how many years ago, and how much, about ...
Donald: I bought my first MD 2 years ago. They're really expensive. They were about $60,000 at the time, and the rep kept poking at me, but I just said ... I couldn't see the value in spending $60,000. Then finally, he came to me and he said they had a demo program, where you can pick up the laser for just under $20,000, so I said, "You know I've probably made sillier choices in my professional life, but for $19,000 and change, I saw the value of the laser.
We got it, the unit worked beautifully. A year and a half down the road, they came out with a improved laser, more capability. They were pretty darn good. They pretty much gave me the full price I paid for it to move up to the latest and greatest I guess we'd call it. I haven't looked back with any disapproval or second guessing.
Lasers really do work. I know when I sit and I chat with my colleagues who taught me in school, Periodontists, and they're kind of poo poo the laser. You know when I see it work in my practice, and I see the healing I get, I can't just push it aside. It makes a big impact. Patients really love it. People call me for it.
Howard: You started with a soft tissue Diode, and now you're using a laser that works on soft tissue and hard tissue.
Howard: What kind of laser is that?
Donald: That's the new MD from BioLase.
Howard: It's not a Diode though so it's a ...
Donald: Nope. It's not a Diode. It's the ... Boy it's always hard, I stumble on ... It's the Erbium Chromium YAG laser.
Donald: It works beautifully on hard tissue. Using it for tooth preparations for normal composites, it works beautifully to incise tissue. I do lingual frenectomies, basically takes from about start to finish, about 15 minutes, there's little to no bleeding. I use very little anesthesia for that, especially with kids. I use a combination of a hard tissue laser and a soft tissue laser because with the hard tissue laser, you get the great cutting, but you don't get good blood control. So hemostasis you don't get.
You get far better blood control with the Diode laser, so I kind of use those in conjunction with each other.
Howard: What's the Diode you're using today?
Donald: The Diode actually is the ... Again, it's a Biolase, because I like the fact that it's very compact, it's portable, the foot pedal is even wireless. It's very intuitive when you look at the control panel. Everything is laid out so it helps prevent you from making silly decisions or mistakes while you're doing procedures and you're changing gears. It works beautifully.
Howard: What was that one called? What was the ...
Donald: I think it's called the Epic 10 or Epic X. They're in the process of changing, I guess, just the labeling on it.
Howard: What did that run?
Donald: That one, it was about $6,500.
Howard: You thought that was the $4,000 extra, but then the very low cost AMD was better?
Donald: I used the MD, and I didn't find that it had the same precision and consistency.
Howard: You mean the AMD?
Donald: Yeah. I just didn't think it had the same consistency, ease of use, in terms of the unit. I think the wave lengths are slightly different. I think one is 980, one's 940. Not a big, big difference, but I found that with the Biolase, I'm getting more consistency with the unit, and that really is the key. You can't have the darn thing to be down, and you can't have it not doing what you expect to do when you're doing a procedure.
I use the ... How I kind of use the 2, I'll use the Diode laser for quite a lot of things. I'll use it for troughing, because you get great hemostasis. I use it for pain control for TMJ. Get patients come in in a acute situation. I can sit and dose those joints and really within 10 minutes they're almost pain free, because it promotes the healing and collagen and so forth, of the tissue.
I even use it for wrinkle removal for patients around the perioral area. We even had a patient that had the Bell's Palsy for 15 years, and we dosed the area for about 5 weeks, once a week. The patient relates she's got about 50% improvement in the condition, how she feels. I can see it in her face. She doesn't have as much of a droop anymore, so I ...
Howard: This is with the Epic 10?
Donald: Yes. That was with the Epic 10.
Howard: I've never heard that before. I've never heard anyone say they've used it for TMJ or wrinkle removal.
Donald: Absolutely, for removal of, or reducing pain, and so forth, it is just amazing. I mean, like I said, I used the two lasers in combination. Like if I'm extracting a 3rd molar on a patient, I'll use that, the hard tissue laser in conjunction with my Periotomes to create that little channel between the root and the bone which helps me do the extraction.
Then when I'm done, I'll dose the coronal or crestal gingiva with a laser bandage procedure that helps to keep [epiphealization 00:18:41] the way I want it because I always do a bone graft when I remove a tooth. When I take something out, I put something back for ridge preservation. It helps prevent in-growth of the epithelium.
I've even had patients come back that have had dry sockets, and dose the area with a combination of the soft tissue and hard tissue laser. Within 24 hours they call me up on the post ops and they're pain free.
Howard: That is amazing. I wanted to also mention about a marketing. I have a friend that's a podiatrist. He's told me in confidentiality that he does all of his marketing laser foot surgery. He says to me, "Howard, in all honesty, I'd rather just make an incision, take out a drill, and knock that thing off in a couple minutes. It actually takes me several times longer with the laser, but the marketing aspects are mind boggling."
He honestly tells me that the reason he got into lasers was for marketing, unique selling proposition, differentiation. Have you seen this ... Do you see this, for yourself personally, more of a technical use, or a marketing use, or a combination?
Donald: It's a combination of the 2. You're absolutely correct. When you're doing a tooth preparation, let's just say a simple class 1 occlusal on a lower pre-molar. It's going to take me probably 9 minutes to prep a simple occlusal, which of course, if we used a high speed hand piece, we're done in less than a minute right, or even less that that?
The fact that you don't have to anesthetise the patient if the patient's concerned about not wanting to have an injection to be numb, or if the patient complains they don't like to hear the drill.
I have patients that seek me out because of that, because they're ruined dental patients. Somewhere a dentist didn't do the right patient-management things, and that patient is a ruined patient. They're afraid to go to the dentist. How many times do we see that? I'm sure you do. I know in your practices is extremely substantial.
I'm sure you see that all the time where patients just hide because they're afraid of pain, or they're afraid of sound. Those are the 2 biggest things.
Howard: It's huge, and it's irrational. I know some of the jokes I've posted before have gotten some negative feedback because I showed a picture of a person with like 50 tattoos who's afraid of the needle.
The bottom line with that is fear's not real, it's irrational, so the person doesn't care if someone tattoos them with a needle for hours in painful areas of their body, because their mind doesn't fear that, but their mind fears something in their mouth.
Back to your time though. You were saying it takes you 9 minutes to prep an occlusal, but only one minute with a drill, but from an operations and logistics point of view, you'd be looking at total time, because you'd have to look at the laser time of 9 minutes minus the anesthetic time.
Donald: Correct. It comes out to about the same time to do routine operative procedures, but I have to tell you, one thing that I've been using the laser for, and it's a combination of the hard tissue and the soft tissue is in how I do periodontal surgery.
I did perio surgery probably just like you, scalpel, full flaps, re-contour all the tissue, remove lots of osseous tissue to create an environment that we can keep clean, or do an added procedure where you're grafting.
It's not that I'm going to say it's 100%, but probably 70% of the time I can go into 7 millimeter pockets and treat them and not graft them. When we go back and re-chart the patient, we're finding those patients now, those 7s have become 4s, and we still have the gingival contour at the same height.
Howard: We always know what we know, but we don't know what we don't know. Gordon Christian was on an earlier podcast saying how he doesn't understand how LANAP, or peri-laser surgery work, because if you go down there and you're killing bugs, while the mouth has probably more bugs in it than there are people on earth.
Within just a minute or so, those bugs are back down there in the pocket, but I have notices with LANAP, like most dental technologies, they never seem to come out of the specialty arena. Just like McDonalds, their headquarter has never had a successful product. The first sandwich came out of St. Louis. Their franchisees always invent the stuff that works.
I see the same thing in dentistry where the specialists never really ... I can't think of too many things they've put forward, but the general dentists started with LANAP, but now I see leading edge periodontists who were naysayers at first going onboard. We don't know what we don't know. 100 years from now, we're going to know a million times more than we know now.
LANAP is working, even though it's counter-intuitive to a lot of microbiologists like [Rollo 00:24:23] Christian who says, "You zap those bugs, but the new ones from the tongue and the cheek just move right back in." Why do you think it's working?
Donald: You know what I think? They're not looking at the fact that the laser stimulates the cells. It stimulates the Mitochondria, the engines of the cells. It's kind of like hitting up your dragster with Nitrous Oxide, where you're taking those cells, and the laser is empowering those Mitochondria to fire off, and produce a lot more energy for the cells. I see it in my practice that you see the healing is so quick compared to what we used to do.
I think that's what they're leading out is that you're changing, I guess we'd say, the host response, and that the healing is improved because the cells are getting super charged. Just to give you an idea, I treat patients all the time for aphthous ulcers, and herpetic lesions, and we dose these.
I'm finding that they're healing within 24 hours, and when they get another episode somewhere down the road, what's happening is the lesions are not forming in the same spot. They're not coming back in that same spot.
They'll travel up that nerve trunk when they become opportunistic, and they'll come out somewhere else. What we're finding is with patients that have been at it for a while, after 2 years, they're reporting now they're not getting those herpetic lesions.
Howard: I want to talk about, to me, the obvious cash cow of a $60,000 hard tissue laser. To me is the fact, and this is extremely controversial, and this generates a lot of controversy, but the truth of the matter is hard core researchers say, "Dental sealants don't last at all." Most of them are saying, "40% are failed in the first year, and they're all failed at year 2." There's so many dentists and pediatric dentists who are saying, "Not mine. Not mine."
They're taking a technology that was designed to acid etch enamel, and they're acid etching pits and fissures filled with God knows what, and crud and Oreo an plaque and debris, and you can't bond to an Oreo cookie and plaque and debris and crud. The research shows that if you do an Occlusal deposit, number one, you're not billing out a $35 sealant, you're billing out $150 Occlusal deposit, but in 5 years, 99% of Occlusal deposits are still working.
It seems like if the person adopted a hard tissue laser and said, "I'm going to acid etch pits and fissures filled with crap, and charge out $35 or $50, or spend 9 minutes, clean out all those pits and fissures, and then put acid etch on enamel and dentin.
When you clean out the pit and fissures, [Warren 00:27:15] Christian in CRA says, "If you clean out the pits and fissures, you will always be on dentin every time." You cannot clean those things out, and be enamel, and then do an Occlusal deposit. What do you think of what I just said?
Donald: I'm going to agree with you because those pits and fissures are deep. You try to get in there with your acid etch, it's not going to get down in there, but I agree if you take a ... You use the laser, you even use a Fissurotomy Bur. I think if you open them up and clean them up, you have access, you have clean tooth structure, and of course, your materials can bond and do their job to them. I'm in complete agreement with you.
Howard: Everything that you don't clean out, that's in the Occlusal surface, that's why the sealant's going to fail because it's all getting it chewed off. It's only in those deep pits and fissures is the only place the bacteria are going to grow, and that's the only place you can't chew them off.
Donald: Right. When I was in dental school, they said, "You put those sealants on", back in the 80s, "and it would cover them over, and any bacteria would be trapped and die." We know the reason that the bacteria are in those deep pits and fissures is because it's an oxygen poor environment, and so the sealant covering it over doesn't kill them.
Obviously we know the acid etch doesn't kill them, so you're right. You're leaving some anaerobic bacteria hidden underneath there that are just going to keep doing their thing and chewing away at the tooth structure.
Howard: If the whole dental profession stopped doing sealants, which 40% fail in year and 100% fail in 2 years is what every [inaudible 00:28:47] I see, and got hard tissue so they're not giving kids shots, and they're sitting there doing ... Would you rather do it once and right, or would you rather keep this Band-Aid thing, or do you want to do it once and right, you would have to clean out those pits and fissures. I think it makes so sense.
Now, let's switch to, I'm sure every listener's wondering, "Okay, the Occlusal, that's maybe half of our issues, but they're approximal. Talk about an MO on 3, an MO on 30.
Donald: No, really it's not difficult to do it all. You have different tips, some that are focused into small areas, some that will work in broader areas. I do Mos, Dos on first and second molars, no problem. Pretty much the same thing for the most part, and I'll tell you in my experience, 9 out of 10 patients don't require anesthesia. We use a topical. We dry the tissue, apply the topical.
We use a lot of distraction techniques with the patients. They'll have hand devices to hold on to, they can have music and so forth. As you're doing that procedure, you're also stroking the lip or something as you're doing it, so a lot of distraction for the mind.
Still I find, 9 out of 10 patients, they'll know I'm doing something, they'll feel cold water, they'll feel something, but they don't report pain. The other 10%, as we all know, we have patients when you walk in and shake their hand, it's uncomfortable for them.
With those patients, they're going to need some sort of anesthesia. I usually use an [intra-lick 00:30:29] so that I'm only anesthetizing the tooth. Again, that's one out of ten, so in terms of a patient management standpoint, it's big win if you commit yourself to using the technology. If you are half-hearted about it, it's not going to work.
You have to make a commitment for yourself and for your staff to teach the patient the benefit of what you're doing for them. I really see, honestly, 9 out of 10 patients, I'm doing an MO on number 19, and the only time they'll feel something is when I open up the contact area and the laser energy kind of hits the top of that papilla.
They'll kind of give me ... They'll raise their hand. That's my little signal. Raise your hand and let me know if you feel something. We just shield that with the wedge, and we complete our procedures.
With all laser procedures, in the end you do have to take your, either high or low speed hand piece and just run it around the margin of it, so that you have a straight, smooth, clean margin.
Again, patients do not feel discomfort to that, and it's kind of crazy, because then when you're doing your bonding procedure, and you blow a little air to dry it, they'll tell you, "Oh I feel that", but the whole time they didn't feel the laser just kind of evaporating that hard tissue with the water. I'm kind of amazed at that.
Howard: Some of my friends, if you're standing out in the hallway, and they say, "Just a minute, I've got to go numb a patient", they're numbing a patient, then they put the needle down, and they walk out of the room, they haven't tooken a breath during the whole shot and they walk out of there and go, "Ha." You look at them like, "My God, they hate giving shots."
I used to sit there and say, "In a physician's office, the nurse is the bad guy, the nurse gives all the shots." In Arizona we can have our hygienists give the shots, but you know, a laser might ... If you hate giving shots, it might extend your career and lower your stress if you tried to stop giving shots.
Donald: I get a lot of referrals. That's what I'm finding. I do a lot of marketing, I try to be proactive, I'm out there, but I'm finding I get patients coming in, and they're asking, they'll say, "You know, Joan was here and I'm coming in because you know I don't want to be numb. I hate having a shot."
Howard: For your marketing, I'm thinking you're last name's Roman, so you should do some Russell Crowe, gladiator ad billboard with you holding a laser. Are you going to be the Russell Crowe of the Roman laser gladiator?
Donald: It's Roman empire.
Howard: Is your name Roman, does that mean ... Is that Latin tracing back to Rome? Have you ever traced your tree?
Donald: Yeah, yeah. Everybody comes from Northern Italy, up in the mountains north of [inaudible 00:33:36], and obviously Italian/American heritage. Up there, nobody has the valor so there aren't any Romanos, it's a lot of Romans.
Howard: That is interesting. If you had to pick one or the other, technical or marketing, what do you think is done more?
Howard: Marketing, wow. That's powerful especially in a market where you have 7 billion people, and they all want to be unique. I thought that was funny in the economics book. I was reading that in the state of California, there's a registered name for Unique spelled 274 different ways. Everybody's trying to be unique, and so a laser would be an easy, unique selling proposition.
Are you using the MD WaterLase or the Epic 10 BioLase for a LANAP type procedure? You're using the Epic 10?
Donald: I actually use them both. I use the iPlus ...
Howard: Is that correct for me to call that LANAP or can I not call that ...
Donald: Well, I guess LANAP is really Millenium's tag line.
Howard: Do they own the rights to that procedure or do they ...?
Donald: I guess they own ... They certainly probably own the little ... an acronym for it.
Howard: Tell the people what LANAP stands for.
Donald: Yeah, yeah. That low level laser technology where BioLase calls theirs REPaiR. They couldn't use LANAP, so they used REPaiR for their perio protocol. I have to tell you, it works. Does everything work 100%? You've been at dentistry probably just as long as I have. I'm 57, maybe I've been at it a little longer. You look pretty young, so ...
Howard: I'm 53 tomorrow.
Donald: All right so you're ...
Howard: August 29. I have the same birthday as Michael Jackson, the greatest singer, dancer, songwriter that ever lived. My mom swears it's Frank Sinatra. I'm like, "No mom, it's Michael Jackson, and I have the same birthday with him. August 29th." He made it to 50, so tomorrow I have made it 3 years longer than Michael Jackson.
Donald: Yep. See, there you go. You're in good shape. You're going to go a lot longer. I've got to tell you, the laser has changed how I practice. We're lucky that we live in a period where technology is advancing so fast. Some good, some not so good, but when you take lasers, 3D, digital, ConeBeam X-rays, CEREC same-day-visit crowns.
People 35 and under, they don't know what a phone book is. They're very technology-savvy, and they're looking for doctors that have the training and the technology to give them what they want. Who would have thought people walk off their smart phones, and that's how they shop for everything now right?
Howard: Amazon is ...
Donald: [crosstalk 00:36:41].
Howard: Did you realize Amazon's the 4th largest distributor in America? It's Walmart, then Costco, then Kroger, Kroger's the under company that owns the major grocery store chain in half the states. In Kansas, it's Dillons, in Arizona it's Frey's, then Amazon. I think it's Amazon, they're coming up on 100 billion in sales.
They just entered the dental market, did you hear that? They made a comment that they're entering the dental market, and they joined the Dental Trade Manufacturer's Association. They totally want to get into the dental supply business.
You just rolled off some things. You're also heavy into [Cerec 00:37:24], and you're heavy into 3D integration. Are you placing implants, and doing ...?
Donald: Yeah, I've been placing implants for almost 30 years now.
Howard: You've got Cerec?
Howard: How long have you been into Cerec and what are your thoughts on Cerec?
Donald: [crosstalk 00:37:43] I've had for, I guess now it's been about 7 years. They've been around for 30 years, I think it's 30 years this August or September, they're having that out in Vegas. I've had it for about 7 years, and it was a no-brainer. Of course, the technology's expensive, but when all's said and done, when you put your training in, you're probably in for about $150,000.
You say, "Gosh, how am I going to advertise that?" It really has been a no-brainer. To be able to provide single-visit restorations is great. To be able to no have to take conventional impressions, fabricate temporaries, and hope that your gingival margin stays where you put it. When they come back for the [inaudible 00:38:37] insertion, it's been fabulous.
Then take 3D ConeBeam and integrate the 2 together, and I've been placing implants for a long time, and I always thought, "Hey I can place those perfectly by my hand and my study models", but when you fabricate a surgical guide, it is just phenomenal, the precision, and the amount of the stress it takes off when you're doing the procedure. It's just unbelievable.
Howard: What 3D X-ray machine did you go with? What CBCT?
Donald: I went with Sirona. I went with the XG 3D. I purchased that one because, at the time, they didn't have the 3D yet, but they told me it was coming, and you could upgrade it. It's a smaller field of view than compared to the Galileo, which pretty much gives you most of the cranium. I don't really need that. I need the maxilla and the mandible.
When you combine the 2 together, I'll take my 3D scan, then import that information after I do my surgical planning, into Cerec, design my restoration so that, of course, the implants are being placed where the tooth needs to be, and not where the bone needs to be, so that this way we get a good longevity in the implant and the restoration.
It's just fabulous technology. I chose Sirona only because they made the CadCam Technology, and they made the 3D technology, so that they would integrate smoothly, so you wouldn't have to have bridges or third parties involved. If there's an issue you only have to go to one technology vendor, not 2 or 3.
Howard: The other big issue, that is the fact that there's a lot of intermediate softwares when someone buys CBCT somewhere else, and a CAT scan somewhere else, and they've got to buy a third piece of software. They've got to be a high tech person, and it really slows down training because a lot of the staff and team is not intuitive, so when you go to Sirona in Germany, and these CBCT people are in the same room as the CadCam people, and it's all integrated, it just makes it easier. Easier to use, easier to implement.
Are you kind of saying that Galileo is more for like Orthodontists to have the whole head, and the XG 3D is more for general dentists?
Donald: When I first looked at the Galileos several years back, it's older technology. The images are not as clean as the newer technologies, and so that Sirona has to do a lot of algorithms and software steps to make their image much cleaner. When they came out with this smaller view [inaudible 00:41:39], it's a much cleaner image, it's the newer technology that's out there, the newer software and algorithms, not that Galileo's is bad, but it's just a little bit of older technology.
It does have more capabilities if you need them. If you want to see more of the skull, more of the neck and so forth, then great, so be it. I guess maybe for an oral surgeon or so forth who may need those capabilities, that's fine. For me, as a general dentist, and an implant dentist, I need to see the maxilla and the sinuses. I need to see the entire mandible and so forth.
That's what I need to do my job, and I can do it with a simpler system, because the XG 3D has 2 sensors. It's a pan, 2 dimensional pan and a 3D sensor. It just automatically rotates. If I'm taking pans, I'm taking pans. If I need a 3D, we take a 3D. You hear talk that you can see a lot of things on a 3D that you can't see on conventional 2D, and I'm going to agree with that 100%, but the answer is should you be taking a 3D on every patient? Should you be taking a 3D on a 9 year old? I don't think so.
The energy is much lower than many other units out there, in terms of exposed dose of radiation, but do we need to be taking that on every patient routinely? My answer is no.
Howard: A big reason why a lot of dentists don't buy a CB CT if they have access to one at their specialists, periodontist, endodontist, oral surgeon, or a radiological center, one of the big reasons they don't like to buy is because the half life of these machines seems to only be about 5 years.
It seems like every 5 years, the next generation's just bigger and better and simpler and easier and less radiation. A lot of people don't want to marry a 25 year old machine that's going to be extinct in 5.
What implant system did you go with? [crosstalk 00:43:52]. I feel sorry for a clone because the number one comment I got back from every general dentist I cloned Germany is that there were 275 different implant companies, and they're just like, at that point you just go home. How's a guy like you, because you are a smart guy, you've got your [crosstalk 00:44:11], you are. You are a very smart guy and it's an honor to have you on. Which system did you pick?
Donald: I've taken a look at everything. I've probably placed most implant systems. One [inaudible 00:44:23] way back in '86 was a ... I met a fellow named Tom [Driscol 00:44:27]. He designed the Stryker Finned Implant. Of course, as years went by, Stryker decided they made money from the implant division, but not what they were used to making in their medical division. It wasn't profitable enough.
A couple of dentists up in Boston area, Vincent Morgan, purchased it and changed the name over to Bicon, and I've been placing the Bicon implant since '86, and I love it because it's simplified. The design works beautifully. Placing it is fabulous. I don't need to do any irrigation except when I do my first [inaudible 00:45:11].
After that, the RPMs are so low, under 50, that you don't generate heat, so you don't have that need for irrigation , so all the bone that comes out of the osteotomy you keep, and you can utilize for the [pension 00:45:25].
Prosthetically, it is very simple to restore. I'm not a big fan of screws. There's just so many darn components when you're putting these abutments together, and doing the prosthetic phase, that with the Bicon implant, it is extremely simple. It uses a Morse Taper, there's no screws.
If you have an angulation issue, you can just rotate that abutment 360 degrees to any position you want, and then seed it in place. Then you restore it as if you were restoring a conventionally prepared tooth, so you don't have to go crazy with all the implant, bone level, transfer copings.
You can if you want, they have them out there if you want to complicate things for yourself, but I've always felt that an acronism KISS, Keep it Simple Silly. I replaced the S, Keep it Simple, is the best way to go when you can.
Try not to complicate things. The only thing that I'd say that the Bicon implant is not conducive to is, it's not fantastic for immediate loading. That's the one place, because it's not threaded into the bone, it's a pressed fit. The design allows you to use 5 and 6 millimeter long implants that will support any tooth in the arch.
Fabulous in the mandible and fabulous in the maxilla. When you don't have the height of bone, why take away the bone if you don't have to right? We live in a day of conservative dentistry right? Minimally invasive. Don't take away what you don't need.
Howard: You said something earlier. You're talking about Bicon, bicon.com, but they have a very unique system that Morse Taper. You used [inaudible 00:47:14] Morse Taper. That's a huge thing that I don't think a lot of our listeners might understand about how you're not screwing it down, you're not cementing it. They actually call it a cold weld. Explain the Morse Taper in more detail for ...
Donald: Sure. Basically what happens, inside the implant is a cylindrical cylinder that Tapers 3 degrees on each side. The abutment has a post that does the same thing. The abutment post Tapers 3 degrees on each side. As you insert that post into the implant body, it becomes so precise and so tight, that it becomes a cold weld. They hold beautifully. They really do hold beautifully.
You don't have to worry about taking a screw, placing it through your abutment, and screwing it into the implant well. Having an internal hex which limits, obviously, the position of the abutment head especially if there's an agulation. If you have a 5 or 15 degree tipped abutment, you basically only have 8 positions you can put that in.
With the Bicon, you'd have the 15 degree Taper, you could just rotate the abutment into a position that you find is most conducive, and then if you need to prepare it any further, you'd prepare it in the mouth, just like you would if you were preparing a natural tooth.
They use the Morse Taper when they build bridges, when they build battle ships, when they build the Space Shuttle and rockets. We know that it does work. One thing I find is if you use it anteriorly, and the patient has a parafunctional movement that you didn't see, and they're striking that crown, rather than it destroying the bone around the tissue or breaking the screw, it will actually cause the abutment to loosen from the implant body, and then it allows you to prevent damage, and of course you go back and you correct your Occlusal pattern so that it doesn't repeat itself.
Howard: Are they the only one using the Morse Taper?
Donald: I think there's one other company. I can't remember who it is. It uses a Morse Taper, but also with a screw into it. They're kind of taking both technologies and melding them together. I forget who the company is, to be completely honest, but I have seen that they are out there. I like it because it's simple. I can also place the implants by hand.
I can actually use a hand instrument that just allows me to use hand rotation, and the [trephines 00:49:48] are so precise that I could create the osteotomy by hand, and that's actually how I did my very first implant because the patient sat down, I was so proud of my twin motor electric hand piece.
The patient told me they were a pariah, and anything that can go wrong would go wrong. As soon as I stepped on the pedal, believe it or not, the implant unit shorted out, and the patient was already anesthetized and flaps laid, so then I did it by hand. That kind of saved my bacon that day.
Howard: I think the Morse Taper, that's M-O-R-S-E Taper, is actually going to get more looked at because it seems like excess cement, even with dentists using 3.8 loops or whatever, they're finding that excess cement that you thought you got all out, but that's a huge problem.
Donald: Right. [crosstalk 00:50:40].
Howard: Yes. I wonder if they'll be making cements that won't be so caustic if there's a little less left over. It seems like all my friends are getting away from cement, and they're going to screw or Morse Taper.
Donald: One thing that's ... Here you go, here's the technology again. One thing that I figured out that works beautifully when I do my implants, I'll try in my abutment, make any changes that I need to make, scan the abutment in place in the mouth with the Cerec, fabricate the crown, then I pop the abutment out, cement it onto the Bicon abutment, and then I reseed it right in place.
I have a cemented abutment, that's being seeded back into the implant body with the Morse Taper, so there's no problem of cement ever getting in there.
Howard: There's another thing that Bicon is known for. They make short implants. There's just some of these ... It's so funny how it's intuitive that, if this implant needs to work, it should be as long as a hammer, and it should stick out the back of your head. There are just so many people on Dental Town posting 5, 10, 20 year follow ups to these little 8 millimeter short and fat implants. Can you talk about that?
Donald: Yeah. The thing that's different, like I said, I got started in it because I met the engineer who designed it, Tom Driscol, and it's really called a Platform Implant. Those rings you see around it on threads, they're actually plateaus.
What happens is, those plateaus create a tremendous amount of surface area, and of course implant dentistry, that's what we look for. How much surface area does that implant have to allow a bone interface for Osseointegration, and with the Bicon the way it works, the 5X8 millimeter implant will ... 5 millimeters in diameter, by 5 millimeters or 6 millimeters in length will support any tooth in the arch.
Tooth number 19, 18. Tooth number 3, tooth number 2, tooth number 4, so obviously if you don't have a lot of height, you can place the 5 millimeter implant, and be assured that it's going to survive.
The key is with the Bicon implants, you're placing them subcrestly. You really want to place them 1 to 2 millimeters. When you say you have a 5 millimeter implant, you really want to have about 7 millimeters of height and bone when the implant is placed in.
I'm finding, especially way back when we were doing it back in the '90s and everybody was seeing saucering around their implants, I'd very rarely ever saw that with the Bicon implant because of the design. Implant abutment also becomes part of the body, and the bottom or inferior surface of the implant is kind of light bulb shaped so it shapes the tissue into that nice shape that we get so we can get the pillars and so forth.
I haven't seen that bone loss. It doesn't mean we don't see failures, but we don't see that saucering consistently the way we used to.
Howard: Is the word saucering, is that a Roman term or a Greek term? [crosstalk 00:54:11]
Donald: [crosstalk 00:54:11] I guess it must be mine, because when I used other implant systems over time, you'd get the crestal bone loss of 1 or 2 millimeters where we all kind of accepted it. Like, "Okay, that's the physiology or biology of it, and that's what we're going to get." When I switched over to the Bicon implant, I just found that I wasn't getting that saucerization or that crestal bone loss.
I know they've been publishing a lot of things where they're actually getting bone height to increase in certain applications with the use of the implants. That's pretty interesting to see how that pans out and so forth. I know they've been reporting that for about 3 or 4 years.
Howard: You know, if the industry would just move to the shorter implants that's working, you would need less sinus lifts, you'd have less fear of hitting the [inaudible 00:55:08] nerve when the nerve exits the middle frame and you've got an anterior lube. Just a lot less things can go wrong when you start using shorter, fatter implants.
Donald: Yeah. I guess we all follow the same thing, and you see it. As human beings, a lot of people don't like change. A lot of people don't like change, and we all kind of, forgive me, I don't want to insult anybody, because I know I've done it, but we're all kind of monkey see, monkey do, where you turn to somebody and say, "Why do you do that?" "Oh that's because that's the way we learn. We always did it that way", when they don't really look at the science or biology behind it and say, "Okay, why does that implant work, or why doesn't that implant work?"
That's really the answer, so when you look at the Bicon, and you look at other ... Every implant has its great points and it's weak points, but when you look at certain implants, you have to say, "Okay, what's the physiology behind it and why does it work or why doesn't it work?" Rather than just saying, "Oh, you know, I don't like that. It doesn't work. Oh it doesn't have screws. It should have screws."
Howard: You were the acting director of CamDen Company Dental?
Donald: Yeah. When I graduated dental school, I couldn't afford to finish so I took a scholarship from the government for the National Health Service Corp, and I went in as a commissioned officer, and I ran a pilot program in Camden, New Jersey back in the early '80s, near the base of the Ben Franklin Bridge, so I guess was kind of a dental troll.
Howard: Good experience?
Donald: It was fabulous experience. I was the only commissioned officer from Health Corp to show up. The other fellows did not get their licenses, so I was in that ... ran that clinic for a few years. One of the first cases I did was an extraction of the 3rd molar, and we never really did them, so I had the patient holding Gustav Kruger's book on his lap as I tried to use a mallet and chisel. It took me 2 hours, but I got that darn wisdom tooth out.
Howard: I only got you for just 3 minutes left. I want to capitalize on the fact that you've been in this industry for ... You're 58 years old, you've been in this industry for 30 years. Some people say that ... When we got out of school, you got out of school in '83, I got out in '87, that those were the golden years, and now it's twice as hard, and there's corporate dentistry, and all that.
If your daughter was just graduating from dental school today, do you think, in the next 30 years, she's going to have the same opportunities that you did that last 30 years? Is dentistry still a good bet? Would you go back, if you had to do it all over again, and graduated in 2015, would you do it?
Donald: Absolutely. In fact, my daughter's at University of Buffalo. She'll graduate in 3 years, so hopefully she'll join me. Back in the '80s it was great dentistry, but you know what? I think we have lots of opportunity now, especially because of the technology, and especially because I think the patients have higher dental IQs, and higher expectations for how they're going to be treated, and how they're going to have their care.
When they walk into an office, what do they expect? They do, they expect all the bells and whistles. They expect the dentist to be trained. They expect the staff to be attentive to their needs, and be able to take care of them from managing their bills, to their insurance, to their appointments. I think there's a higher level of expectation out there, and I think there's a lot of opportunity.
It doesn't mean we're not going to work hard. Will it mean that the solo dentist, like me, will slowly disappear, and it'll be not, forgive me, not a clinic, but a group practice situation where it is a private practice, where you have, let's say, 2 general dentists, and maybe a specialist or 2.
Maybe that's the way to go, I'm not sure, but I've been at it 32 years, and I'm actually working harder now than I ever did which is pretty darn good, so I'm quite happy. I think there's an enormous amount of opportunity for dentists who want to do the best for their patients, aren't thinking so much of the market, and no, I'm not a Rabbi or a Priest.
I don't want to be poor, but I think if you really are having exceptional patient care, and you're backing it up with the training, and the staff, and the facility to do it, I think dentistry's got a really bright, bright future.
We know dental insurance isn't dental insurance. It's a dental benefit. What does $1.500 get you nowadays? It doesn't really get you very much, so I think there's a lot of opportunity for us if we just keep our eye just a little bit ahead of the curve.
I think dentistry's going to be a great opportunity for everyone. Probably in the next 20 years at least to come. I'm not planning on going anywhere.
Howard: I agree. You said so many eloquent things because when we were little ... I grew up in Kansas in Catholic schools, and everybody had 4 to 8 or 10 kids. Only the craziest looking kid got braces. Now, it's down to 2 kids a family, and both kids get braces. The dental IQ is much higher and dentistry, at the end of the day, we're all surgeons, and at Walgreens and CVC it's just a standardized product.
I've seen in other countries where they're being filled automatically like an ATM machine. I still see ... The biggest take-away I take from this is that 2 things. Number 1, seems like everybody I ever meet on the street, everybody I sit next to on an airplane, if I just sit there, and they're your age, and my age, and I just say, "Go through your life of when you've been living in the same zip code, how many dentists have you seen?"
If they're our age, they've gone through 6 people that aren't then, because no one's making them happy. As far as corporate, I think the legal world, there's a million attorneys, only half of them work in firms. They had corporate law way before corporate medicine, or Walgreens or that. Half of them are in big firms for various reasons, but the other half are all individuals.
If you want to get good at what you're doing, just like the lawyers, you go to your one guy, pay him $400 an hour and he gets it done. Hey, we're out of time. Seriously, congratulations that your daughter's at University at Buffalo.
That's a big controversy because when I grew up, people said, "Well why do they call it Buffalo because there's only a water buffalo in Africa, and the buffalo in America is considered a Bison." Now they're saying in Buffalo that Buffalo is actually the sound of what the Native American Indians called, the river, or the region. They called it Buffalo, that it had nothing to do with a water buffalo or a bison. In fact, ... What does your daughter say?
Donald: You know what? I haven't the slightest idea.
Howard: Okay, well that's the latest, but hey thank you so much for your time. You're an interesting man, and I'm a big fan of your posts on Dental Town. I also wish some day if you ever have any time, which I'm sure you don't, I wish you'd make us an online dental CE course on these lasers because ...
Howard: We put up 327 courses and they've been viewed over half a million times because dentists just like to learn an hour at a time. They don't like to close down their office and lose production and fly to another city when they could just get on Dental Town and listen to you for an hour. If you ever want to make us an online CE course, I'd be salivating to see it.
Donald: I want to thank you. You are an amazing man. You always surprise me at your range of knowledge. I am definitely humbled whenever I see you.
Howard: Oh you're a cute guy. Hey have a rocking hot day.
Donald: Take care.
Howard: All right, bye bye.