Dentistry Uncensored with Howard Farran
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899 Oral Surgery Update with Jay B. Reznick, DMD, MD : Dentistry Uncensored with Howard Farran

899 Oral Surgery Update with Jay B. Reznick, DMD, MD : Dentistry Uncensored with Howard Farran

12/13/2017 4:36:09 PM   |   Comments: 1   |   Views: 291

899 Oral Surgery Update with Jay B. Reznick, DMD, MD : Dentistry Uncensored with Howard Farran

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899 Oral Surgery Update with Jay B. Reznick, DMD, MD : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #899 - Jay Reznick



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AUDIO - DUwHF #899 - Jay Reznick



Dr. Jay Reznick is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his undergraduate Biology degree from CAL-Berkeley, Dental degree from Tufts University, and his M.D. degree from the University of Southern California. He did his internship in General Surgery at Huntington Memorial Hospital in Pasadena and trained in Oral and Maxillofacial Surgery at L.A. County- USC Medical Center.

Dr. Reznick was one of the first North American adopters of fully-guided, prosthetically-based implant surgery and was the first specialist in the U.S. to integrate CBCT and CAD/CAM in his practice. He has taught dentists about basic and advanced implant dentistry, surgery, and 3D digital technology for the last 2 decades. Dr. Reznick has published extensively in the dental and medical literature, and founded the educational website OnlineOralSurgery.com. He lectures frequently at dental meetings and educational conferences, as well as giving live training courses to dentists from all over the world.

Dr. Reznick is also a consultant to a number of manufacturers and suppliers of dental and surgical instruments and equipment, and is on the Editorial Advisory Boards of a number of dental journals.  He is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California.

He is the Director of the Southern California Center for Oral and Facial Surgery, in Tarzana, California. (www.sccofs.com)

www.OnlineOralSurgery.com


Howard: It is just a huge, huge honor today to be podcast interviewing for the second time my best bud for years, Dr. Jay Reznick.


Jay: Good to see you Howard.


Howard: My gosh, you are just the eminent oral surgeon on Dentaltown. I don't know who else the hell it would be.


Jay: There's (00:00:20 inaudible). There's a few of us around. I think I've been around the longest though. I'm the old one. I'm the old guy.


Howard: We launched Dentaltown back in 1998 and right out the gate Jay was a townie and for literally going on twenty years, you've probably answered five-thousand oral surgery questions.


Jay: Has it been that long? Wow.


Howard: Sometimes I'll be reading a question, I'll just think, "God, who could answer that?" so I hit forward and I email it to you and twenty-four/seven he answers. He's just a saint.


Dr. Jay Reznick is a diplomat of the American Board of Oral and Maxillofacial Surgery. He received his undergraduate biology degree from Cal Berkeley, dental degree from Tufts University, and his M.D. degree from the University of Southern Cal. He did his internship in general surgery at Huntington Memorial Hospital in Pasadena and trained in oral and maxillofacial surgery at L.A. County, USC Medical Center.


Dr. Reznick was one of the first North American adopters of fully-guided, prosthetically-based implant surgery and was the first specialist in the U.S. to integrate CBCT and CAD/CAM in his practice. He has taught dentists about basic and advanced implant dentistry, surgery, and three-D dental technology for the last two decades. Dr. Reznick has published extensively in the dental and medical literature and founded the educational website, onlineoralsurgery.com, which has how many hours of content?


Jay: Right now we're up to twenty-seven.


Howard: Twenty-seven hours. He does that surgery. He's got a camera on his head. He's got one on the pole. The assistants aim another. It's a three camera.


Jay: We've got three cameras.


Howard: Three cameras.


Jay: Three simultaneous cameras.


Howard: Yeah. He lectures frequently at dental meetings and educational conferences, as well as giving live training courses to dentists from all over the world. Dr. Reznick is also a consultant to a number of manufacturers and suppliers of dental and surgical instruments and equipment and is on the editorial advisor board of a number of dental journals. He's a director of Southern California's Center for Oral and Facial Surgery in Tarzana, California.


Howard: Tarzana. Like Tarzan.


Howard: Didn't Samir, didn't he used to live there?


Jay: Yeah, Samir used to be down the hall from me.


Howard: Yeah, Samir used to live there.


Jay: Yeah, it's how we know.


Howard: He is the director of the Southern California's Center for Oral and Facial Surgery in Tarzana, California. By the way, is that all on fire these days?


Jay: Not at the moment. Hopefully not. Right now, closest fire is about ten miles away.


Howard: It's weird because in my fifty-five years the fire season just used to be a couple months in the summer.


Jay: Yeah.


Howard: It's December.


Jay: Yeah, well, we had really hot weather in October/November and it's been really dry. Now we've got these Santa Ana winds picking up, like forty-fifty mile an hour winds. It's just a recipe for disaster.


Howard: Yeah.


Jay: There's six big fires going on. There's one up in Ventura County toward Santa Barbara. That's huge, so like one-hundred and forty-thousand acres. One-hundred and forty square miles I think have burned.


Howard: Not to get sidetracked. I don't like to ever talk about religion, sex, politics, or violence but you're a double doctor. You're a dentist, DDS and MB, being warm this late in the year, do you think that is global warming man made?


Jay: I don't know. It all goes in cycles.


Howard: Do you think it's just a cycle?


Jay: Yeah, because actually as I was driving from my house in Malibu through Malibu Canyon to the office this morning my thermometer on my car said thirty-four degrees in the canyon, so if that's global warming, I don't know.


Howard: Yeah.


Jay: It was cold in the morning. I think this all goes through cycles.


Howard: Well, I'm from Kansas and they had a dust bowl storm there one-hundred years ago that's like, three years no rain, everything was dust that was before the car.


Jay: Yeah. These things all recycle. It could be we're getting a little warmer, but I think we're just going through normal cycles and we'll start cooling down again.


Howard: Yeah. Read up on the Kansas Dust Bowl. They had a several year drought and the whole state was pretty much just dust.


Jay: Yeah. We had a drought in California for like six years and now last winter we had more rain than we knew what to do with.


Howard: Jay, you teach hands-on Essentials of Implantology levels one, two and three. What do you want to talk about first? Do you want to talk about your online first? (00:04:39 inaudible) here. I always ask this. Send me an e-mail, howard@dentaltown.com. Tell me where you're from, how old you are. 25% you're talking to are in dental school and the rest are all under thirty.


Jay: Wow, okay.


Howard: I get like one e-mail a month from some old senile guy that's over fifty that says, "Hey dude, I'm as old as you." They're in dental school. They going to come out of school and here their deal. They're all going to say the same thing. They're going to say, "I've got $250,000 in student loans and we never placed one implant." Then they need to pay their $250,000 student loans back but they didn't do any Invisalign. Should they go learn ortho? Should they go learn oral surgery?


I like them to do the bread and butter meat stuff. If you can't do a molar root canal and pull a tooth, you're in trouble. Let's start with this. Let's just say that your daughter just walked out of dental school. She's twenty-five. She's a quarter million dollars in debt and she doesn't know how to pull a molar. How would you start with that skill?


Jay: Well first of all, as a specialist, I've got to tell you that my training is a little different than basically dental school. Dental school we're taught some basic skills. In surgical residency and specialty training you really hone that down and there's a kind of a different mindset that I'll talk about.


What I would tell someone getting out of school is start off doing what you learned in dental school and become really good at it. Then as you start bringing more procedures in to your practice like, extractions, implants, what you want to do is first of all you want to learn everything you can about that subject. You want to really understand it, whether it's taking out a tooth or doing an implant, totally understand the procedure. Be able to get to the point where you can mentally walk through that procedure, start to finish in your mind, anticipating all the possible complications, and how you're going to avoid them, and how you would manage them if they occur. If you can't do that, you don't do that procedure.


That's something that we're taught in surgical residency. We're taught that you don't do anything unless you can complete it to the end. The same thing goes whether you're starting to get into extractions, if you're doing perio, if you're doing endo, if you're doing ortho, you need to totally understand what you're doing and have that mindset of, I would say, think like a specialist and just be able to do that mental exercise of walking completely through the procedure, understanding everything about it, and being able to complete the procedure. Then once you've done that, do two dozen of those and once you've completed those, you can do those in your sleep, then you go to something a little bit more complicated. Get something a little bit more complicated than that after you can do two does those in your sleep.


When you do that, you're going to have success and you're going to have happiness. You're not going to be stressed. You're going to sleep at night. The bottom line is you're going to do what's best for your patients. Just because something walks in your door, doesn't mean you have to do it. That's why specialists are there. You want to have a specialist that you work with closely, that's sort of like a mentor, that will help you because there's plenty for all of us to go around if you want to be doing these procedures.


But the bottom line is learn to do it the right way and grow the right way. Don't think just because you put in a single tooth implant with a tissue punch that the next case you can do is a (00:08:37 inaudible) case. You're really kidding yourself and you're going to do everyone a disservice, your patients and even yourself because you do that, you have a disaster, you're never going to want to do another implant again. If you start with a simple extraction all of a sudden you have a full bony impaction that you want to try and you have a complication, you're never going to want to do another extraction again. Same thing with ortho, endo, etc.


Howard: I think half the specialists or half the dentists or half the humanity thinks in fear and scarcity and the other half think in hope, growth, and abundance. You need to find an oral surgeon or periodontist in your own zip code or county that if you call them and say, "I'd like to come watch you learn how to place implants," he says, "No, refer them to me. I'm not going to teach you how to do this." Just cross his name off.


Jay: Yeah, go somewhere else.


Howard: Never call him again. Call the next periodontist. He'll say, "Yeah, come in." Then when you got an open schedule because you just started your associate job and you don't have anything going Thursday afternoon, call your periodontist, call your oral surgeon, "Can I come sit by you?"


Jay: Yeah, exactly.


Howard: Or endodontist.


Jay: The good specialist, oral surgeons, periodontist, orthodontist are all very comfortable with what they do and they get it. They understand that there is plenty for all of us to do. We all benefit when the general dentist understands implantology, understands ortho, understands endo because it's perfectly within your training and it's within your wheel house. You're smart enough to do it and you have the skills, you just have to do it the right way. There's enough for us all to do as long as we do it the right way and a smart specialist understands that and will mentor the GPs who follow that.


If you're doing things that are beyond your training, beyond your skill set or just that you really are not prepared to do, they're not going to want to help you, but if you make it very clear that I want to watch you, I want to see how you do it, I want to do some simple cases and help. As a result, using implants as an example, some of my best referrals are dentists who now place implants because maybe ten years ago they would have done, let's say if a patient's missing six teeth, they would have done a bridge or removable. Now they're thinking, "Oh this is a good implant case. Patients going to need some bone grafting but this will be a good case. I know just who to send this to." As a result my referrals for complicated implant cases and bigger implant cases has improved. I'm not doing as many little cases, single tooth implants but I'm doing more of the bigger cases, which as a specialist, are pretty fun.


Howard: I know orthodontists in many, many different major markets, where when Invisalign started taking place ten, fifteen years ago, they thought okay these guys are going to do it, but they don't know how to do it.


Jay: Yeah.


Howard: All the other orthodontists were afraid of Invisalign and you'll get one that thinks in hope, growth and abundance, that tells every dentist within twenty miles, "I'm going to have an Invisalign study club."


Jay: Yeah.


Howard: "I'm going to come and bring your cases. I'm going to help you do these cases." What did all those dentists turn into? Referrers.


Jay: Exactly.


Howard: They built the biggest practices ever. Those orthodontists tell me the same thing. They go, "Once they started learning ortho and doing some Invisalign, they started seeing ortho."


Jay: Right. Exactly.


Howard: They just started diagnosing the heck out of.


Jay: It's a win-win for everybody.


Howard: When I got out of school I went and did Carl Misch's seven three-day program.


Jay: Yeah.


Howard: What changed my mind is when I walked in there I had this belief that a sinus lift was just crazy. We're talking back in the eighties. But watching Carl gave me faith that this procedure-


Jay: Oh, it's such a routine procedure. I did one today before I got on the plane. As long as you understand it, understand the physiology, understand the procedure, it's a very safe, reliable, predictable procedure. Most patients have very minimal swelling, minimal discomfort, really very few problems afterwards.


Howard: Would a sinus lift be something - again we're talking about a quarter of our listeners are in dental school, three quarters, they're all under thirty. Do you think in the first one-hundred implants a sinus lift goes in that category


Jay: No, no. It's not something you're going to do until you're very comfortable


Howard: The first one-hundred, there's no (00:13:23 inaudible). There's not going to be any PRF. Are you going to be drawing blood?


Jay: No. No.


Howard: Making sticky bone?


Jay: Mm-mm. Now until you've done at least one-hundred implants do you even start thinking about doing some advanced procedure.


Howard: You're going to stay out of the aesthetic zone. That was my first big mistake. One of my first, I think it was like fifth ones on to this gorgeous blonde girl on number eight. They god, I prosthodontist I could bribe to go fix it. But stay on this side. In the first one-hundred, what are your favorite teeth to place?


Jay: I think at least for the first twenty-five for sure, first premolar to first molar. The first twenty-five should be flapless surgery, which means you've got plenty of bone, plenty of (00:14:10) nice tissue. You don't even have to think about laying a flap.


Howard: Really?


Jay: In the next fifty or next seventy-five, then you start from a very simple flap, very small incision, some minor bone grafting, maybe an indirect sinus lift as you get more advanced, and simple suturing. Once you get to one-hundred, then you can start building on that foundation of what you know and your skills and start doing more complicated bone grafts, sinus lifts, etc. In the courses that I teach, Essentials of Implantology-


Howard: One, two and three, right?


Jay: We have three levels.


Howard: Are those two-day courses?


Jay: They're all two-day courses and with three levels.


Howard: Where are they at?


Jay: We're doing them all over the country, so we're doing one in February here in Scottsdale, and we're doing one in March in Dallas, and we've got dates coming up for the whole rest of 2018. 2019 we're going to expand it even further probably have an implant continuum, where you bring your cases and we do the surgery together.


Jay: But we have three levels, so we have Level one and that's for the newbie dentist, when it comes to implants, you haven't done a single implant before or maybe you've done two or three or ten. Zero to twenty-five implants, we start you off learning the basic principles of implantology, what is type one, type two, type three, type four bone, what do we mean by biologic width in relationship to implants, talk about the science between using short implants, long implants. We talk about basic bone physiology, how you drill, drilling speed, what drilling speed you use and why. It's very, very foundational.


We teach you first premolar to first molar flapless surgery, plenty of care, nice tissue. We tell you that's all you want to do for your first twenty-five cases. Once you've done that, then you come back and do level two or if you've already done that in your experience, you come in for level two.


Level two then we start bringing in small incisions, maybe a little bit of particulate (00:16:31) augmentation, indirect sinus lifts, maybe taking on a lower second molar where space is a little bit more limited, maybe towards the end, anterior aesthetic zone in a very straightforward case, and start talking about extractions with immediate implant placement. But the first two dozen you do, if not more, should be very, very basic, healed ridges, flapless surgery. Then level three would sort of be expanding with open sinus lifts, rich splits, bigger cases.


Howard: Patients always want to leave with the tooth. In these first one-hundred, would these be two-stage implants, would these be immediate load?


Jay: Well, the first twenty five that you do, are going to be implant is placed in a healed ridge with a healing abutment or a cover screw. That's it. That's as far as I want you to go because I want you to be very comfortable at working up and treating this very simple, straightforward case before you start moving on to something more complicated.


Immediate provisionalization, immediate loading, whatever you want to call it, it's just as successful, but it's a little bit more technique sensitive, so you want to make sure you've got the fundamentals. Implants and immediate extraction site, again very high success rate, as high as placing an implant into a healed ridge, but, again, the technique is a little different and you've got to master the basics first before you move on to something more complicated.


I would say after you've done at least fifty implants then you can start doing immediate implant placement and extraction sockets, start possibly doing immediate provisionals, and then work your way up. Once you've got those two skills mastered, put them together and do an anterior aesthetic zone, extract number eight, immediate implant with immediate provisional, but very slow stepwise, very deliberate.


It's like in my residency, I didn't start off taking out impacted wisdom teeth. I didn't start out doing mandible fractures and orthodontic surgery. We started out very basic. We did basic surgery, surgical extractions, then progressed through the year to do impactions, and then from simple soft tissue, partial bony, full bony. Second year we started doing trauma, pathology. Third year we started working at orthognathic TMJ. But, again, when we learn in residency we have a mentor, we have our attending staff, we have our senior residents, who show us how to do it and then we watch them do it, and they do it with us, and then they watch us do it before we do it on our own. It's a very different mindset than the way we are taught things in dental school.


One of the things that can get you into trouble as a general dentist if you're starting to get into doing surgical procedures or any kind of specialty procedure, is getting outside your boundaries getting outside your comfort zone. When you look at a procedure that needs to be done, whether it's an Invisalign case or an endo or an extraction or an implant, you look at the case and you go, "I think I can do that." If that's what you say, you don't do it. Only if you can say, "I know I can do it," that's when you can do it. You can only say I know I can do it until you've had the fundamentals, the basics, and some experience under your belt of the really simple stuff and then you've slowly progressed into the more advanced.


Howard: I've heard you lecture a gazillion times. I've read all of your five-thousand posts for twenty years. I know where you stand on this, but I still have to make the question. This is dentistry uncensored. She comes out of school and she's working for her old man out in the middle of Hays, Kansas. He's placed one-thousand implants with a pano. Jay, seriously, here's the truth. I would say 80% of every living dentist who's placed over five-thousand implants, did them all with panos.


Jay: Well, I did too. My first ten years of practice, I did it all with panos because that's all we had.


Howard: Let me continue this rant because I've got this email one-hundred times. Then when she talks to that surgical guide, her dad's like, "What do you need training wheels on your bicycle? You need three-D and training wheels." Dad's placed a thousand with the pano. What would you say to her dad listening here right now?


Jay: I would say it's time to advance yourself a little bit. How many things that we have, that we do in our life are we doing the same way we did twenty years ago? Okay.


Perfect example. Twenty years ago, who would have dreamt - if I had to write a paper, if I was writing an article, I would get out my typewriter with my Smith Corona with the eraser cartridge and I would spend time typing and then have to correct and correct and then redo it over and over again. That worked great. It was fine but with a word processor, with templates, how much easier and how much more efficient is it to do now.


I can place an implant, I can place ten implants with a pano and free hand, but with cone beam I have much more information to understand the anatomy, so where the sinuses are located, where the nerve is, what the width of the ridge is. I don't have to flap it open and say, "Oh, it looked like the ridge was like this on pano but in reality it's like this. What do I do now?" I know ahead of time what I'm getting into.


I can place ten implants with that guide in less than half the time with greater accuracy and precision than doing it freehand no matter how many implants I've done. I can do it with better efficiency, safer for the patient. I don't know if you remember, but there was a time where there were a number of case reports of implants being placed through the lingual cortex of the mandible because remember how the you have the mylohyoid concavity? Implants placed - the nerve was way down here, but the concavity came like this and implants were placed into the floor of the mouth resulting in floor of mouth bleeding, airway obstruction, and death in the dental office. Wouldn't you want to avoid that? Would you not want to have that headache?


Or with a sinus, you can't tell in two-D what's going on. The patient's not a block of wood. They're a three-dimensional person. Three-D imaging gives you more information, more accurate information.


The analogy that I use when I lecture is GPS. Guided implant surgery, three-D imaging is like GPS for placing implants. You may say, "Well, I can drive from here to the airport without GPS. I can drive from here to my office without GPS. I've been doing it for ten years just fine," but what other information does that GPS in your car give you?


Howard: How far away the girls on Tinder are.


Jay: Okay, other than that.


Howard: By the way, did you know Phoenix is the test site for Google's Waymo?


Jay: Oh, really. You'll have to tell me about that afterwards.


Howard: In Ahwatukee there's driverless cars now. You see one every other day.


Jay: Wow. That's amazing.


Howard: Back to GPS.


Jay: What's missing or the thing that I didn't mention is real time traffic. If you put that real time traffic information together with the GPS data, what do you get? You find the best way to get to your destination, the most efficient, the least stressful way, and the quickest way to get there. Guided implant surgery is like GPS with real time traffic. It gets you to your final destination more efficiently, with less stress, and more accuracy.


Howard: Jay, when we were little, thirty years ago, the goal of the implant was the longest one you could get. People would move (00:25:45 inaudible) nerves over just to get the implant five millimeters longer. Now they tend to be trending to go shorter and fatter. Are you personally doing less sinus lifts because they're shorter?


Jay: Yeah, less grafting because what the studies are showing us - and when you look at the stress patterns on implants, and you look at the long-term success of short versus longer implants - so if you have six, seven, eight millimeter implants and you compare them with placing let's say, ten, eleven, thirteen millimeter implants, where possibly you have to graph the site to be able to put that longer implant. What the studies have been showing is that the success rate of that short implant is just as good as that longer implant, except that when you did the grafting for the longer implant, that has a higher complication rate.


It's made us rethink a lot of what we were we were learning before, what we were doing of we always wanted to put the longest implant possible. Now what we're finding is that short implant, and if we can go wider, great, but shorter implant is just as successful as the longer implant and if we don't have to graft to be able place that shorter implant, our complication rate is lower.


Howard: That was a beautiful story. It almost made me cry. I love when the short, fat guy wins.


Jay: It's been my story. The same thing we've learned is with insertion torque. We used to think that the tighter you could crank that implant in, the better it was, but now we know that those higher insertion torques cause necrosis of bone and more remodeling and that may be one of the things that was leading to bone loss and implant failure. Now we prep our sites differently so we can place those implants in at lower insertion torques.


Howard: Back to that little twenty-five-year-old girl going in with her old man or her old mom and they're going to get a CBCT. The major ones are Galileos from Dentsply Sirona, i-CAT, Carestream. What advice would you give her on which one to get?


Jay: I think if you look at them all, they all pretty much give the same image. You go to the different cone beam manufacturers and they're going to show you all these cases on their computer. They always pick the best images to show you. Every cone beam out there can give you some amazing images on your patients and it can give you some horrible images and it has to do with how much metal is in the patient's mouth, it has to do with the patient's density, all kinds of factors. They all give you good images.


What I tell people to look for is you want to have software that's easy to use, that's user friendly because if the software is cumbersome to use, you're not going to use it. If it's a pain to navigate through those volumes or to plan those implants in the software, you're going to stop doing it because it's too complicated to learn and it's taking too much time to do with your patients.


If you have a system let's say where it's hard to get training or it's hard to get support, that's going to be a problem too. You're going to stop using the technology. You want to go with a system and go with companies that give you good support and give you training as part of the package.


Howard: Who do you think does that best?


Jay: I've been working with Dentsply Sirona for ten years and I went with them for those reasons and I think they still are the leader in those two categories: support and software and innovation.


Howard: The way I see it as there is it just goes back to Apple or Android. Basically, the open/close Apple's a completely closed system, like Dentsply Sirona, but the CAD/CAM talks to the CBCT and it's really simple.


Jay: It's seamless.


Howard: It's seamless and simple.


Jay: But they are opening things up. It's happening in the last year or so.


Howard: There's these other people who say, "Well, I want to mix and match printers, CAD/CAMs, CBCTs," and that's cool if you're a really sophisticated techie.


Jay: Exactly.


Howard: But I've gone into so many offices where they want to do the open system, they've got all these machines and then you go ask anyone in the staff a simple question and they can't figure it out.


Jay: Exactly. You want to do (00:30:46 inaudible) systems.


Howard: People are badmouthing that the closed system is so bad, it's kind of funny when they're saying that when they have an iPhone.


Jay: Exactly.


Howard: An iPhone and Galileos, which is owned by Dentsply Sirona - I think it's a closed system.


Jay: I think it's a great analogy.


Howard: It's intuitive like an Apple.


Jay: Yeah.


Howard: But if you start mixing and matching pieces, that's super cool if you're a nerdy techie


Jay: Yeah and if you have the time to figure out how it all works together. I don't know if I told you how I first started speaking for Sirona ten years ago is Sam Purry, I had worked with him on CEREC and he introduced the-


Howard: I thought you meant him on Dentaltown.


Jay: No, I met Sam because he was down the hall from me.


Howard: Oh, okay.


Jay: He's the one that brought me into Dentaltown.


Howard: You met Tebow on Dentaltown.


Jay: Yeah, he met Tebow.


Howard: That's right. He was down the hall from you.


Jay: Down the hall from me. He introduced the imaging Germans to me and when they were coming out with the software, when they were coming out with Galileos, they were going to be providing a speaker to my study club that I do once a month for my practice. I was told that before the meeting they wanted to meet with me.


I met with them at the venue and they sat down and they showed me the software, the Galileos implant software, and had me play with it for about - they took about five minutes to show it to me and let me play with it for about fifteen minutes. I said, "Okay, this is great. This is really easy to use. I really like it. When's the speaker going to be here?" And they said, "You're the speaker. You now know everything there is about this software and how easy it is to use, and intuitive. Want you to talk about it for an hour in front of your referrals," and I did.


That's how it all got started about ten years ago. I've been with them ever since. I did the very first live guided surgery with the Galileos implant system live on stage at the Scottsdale Center with five hundred people there.


Howard: How many years ago was that?


Jay: It's going on ten years ago.


Howard: Wow. Have you ever been to Sirona in Germany?


Jay: Yeah.


Howard: What's that city called?


Jay: They're in Bensheim.


Howard: Bensheim. I'll tell you what, if you've never been to Germany or Tokyo, you'd-


Jay: Yeah, it's amazing. Bensheim is where they have Sirona and then-


Howard: I've been in fifty U.S. dental companies, minimum. Germans and Japanese - they're the only two countries to make a car. You'd only want a German Volvo.


Jay: Those are the Swedes. Yeah.


Howard: What do the Swedes make?


Jay: Volvo.


Howard: Oh, is that Swedish? Volvo


Jay: Yes. It's Swedish.


Howard: Okay, but I mean Mercedes.


Jay: There's Italian. Italians make cars.


Howard: But Mercedes and Porsche. Here's the difference, when you go into a German deal, you don't have to ask where's the bathroom, there's a blue line that takes you to the front, there's a red line that takes to the bathroom above every switch.


Howard: What blew my mind the most, you totally get German manufacturing if you remember the spaceship Columbia, had this big old huge black arrow, ten feet wide by the fuel deal. I remember looking at that thinking they are astronauts, they are scientists, there's no big arrow pointing to my gas tank. Why the hell do these guys need an arrow pointing to a gas tank? It's like that's German manufacturing.


Jay: Yeah.


Howard: Another thing, you walk into almost every American dental manufacturing company, they have not one person with a Ph.D. or an R&D, but they've got a thirty-person call center.


Jay: Yeah.


Howard: Then you go to the German and Japanese companies and they have fifteen - twenty PHDs and they don't have a marketing department. The Germans the Japanese think, "We will make this so damn good, it'll sell itself," and the Americans are like, "I can sell anything to anybody with my telemarketing skills," but German and Japanese - I want to go back to the other thing. You like the Galileos with-


Jay: With CEREC.


Howard: With CEREC because it's a closed intuitive system.


Jay: Closed system and it just all works seamlessly.


Howard: And the Carestream and the i-CAT are very popular too.


Jay: Yeah.


Howard: But they're not as user friendly.


Jay: They do have solutions to integrate CAD/CAM with cone beam and make surgical guides but they're a little bit more cumbersome and they don't always work as well.


Howard: So know your own wheelhouse. If you're that techie, nerdy, geeky guy that can wire and splice everything together, you'll be fine. The other thing, I recommend that she picks a mentor in her county first, then use that system.


Jay: Right.


Howard: But you work with Dentsply Sirona and BioHorizon. Dentsply has - they have the Astra Tech, they have the (00:35:55 inaudible), they have XiVE and BioHorizon. If she was asking you, "Jay, what implant system should I start with." Does it matter if it's one of the big six brands


Jay: My bias is always go with a name brand, especially starting out because you've got the company behind it, you've got the reps that are there in the field to come help you and show you the ropes, and make it easy for you. A lot of the systems are very similar. The connections are a little bit different, the screwdrivers a little different, but they're all pretty much the same.


If you go with the big names, Astra, Nobel, BioHorizons, Straumann, all those implant manufacturers are giving you high-quality products. They also have the research behind them. Some of the budget brands don't have their own research. They're kind of piggybacking off of let's say, Nobel and saying, "Well, it's just like Nobel, so it must be the same," but there are subtle differences. What we're finding over time is that the very subtle differences in surface, in alloy, and screw pitch design, etcetera, do make some differences.


I always recommend go with the name brand and go with, again, a company that's got good reps in your area and that varies geographically. There are some areas BioHorizon is the strongest and they've got really good reps.


Howard: They're out of Birmingham, Alabama.


Jay: They're out of Birmingham. Or in your area the best rep may be with Nobel or maybe with Straumann or Astra Tech. You want to have a really good rep starting out.


Howard: I like to look at what did the successful people have in common. Every dentist I know that has placed a hundred implants or more have a very close relationship with a rep.


Jay: Yeah.


Howard: Then everybody sits there and says, "I'm going to buy it online. I'm going to say 25 cents." Yeah, go save a lot of money but you just never get it done. The other thing I've noticed is that in 1900, there were no specialties and the doctor did everything. By 2000, there were fifty-eight specialties within MDs and nine with dentists. I also noticed that there's a critical mass on probability that if you don't do it once a week, you don't reach critical mass.


Jay: Or even more than once a week. Yeah.


Howard: If you're going to get into implant dentistry, you need to place one a week. You're going to get into Invisalign; you need do a case a week. The procedures that you do once a month or every other month, when you factor in all the continued education, all the overhead, all the cost, you lost money.


Jay: Yeah. I'm fully trained as an oral maxillofacial surgeon. I can take apart your face, put it back together. I can do TMJ surgery, orthographic surgery, tumor surgery, you name it. I trained doing all of it, but I don't do those as often. In fact, I stopped doing TMJ surgery because 90% of the patients who came to me with TMJ problems got better with nonsteroidals and splints. 90% of those that didn't got better with arthrocentesis. That left about two or three patients a year that actually needed surgery.


You can't be good at a really complicated surgery, like TMJ surgery, if you're doing it two to three times per year. Same thing when it comes to cancer surgery, orthographic surgery, all of those things that are part of my specialty, as my practice has evolved and I've spent more time with education, with online oral surgery, with lecturing and I'm not in the office as much, I'm just not doing those procedures that I'm fully trained to do and I've done dozens of, since I don't do them on a regular basis anymore I stopped doing them, especially as you're starting to get into procedures.


That's why I say start very basic first. Do those simple cases and do them well and then progress. Don't ever get in over your head. Like I said, don't tell yourself I think I can do it. You have to say that you know you can do it. Being able to know you can do it, comes from having done it a number of times.


When I was in general surgery residency, I remember one of the attendings would always tell us that good clinical decisions in surgery come from clinical experience. Clinical experience comes from having made bad clinical decisions in surgery. Hopefully, you don't want to make bad decisions but you will have the most success if you start off very basic, get that under your belt so you can do it in your sleep and incrementally expand and grow.


Howard: No doubt. You're saying pick a system that's got research. The one thing American dentists don't talk enough about is there are one million attorneys in the United States and they bill out one trillion a year. When you look at our nineteen trillion dollar economy, a trillion of it's a million lawyers. Let's say you do an implant case, the implant snaps or whatever and it goes to trial and it's not Noble, Biocare, BioHorizon, Straumann, Dentsply, Sirona, Astra Tech, big names, because Italy has a hundred different- Do you think if you get a no name knockoff generic, that that could look bad in court?


Jay: This is something actually in our Essentials of Implantology level 1 we talk about because one of my goals in the course is to have you never be in court but if you are, be able to defend whatever you did.


I was an expert witness mostly defense but sometimes plaintiff, if it was really an egregious case. I was a medical expert and did a lot of expert testimony and one thing that I learned from doing that is that a malpractice trial is not a trial by a jury of your peers for one. People who don't know anything about what you're doing, they think you're a rich dentist.


Howard: They (00:42:44 inaudible) dentists.


Jay: It's not about whether you did everything correctly and to the standard of care. That doesn't matter. What determines whether you win or lose in court is which side puts on the best dog and pony show.


One thing you want to do is if you're doing any procedure, whether it's general dentistry or a specialty procedure like, implants, ortho, endo is that you always need to be able to defend what you did. You need to do it to the same standard of care that a specialist would do.


Now when it comes to things like using a knock off or not a knock off, but not one of the big six implants, that may not have had anything to do with why the case failed or became a disaster, so you end up in court, but I can guarantee you that the plaintiff's expert will make it an issue.


Howard: You just said the big six, in your mind what are the big six?


Jay: Astra Tech, Straumann, BioHorizons, Nobel, 3i. That's five and let's see. What's another big one? Let's see, 3i.


Howard: Implants Direct?


Jay: They're basically a knock off. Let's call those five.


Howard: Did 3i get swallowed by Zimmer?


Jay: Well, yeah. It's owned by Zimmer but it's still 3i or Zimmer or Biomet, 3i.


Howard: 3i, Biomet, that's Zimmer. You're saying Zimmer, Nobel, Biocare, BioHorizons, Straumann, Astra Tech. That's five


Jay: Those are the major systems out there.


Howard: Okay. Let's talk the controversies. Cement or screw.


Jay: Something easy.


Howard: Are you a cementer or a screwer


Jay: Well I would say that you should plan on doing a screw retain restoration as much as possible. It's a lot more retrievable if you have to get the crown off or the prosthesis off, but it also avoids the issue of cement sepsis and cement getting under the under the tissue and causing bone necrosis


Howard: Isn't that just insane that they make cement that says dental implants cement and if you have a little excess it causes a disaster


Jay: Because what happens is cement violates the biologic width. It gets where it's not supposed to be and it sets off an inflammatory reaction.


One thing I learned in dental school, in crown and bridge was you use as little cement as you need and then you cut that in half and that's what you use. If you follow that, if you're doing a cement retain restoration, chances are if any cement oozes out your margin it's going to be very minimal and you'll be able to see it.


Now what we tell people in our course is if you're going to do a cement retain restoration, keep your margin no deeper than one to one and a half millimeter subgingival so that you can really see and clean out any excess cement or super gingival would be even better if you can if you're in the posterior.


The one thing about being able to do screw retain restorations, especially in the anterior aesthetic zone, is that this is where I think that three-D imaging and guided implant surgery is so critical because what you're doing when you're doing cone beam imaging and treatment planning in the software and then creating a surgical guide, is you truly are planning the implant position based on the final prosthesis. Then you're using these tools to deliver the implant at exactly that spot so that if you plan the implant to be right here, it's right here. It's not just a little bit off, where you thought you were going to do a screw retain restoration and you end up having to do a cement retain because the implant is a little bit off.


Guided implant surgery is a tool to place that implant more accurately and precisely on a consistent basis and you're basing your plan on the final prosthesis. That's why when we get back to Panorex and freehand implant placement, sure you can do it that way, but if you want that accuracy and consistency of good results, then using the technology that's available to us in 2017 is the way to go, not the technology of 1985.


Howard: You think you can freehand and line it up but you know what? Every lab man I know who's done ten-thousand crowns can tell 100% of the time that the dentist was right-handed or left-handed (00:48:08 inaudible) placing the implants.


Jay: Yeah. Oh, absolutely.


Howard: If it was a right-handed guy, it's all freehand. The implants were drifted towards the dentist. Which website would my homies find most of your information like, you're saying these courses are in Scottsdale and Dallas?


Jay: We have everything on onlineoralsurgery.com.


Howard: Everything is on onlineoralsurgery.com.


Jay: Then we've got some links on the home page for Essentials of Implantology and then any live lectures I'm giving. All the information is on the home page of Online Oral Surgery. Also, on the website we've got, as we mentioned, twenty-seven hours of online content that is dental alveolar surgery, impactions, pathology, radiology, and implants. We're expanding our website to bring in more faculty members, so we're going to have an oral maxillofacial radiologist.


Howard: Who's that going to be?


Jay: It's going to be Dr. Heidi Kohltfarber, who's out of Loma Linda and also at UNC Chapel Hill. We're going to have an oral pathologist from USC, Dr. Audrey Boros, is going to be on our faculty and helping us build our content. We're also going to have Chris Farrugia, who's a dentist out of Pensacola, Florida, who specializes in medical billing.


They're going to be doing courses with us to give not only how to do the surgery but also to learn about pathology, radiology, and of course medical billing, so you can get paid for some of the procedures that you're going to learn from the website.


Howard: How much is onlineoralsurgery.com? I'm on your website right now.


Jay: It's $50 a month or the better deal is to do an annual subscription for 495.


Howard: No, you don't want to do that.


Jay: So it's like getting two months free.


Howard: No, you don't want to do that.


Jay: Why not?


Howard: Because the whole deal is your marketing and advertising should get them on a reoccurring revenue.


Jay: Well it is. It's an annual recurring.


Howard: You don't want to ding them 495 once a year. You want to ding them - what is it? How much a month?


Jay: 50 bucks a month.


Howard: 50 bucks so you emotionally want to make that 49 and then it's a reoccurring thing.


Jay: 49.95.


Howard: Because look at these deals. Like Apple, realized they lost tens of billions of dollars because they would sell you a song for 99 cents and then Spotify said "No. Let's use all that marketing to get you to sign up for $4.95." Look at Netflix. It's worth 70 billion dollars because once you join up for Netflix - I have Netflix. Ryan when's the last time I watched a Netflix movie?


Ryan: I don't know if you ever have.


Howard: I am on Pandora and Spotify and I haven't listened to - and Lifetime, just look at me. I look fricking pregnant with twins, but Lifetime is dinging me every month for a subscription, Spotify, Pandora. Netflix is one of the top five biggest companies because when they decide they're going to cancel, they're driving to work and they're like, "You know what? I'm going to cancel Spotify. I never use it." Okay, you have that thought, but you're driving to work. Humans can't get it done. They're not organized.


Jay: Well, okay.


Howard: What percent of dentists can't even reconcile their bank statement.


Jay: True. All right, so if you want to spend 600 a year, do a monthly (00:51:32), but-


Howard: No, you only offer the recurring revenue. You only offer it for $49.


Jay: No, both the monthly and the annual are recurring, but the advantage is we are always adding new content and starting actually next week we're launching, not only can you go on the website to .


Howard: But if you ding them a year later for 500 bucks, that might motivate them to sit down and call you up and cancel and get off the deal, but the little 49, they know they need to watch it.


Jay: We get more people who cancel their subscription on the monthly than on the annual. Anyway, we're going to start providing online CE through the AGDP certification, so not only can you get on onlineoralsurgery and learn something, you can actually get CE credits to help renew your dental license. That's another thing that's happening too.


Howard: And what is what is Medicus Multimedia


Jay: That's just our parent company that runs the website and our educational courses.


Howard: Is that your company?


Jay: Yeah.


Howard: Is that where you live, Pacific Palisades


Jay: That's where my P.O. Box is. I actually live in Malibu.


Howard: Do you live in Malibu. Doesn't Fred (00:52:42 inaudible) live in Malibu?


Jay: I think he lives in South Bay somewhere. I think he lives in Huntington Beach area.


Howard: My boys still talk about that.


Jay: Manhattan Beach or Hermosa. One of those.


Howard: We got an RV and we left Phoenix and we drove to Fred's house in LA and then we drove all the way up the beach that all the way and we saw Ken Austin.


Jay: You probably drove right by my house.


Howard: Oh, yeah. They told us they thought Fred (00:53:05 inaudible) was the coolest house they'd ever been in.


Jay: I bet.


Howard: Let's talk about more controversies. There's a lot of research saying that at sixty months, five years, 20% of these implants have peri-implantitis. At nine years, 36% have peri-implantitis.


Jay: You mean the other way around.


Howard: Well, at five years, it's up to 25.


Jay: Oh, 25, okay.


Howard: At five years and at nine years it's up to 36.


Jay: Yeah, I would say that is absolutely spot on. As we are learning, as more and more implants are being placed, we're seeing more and more peri-implantitis. Actually one of the things that we're doing in our practice is we're actually focusing on peri-implantitis. We have patients that are referred to us from all over, all over L.A., all over California, all over the country to manage peri-implantitis. We use all the technology that's available to us, using lasers, Piezo surgery.


Howard: Using lasers


Jay: Mm-hm.


Howard: Now is that LANAP


Jay: No, well, we're using the Biolase.


Howard: You're using the Biolase.


Jay: Yeah.


Howard: Why are you using the Biolase instead of - which one is the LANAP


Jay: That is the Millennium.


Howard: Millennium.


Jay: Yeah.


Howard: Why did you go with Biolase instead of LANAP with Millennium?


Jay: Studies I've shown, showed a higher success rate of being able to sterilize the implant surface and also being able to regrow some bone around the implants, so that seems to be very effective. We're also looking into using Piezotome, Piezo surgical instruments, for debriding around the implants, as well as, basically the grip (00:55:02 inaudible) with - blanking on what - the drill. But we're looking at all the new technologies for treating this problem because we're seeing it as an emerging issue that's going to start haunting us in implantology and we want to be - in our practice we're kind of positioning ourselves at the forefront of managing these complications (00:55:22 inaudible).


Howard: When you manage these peri-implantitis, will a laser always be part of the protocol?


Jay: Well, I'm not going to say always because - so right now the technology that we've researched and we're bringing to our practice that is the most effective so at the current time that's what we're using. As technology changes it may be that we find something else that's better than laser, in which case then we'll switch technologies.


Howard: Do you think some implants and their surface are more susceptible to peri-implantitis than other implants


Jay: I think probably, Yeah.


Howard: Because remember when we started thirty years ago, remember it was the HA coating and now it's all falling off, showing up in kneecaps and macrophages.


Jay: Yeah, and there was an implant system that I placed that had a very large like a porous surface that had a large surface area, which allowed you to place very short implants with a high success rate. The problem was one because of the surface, if you had a little bit of bone loss, once the bacteria started getting into that porous system, you had massive bone loss including spread to adjacent teeth.


Definitely the implant's surface does make a difference. I think we're learning more and more about those things as time goes on. Possibly different titanium alloys may make a big difference as far as peri-implantitis. We're just at the tip of the iceberg learning. Now that we're seeing peri-implantitis as not just a rare occurrence but as being something that we almost should expect and prevent from the time the implant is restored. Now we're seeing it as something completely different. Our knowledge is changing. Our perspectives are changing. The technology is changing and this is all evolving.


Howard: But you know what's not changing? The patient and the treatment planning because if they could walk in there and snap off their denture and brush implants, but that's not what the dentists are doing because the patient wants it fixed. Then they come into your office, they have a full loaf of bread underneath their All on 4 implants. If you spray water in there, you've got to turn your head. How many implants have you had in your own mouth


Jay: None. Yeah.


Howard: The vegan yoga instructor isn't the one getting implants.


Jay: Right.


Howard: Why did these people lose their teeth to begin with? They weren't taking care of them.


Jay: Exactly.


Howard: They weren't brushing, smoking alcohol. The patient selection-


Jay: Is critical.


Howard: Is critical.


Jay: Yeah. I don't really do that many all-on-four as I used to do.


Howard: But it's not even all-on-four. If you had the behavioral patterns to lose a bunch of your teeth-


Jay: Exactly.


Howard: I can go give you all new teeth, but you're still Uncle Joe.


Jay: Yeah. You're still not going to floss. You're still going to - yeah.


Howard: I want to talk about my implant failures. Looking back, it's really sad to me when a patient calls and in and their mom's in a nursing home, you go in there and you give two implants. You got rid of her partial. You did two implants - two, three unit bridges. Twenty years later she lose one of these implants and I'm sitting there thinking if I replace three implants and a three unit bridge, I wouldn't have lost the case.


Jay: Yeah.


Howard: And twenty later I've lost a half dozen bridges because I put -so now I'm like do you treatment plan one implant per tooth


Jay: Well, one of the nice things about using the technology and the software with cone beam and implant planning software is I can show the patient the differences, so I can show them, "Look, you're missing three teeth. We can place three individual implants and have three individual crowns or we can place two implants with a bridge but with a bridge you're going to have the same problem you had before is that it's hard to floss underneath there and if you lose an implant then you're stuck with one implant and two missing spaces."


"If we do three implant or if we have three implants and they're individually restored, then it'll be easier for you to keep clean and if we lose an implant then there's still a prosthetic option that we can do even temporarily while we're waiting for another implant to re-integrate. It's going to cost you more up front. The prosthetic cost is probably going be about the same. You're talking about the difference between two versus three implants but it keeps your options open. I think it's going to be better for you long term and you're investing a lot of money into your mouth to do this to begin with. Don't you think it's worth the difference?"


Howard: Yeah, you've got to have spare tires.


Jay: Exactly.


Howard: Here's what you don't know when you started the practice. When you started the practice at twenty-five, you don't ever believe that somebody you're going to be old and fat and bald like me and be fifty-five. When you do those implants and crowns on those sixty-five - seventy-year-old grandmas, you don't even comprehend that they still may be alive at ninety-five.


You're in these nursing homes. They bring them in and they're all bruised and they're all frail. No one's going to do implant surgery on her. It would be frightening to do that. I'm sitting here knocking myself in the head thinking why did this whole prosthesis lose because of one implant. Where was the spare tires? Where was the treatment planning?


That's another thing the young kids don't realize. They'll sit there and they'll see an old guy and they'll think, "I don't want to fix them all up because she'll probably only live another couple of years." Now ten years later he's still in your practice. Twenty years later he's still in your practice. I'm telling you they don't die. They don't die.


Jay: I have patients that come to me that are in their eighties and nineties and they're losing their first tooth or they're missing a couple of teeth and they come to me for implant consult and they say, "Well, am I too old to have an implant?" I say, "Well, first of all, you look like you're in really good health for eighty or ninety or whatever age you may be. You've got some minor medical problems but you're probably going to be around for a long time."


"Let me ask you this. What do you what your quality of life to be like? Do you want to be wearing a removable partial denture or do you want to have some implants so that you can really enjoy your food and have a good quality of life? If you're willing to make the investment and a little bit of time for the implant healing process to occur and some money, I think you're going to enjoy things. You're going to have a much better enjoyment of your life for the remaining years that you have, whether it's five, ten or twenty."


It's that discussion that you have, that consultation with the patient is so important. Patient consultation, patient selection and just giving the patient all the different options. There is no one way to do things. Giving the patients those options really does result in a better long term result.


Howard: You had the first CBCT CAD/CAM combined because you were using the CAD/CAM not to make empress crowns, you were doing it to make surgical guides.


Jay: Exactly. I was the first specialist in the US to have both CAD/CAM and cone beam and a milling unit in the office.


Howard: How big of a surgical guide can those things make these days?


Jay: I actually don't use the milling unit to make surgical guides. I actually have a three-D printer so when I can make the surgical guide in the office, then I use my three-D printer.


Howard: What three-D printer did you go with?


Jay: Currently, I'm using a Formlabs. The Formlabs Form 2.


Howard: Can you send me that, Ryan? Formlabs. Where are they out of


Jay: I think they are in the Boston area.


Howard: Do you think surgical guides are better to be milled (01:03:41 inaudible) CAD/CAM reduced down or printed up


Jay: The accuracy I think of all the different techniques is the same, what's different is operator. For example, the course I'm teaching in Scottsdale tomorrow, Advanced User Training for Galileos, we're going to talk about doing CEREC mill guides. I tell dentists don't make a CEREC mill guide until you've done at least twenty-five guides that were made for you. Don't print your guide with a three-D printer until you've done at least twenty-five cases because you're not going to know what's good and what's bad.


It's like why did we learn to wax up a denture in dental school? Not because we were ever going to do that when we got out, but that's how we learn what's good and what's not. You don't need to print your own surgical guide. You don't need to mill out your guide. There's plenty of companies that will do that for you fairly inexpensively now and with a pretty quick turnaround. If you want to do it yourself, if you want to have that control of doing it in your office, do it. Just make sure you've got twenty-five, thirty, fifty, one-hundred cases of having someone else make the guide for you under your belt before you embark on doing it yourself. Remember it's going to take you more time if you do it yourself.


Howard: I cannot believe we are at an hour and seven minutes.


Jay: Oh my gosh.


Howard: We've gone overtime seven minutes.


Jay: We've gone overtime.


Howard: You have courses on Dentaltown.


Jay: I do.


Howard: How many courses do you have on Dentaltown?


Jay: I think about seven or eight.


Howard: Jay Reznick, you were not only the first online CE course to hit ten-thousand views, you were the first three courses. You did three, boom, boom, boom. Remember you made it with Rita?


Jay: Yeah.


Howard: My god, he was the first guy to hit ten-thousand views. He was the second guy to also get ten-thousand views.


Jay: I was one of the first CE courses, me, Marshall White, and who else did the first one?


Howard: Marshall White.


Jay: Didn't he do like the first?


Howard: Yeah.


Jay: Yeah. And then one more. I think there were three courses that you launched with and mine was one of them.


Howard: Was it Annie Koch ?


Jay: Okay.


Howard: She was the first endo course that hit ten-thousand views.


Jay: Okay, wow.


Howard: Did you ever listen to a Koch and (01:06:16 inaudible) lecture?


Jay: I don't think so. No.


Howard: They're just workhorse, man. They were lecturing every weekend for decades, just total workhorse. But, hey, seriously you're a friend, a mentor, you've helped so many dentists. I couldn't think of a Dentaltown - it would be missing so much if it wasn't for you.


Jay: Oh, thanks Howard.


Howard: You were the helicopter oral surgeon hovering over that group, keeping so many people out of trouble, answering so many - you're so generous of your time. I just love you to death. Thank you so much for coming over by the house. Go to onlineoralsurgery.com.




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