Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1010 Oral & Maxillofacial Surgery with Dr. Andonis Terezides : Dentistry Uncensored with Howard Farran

1010 Oral & Maxillofacial Surgery with Dr. Andonis Terezides : Dentistry Uncensored with Howard Farran

5/8/2018 8:10:38 AM   |   Comments: 0   |   Views: 228

1010 Oral & Maxillofacial Surgery with Dr. Andonis Terezides : Dentistry Uncensored with Howard Farran

Dr. Andonis Terezides graduated from the University of Maryland School of Dentistry and completed specialty training in Oral & Maxillofacial Surgery at Jackson Memorial Hospital/University of Miami. He practices the broad scope of the specialty with a special emphasis in facial trauma & reconstructive surgery, tissue engineering, digital work-flows, minimally-invasive techniques, and full-arch/immediate load techniques. He is a Diplomate of the American Board of Oral & Maxillofacial Surgery.

VIDEO - DUwHF #1010 - Andonis Terezides

AUDIO - DUwHF #1010 - Andonis Terezides

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1010 Oral & Maxillofacial Surgery with Dr. Andonis Terezides : Dentistry Uncensored with Howard Farran

Howard: We're at Townie meeting 2018 in Orlando and I am here with the man, the legend, my idol, Dr. Andonis Terezides graduated from the University of Maryland School of Dentistry, which was the first dental school in the world. What 1840?

Andonis: 1841, somewhere around there.

Howard: 1841 - and completed a specialty training in oral and maxillofacial surgery at Jackson Memorial Hospital, University of Miami. He practices the broad scope of the specialty with a special emphasis in facial trauma and reconstructive surgery, tissue engineering, digital workflows, minimally invasive techniques, and full arch immediate load techniques. He is a diplomat at the American Board of Oral and Maxillofacial surgery. On Dentaltown he is known as Bifid Uvula. What is it?

Andonis: Bifid Uvula, but I don't have it.

Howard: So you have the uvula --

Andonis: Back when I made the screen name, I was thinking about going into cleft and craniofacial surgery, so I picked that as the handle.

Howard: So is bifid when you have two?

Andonis: When it splits, yeah.

Howard: Is that pretty rare?

Andonis: It's pretty rare. It's kind of cool to see it.

Howard: That is so funny.

Andonis: And at the time I made the handle, I had a patient that had one. I'm like, okay, I'll make my username on Dentaltown Bifid Uvula.

Howard: You know, what I love the most about him is, you're sitting there in dentistry and you're all worried about your little crown margin or you're trying to get the contact on the mesial of a composite. And then you'll see one of his cases, it looks like some kid ate either a grenade, a baseball bat, a head on car wreck, and you look at his cases and your first thought is, I can't believe somebody can even do this who is alive on planet earth. And then you just do it like it's no big deal.

Dr. Terezides has contributed many amazing cases to the message board posts on Dentaltown. You know what you reminded me of also is, when I first started placing implants, I went down - I did the Misch Institute - and I went down there and here I was all worried about placing one little implant on a maxillary second bicuspid or a first molar and your heart's beating and all this stuff. And then you went down there and you saw Carl and he would put a scapula on one retro molar pad and go right to the other, reflect the lingual, sew it to this side, refract the lingual and just peel this whole thing open like a banana and drop like eight implants. Then he'd turned around and do the upper. And the whole time he was doing it, he reminded me of the most annoying driver in the world, who, when they're talking to you they're looking at you and you're like, "Look out the windshield, don't look at me!" And he's doing this - well, probably 50% of the time he's talking to you. It was like going to war and then when you came back home you're in a paintball fight, with your single implant. So it just really numbed you to surgery. When you see somebody do that big of a case, it numbs you that your little dinky case is nothing.

And that's what I was saying, when I see your cases, you must have balls of steel that drag on the sidewalk when you walk.

Andonis: No, honestly not. It just becomes a routine and that's really what it is. And that's how a residency structure begins for us. We start with the basic fundamentals, which has been alveolar surgery --

Howard: Which is what?

Andonis: Dental alveolar surgery, right? That's the basic part of surgical training for us. We spend a lot of time in the clinic learning how to take out teeth and manage emergencies in the middle of the night and start sewing facial lacerations, things like that. And as you progress through the residency, they kind of build that skill-set up to the point where it becomes second nature for you to take a chisel or take a saw and actually cut through a jawbone or open somebody's neck from ear to ear to get to the mandible.

So, I think that's indoctrinated in all the surgery programs really, but they start you up kind of giving you the basic building blocks and they take you to that comfort level. It just doesn't happen overnight. That's why residency is four to six years or longer, really, for people.

Howard: And what causes the severe cases? Are those usually car wreck, are they cancer, are they --

Andonis: There's a little bit of all of those things. Trauma's a big deal, interpersonal violence and facial trauma.

Howard: Interpersonal violence.

Andonis: Yeah that's usually what it is. Fayette, Toothache 32, is my good buddy on Dentaltown. He says it, and we've all had this common saying like, "We've never met a mandible fracture that probably didn't deserve it." Because usually people get in these big bar fights and they speak up and somebody is always a little tougher and that's how they end up with a broken jaw, fractured cheekbone or broken nose that we have to treat.

But it's that, automobile accidents, motorcyclists without helmets. There's a certain --

Howard: We used to call those organ donors.

Andonis: Yes, that's true. It's still called that. They're high speed organ donors.

Howard: I always had a very hard problem with the helmet laws because I'm a huge libertarian. I've always been a registered libertarian. And to me it's kind of annoying when most dentists are Republican or Democratic in America, and I always thought that's like Bonnie and Clyde, Mickey and Mallory. I mean one robbed the bank, one drove the getaway car. And how could you be proud of either team? I've always been a libertarian, so I always thought, "You know what, if you want to ride a motorcycle without a helmet, that's your call." But being an oral surgeon, do you think that right should be taken away from that person? Do I have a right to ride a motorcycle down the interstate at eighty miles an hour with no helmet?

Andonis: I'm sure you do, but then at the same time there's someone on the other end of it that's still going to be affected by it. There's going to be a doctor who gets pulled away from his family to have to take care of you in the middle of the night. There's the drain on the healthcare system as well, for a preventable thing. So it's a tough call. It's definitely a tough call to deal with. But I think common sense has to play a big portion of that and there's responsibility --

Howard: We're in America, common sense is not very common.

Andonis: Yeah it's out the window. It changes with the feds, I guess. Think about a patient that comes in with a head injury --

Howard: If you were the dictator of America, you had no checks and balances, you were the king. Would I have the right - would I have to wear a helmet or would you let me make my own decision?

Andonis: I don't know. That's a tough question. I'd probably want you to wear a helmet. I would. Because I look at the other side of it; you may not have the foresight to think about that, but you probably have a wife and children. You probably have family and parents still to take care of at some point in your life. There's a drain on the healthcare system and it costs. There's  more to it than just you enjoying the wind flapping through your hair or just going over your bare, aerodynamic skull.

Howard: Come on. We're only five minutes into this interview and you brought up hair? And it's embarrassing for us, being boys, it seems like those big fights and motorcycles, it's always a boy. When was the last time you fixed up a girl from a bar fight or a girl from not wearing a helmet on a motorcycle?

Andonis: Couple of times a year usually for the bar fights.

Howard: And then how many times for a boy?

Andonis: Well, a lot more times it's for interpersonal violence, domestic violence. That's when I usually end up with female mandible fractures and facial trauma. And then automobile accidents. Very rarely is it ever a sports injury. Every once in a while you get a kid that's got a sports injury; baseball to the mid-face and they get an orbital floor fracture or sinus fracture.  It's sad, but there's a significant amount of women that we see that come in from domestic violence.

Howard: Women - it's very sad - they started 911 a long time ago -- By the way, I don't know if you realize this, 911 just updated last week where you can text 911.

Andonis: Yes.

Howard: We always make fun of the Department of Motor Vehicles, the driver's license. We really should make fun of 911. The few times I've ever called 911 is to report a car accident and they were like, "Can you give a description of the car?" It's like, "Dude, I can Facetime my eighty-year old mother, why can't I Facetime 911 and show you the deal?" And then here it is, 2018, after I've sent a gazillion texts, I can finally text 911. It's like, the government is always the last person to do the obvious. But yeah, you can text 911. But I was looking at the data on 911 - they were reviewing it because of the new text technology, but the number one call for every state -- when it came out, I thought, "Oh, grandpa had a heart attack or someone had a car wreck." But domestic violence is the number one call of every state in every year. And I also read that 95% of the time a woman is murdered, it's by her lover. So what goes on behind closed doors of families is --

Andonis: It's scary, when you work in a trauma center you see some pretty crazy things.

Howard: And it also makes me rethink the nuclear family. The Americans; when you're eighteen they kick out the kids. And then when grandma doesn't know her name, they put her in a nursing home. So about 5% of American women will die in a nursing home. But that's only in the western countries like United States, Canada, Western Europe. When I traveled to South America, Asia, India, the whole family lives there. They call it a nuclear family. I forgot what they call ours. I think they call it love marriages versus nuclear. But six billion out of seven billion live in a nuclear family. Well, I was talking to dentists about that nuclear family. Well, you couldn't beat the hell out of your wife when you're living with your dad and your brother and your mom and babysitters. When those women dentists in India go to work, their mom and their grandma and their aunts babysit the kid. And the older I get, I really think the rest of the world - nuclear family is probably a better idea than the west.

Andonis: I think it's a pretty great concept, or some hybrid in between. 

Maybe too many people in the house is too much --

Howard: It's interesting because it sounds -- so the mom and the grandma and grandpa live here and there might be a couple of kids living in there, but then the sister lives next door with her family and so it's all --it might be even four or five houses just on one cul-de-sac, but they all live in close enough relationship where I could go to your house and borrow a cup of milk. They're all right there on top of each other. And it just seems to me a lot of advantages that -  and the arranged marriage isn't that, "Oh, you have to marry Billy, it's just that you're only going to date leads I serve up to you." So some of those people might have been fixed up 10 times before they were married. But the key is all the leads were qualified. And it's funny, when you go into business, you don't want to just start dialing out of the phonebook, you want qualified leads. If you're selling to dentists, you want the list of just dentists, and in sales you always want qualified leads, and in those nuclear families, all the dating is served up on leads and they have about a 10% divorce rate. And they call the western world having a love marriage, where you go out and fall in love and you have a 50% failure --

Andonis: Well, higher, it's still growing I bet.

Howard: Yeah. So how long have you been an oral surgeon?

Andonis: Since 2013 officially.

Howard: 2013. So that was after --

Andonis: After residency, six years of residency.

Howard: 2013, so five years.

Andonis: I practiced general dentistry for a couple years in between. I actually started residency -- I had a family emergency and left residency to take care of -- I'm an only child, so took care of my mom and some family issues that we had. Did general dentistry for a couple of years and then found an opening again back into a program as an intern, which was no guarantee. Went and did the internship, they liked me enough to keep me around and I stuck around for another four years on top of that. So ended up doing six years of surgical residency before it was all said and done.

Howard: And how is your mom doing?

Andonis: Better, great.

Howard: Nice. Good job buddy.

Andonis: Family comes first.

Howard: Family first, business second. Absolutely. That's what I always say. So there's nine specialties: oral surgery, orthodontist, endodontist, periodontist. The one that never gets talked about, which is my favorite, is public health. When I started my practice in '87, the first thing we did is we blocked off every Friday -- it took two years to fluoridate the water of Phoenix, Arizona, because I thought it's better to prevent the decay than sat on assembly line drilling, filling and billing. And then that expired after 20 years. And we got involved and got it passed again. It really bothers me about our profession when I see the data that 8% of emergency room visits are odontogenic in origin.

Andonis: Oh, it's huge.

Howard: And so many of these dentists, they don't do extractions. They're as bad as the hospital. They give them Pen VK and Vicodin and tell them to go to an oral surgeon or go somewhere else. And then this person ends up in the middle of the night in the emergency room. How does a young kid - podcasters are young, 25% are still in dental school, the rest are under 30 - how does this kid go learn how to do exodontia extractions? Get people out of pain?

Andonis: You know, I haven't followed what the dental school curriculum is like now, but at Maryland when I was in school, I did the oral surgery elective or selective that they had where twice a week we actually did more advanced dental alveolar surgical things. We used the whole drill. We did Torit, we got into more advanced pre-prosthetic surgery, I was doing tuberosity reductions and we were doing full mouth extractions with alveolar-plasty and it was closely supervised by oral surgery attendings, but we really were doing the cases. So when I came out of dental school I felt pretty comfortable taking out teeth and it was a good requisite. I knew how to suture fast and I was able to get up and running in my oral surgery program right from the get-go on July first. To have a basic surgical foundation for it, took out several hundred teeth while I was in school.

I don't know how that is now, but I have AGD residents at my VA hospital - because I'm full time at the VA hospital now - and they're coming out with very, very minimal exodontia and oral surgical background skills. And so I think they're being failed that opportunity in school. I think that there's been a big focus on shifting into a lot of digital technology probably, at school. These guys are getting CEREC training and some of the things that they need, but they're missing a lot of the fundamental anatomy, physiology, basic science things that they need to have as a true fund of knowledge to practice any dentistry with that. So I'm less worried about them being able to pull a tooth if they can't tell me sometimes some of the muscle attachments underneath where they're working or what they're injecting through, and they can't tell me the names of the nerves that they're injecting. And they're coming out -- very bright, smart kids that are coming out from school now. So I think that there's so much to pack in to four years that they just get brushed over. You memorize it for a test and it's gone.

As far as what schools are permitting them to do for teaching, there's a lot of schools now that don't have enough specialists actually teaching the specialty procedures to them as well. Where, say, exodontia may be supervised by whoever the clinic supervisor is for the day, whether it's an endodontist or whether it's an oral surgeon, or whether it's a practicing general dentist. And there's a different subset of skills, but there's something to be learned about learning specialty procedures under direct supervision from a specialist. To impart that knowledge and impart that safety factor that I just don't see happening now.

Howard: True or false, in your opinion, when someone says they want to start placing implants, I always say, "Well, you have to master exodontia first." I mean, you can't start placing implants if you don't have the surgical skills to remove the teeth. You need the skills to extract the teeth before you start replacing. Is that true or false?

Andonis: Well, I think it's true. I think it's very true and it's back to the same thing I told you for becoming a full-fledged surgeon: you start with the basics and you develop a certain skill set. You have to be able to lay a flap before you can place the implant. You have to be able to know how to suture that flap back and how to manage that tissue first, and that comes with basics of being able to first understand how to give a block and give good, profound anesthesia where you need to work, being able to manage some of the complications. You can drill into something and deal with some significant bleeding. Well, if you know how to pack a socket that's bleeding with gauze or whatever, you need to get control of a hemorrhage from an extraction site. Maybe if you had an osteotomy of a drill that went too far or whatever, you can learn to manage that portion as well.

So I think if you can do the basic subset and you have the confidence to pull some teeth and to pull teeth comfortably, and then see how you manage that patient postoperatively as well. Manage their swelling, manage their discomfort, manage their dry socket. If you have that basic fund of knowledge, then you can take it to more advanced surgical skills, which might not be technically as demanding, but it's a high stakes game when you're putting in something that's going to be permanently implanted into somebody's jaw. Once it's in, it's in, and I think it's a high stakes game. So if you can start with the basic skill set, for sure you can continue your knowledge and your training to place implants. And implants get old after a while, they really do. There's so much dentistry has to offer and you have to look at what your time is and -- I have a lot of friends who actually went and did a bunch of implant continuums, they spent a lot of money and got on courses, they placed implants, then they find that - okay, it's a novelty and it's cool and they're doing some surgery - but then they find out that really, there are other things they could do that's more profitable for them as well.

Howard: The highest is with orthodontics. They say, "I want to start doing orthodontics." And you'd come back and they'd take all the courses, they banged out ten cases, you come back two years, they go, "My God, I don't want to be married to someone for monthly, for two years, for, --"

Andonis: Yeah. I'm a results guy, I couldn't do ortho anyway for that very reason. I need to cut something and see a change.

Howard: I'm seeing it already in sleep apnea. Almost every friend of mine in Phoenix who -- we all went through all those courses together, five, six, seven years ago, and I don't know any of them that are still doing it. But I want to ask you -- I think what the Internet is doing - well actually, not the internet, it's actually the smartphone - is really flattening the earth. You used to have big differences in quality of healthcare between continents and countries and it's really coming together quickly. And I noticed the German oral surgeons are not quiet about what they think of American oral surgeons and the fact that they believe --  kind of like when I was little, first time me or my five sisters got a cold, they took out our tonsils. So I have no tonsils or adenoids. The Germans feel that way -- they say in America, they pull the wisdom teeth if they exist and in Germany they say they pull about a third as many wisdom teeth as Americans. Do you think Americans pull too many wisdom teeth that would have lived a happy life forever? Or do you think the Germans are too conservative or --

Andonis: I think they're maybe a little too conservative, to be honest with you.

Howard: You think the Germans are too conservative?

Andonis: And again it's probably -- I don't know their model of health care completely, but I think that there's a certain aspect of socialized medicine with them as well, right? They obviously don't practice the same way or sedation the same way that we do as well. So when they're doing it, they're probably doing more cases under local anesthesia or with an anesthesiologist in a hospital setting, is my understanding, and that's the way it is with a lot of Europe. You know, in Europe, most people have their wisdom teeth and most of the rest of the world removed under local anesthesia, which is fine, but we have a different philosophy. The way we look at things, we try to get the patients early: fifteen, sixteen, seventeen years of age before the roots are fully developed, before they've ever had a problem, before there's been any pathology, when we know that that patient is healthy. That's usually sometimes a young teenager's first real experience with dentistry other than maybe a couple of fillings or something as a pediatric patient. And they're scared and they have a lot of apprehension. And our philosophy is to take a patient like that and be able to take them through one of their first surgical experiences and show them that it can be a pleasant, easy, manageable, not so fearful, not so difficult experience. And if we can pick that patient and turn them around and say, "Okay, here, we're going to put an IV in your arm, I'm going to sedate you. You're going to wake up and not remember anything. You're going to get chipmunk cheeks for a couple of days." But after that it is a rite of passage, and we look at it that way. And for us, we know that at that age, statistically the complications are the least: less risk to the nerve, less risk of developing cysts and tumors from a naughty wisdom tooth that hasn't had anywhere to go that's been impacted in the mandible for so many years.

And so I think that's really a way of practicing a preventative sort of medicine. Because on the other end of it, at the other end of the spectrum, is when I get a patient in their fifties or sixties who's now got COPD, heart disease, has had four cardiac stents and triple bypass and now they have an impacted wisdom.

Howard: You just gave away my health history, that's a HPA violation. My god.

Andonis: Actually, you gave it away. But the fact is is that now this patient is a significant anesthetic risk. They are a surgical risk patient that is going to also have a much more miserable recovery and now they have an odontogenic tumor, an ameloblastoma or an OKC in the mandible.

Howard: OKC?

Andonis: Yeah, they have an OKC: odontogenic keratocyst or what they call now a kerocystic odontogenic tumor. It's an aggressive cyst in the mandible. It can cause some people to need  a resection. That's not easy, to take Miss Jones at 60 years of age now to do something that was completely preventable by having taken out her wisdom teeth as a teenager. So you won't find very many oral surgeons who have children of their own who leave those wisdom teeth. So we practice what we preach. It's not that we're just doing it because you've got money to spend on your daughter. We believe in that philosophy because we see the other end of it and the benefit of getting it done early in life.

Howard: Interesting. Because when I started having a family, the whole big deal back then was that circumcision was just a religious thing, it had no medical validity. It was culture and all the young hippies in the eighties were not circumcising their little boys. And almost every single one of my friends that fell in that trap ended up having to take their boy back at age two or three and getting an epidural and putting his lower half to sleep to circumcise him because of all the urinary tract infections. And what was funny was all the older sixty year old pediatricians were saying, "This isn't a good idea. There's a reason they figured that out two thousand years ago." You know what I mean? So what percent - if you saw one hundred, fifteen year old Americans, what percent would you recommend the wisdom teeth coming out based on a panel at age fifteen?

Andonis: Fifteen? I'd say somewhere between eighty-five to 90%.

Howard: Eighty-five to ninety? And what would be the criteria of the 10%?

Andonis: There's some people that aren't developed enough, where I think if they wait another year or two --

Howard: Oh, okay. Well let's say sixteen or seventeen.  What percent of Americans would you say need to have their wisdom teeth taken out or would benefit from having their wisdom teeth taken out?

Andonis: Probably 95% of Americans?

Howard: 95%. And what would be the one in twenty?

Andonis: The ones who don't have it and the ones who are actually in a functional occlusion in an area that we can probably maintain a decent hygiene regimen. There are some people that just have a mandible that's large enough to accommodate.

Howard: Yeah. And also, I learned that research is tough, because the New York Times did an excellent expose that there was no research on floss. Now, of course, every dentist in America, every hygienist in America said, "No, no, no. There's massive benefits to flossing every day." But the New York Times was accurate in pointing out that there is none. I mean, how would you do it? What would you get? Identical twins and one flosses and one doesn't floss and then --

Andonis: It's impossible to do that study.

Howard: It's so multifactorial. Sedation: there's another international thing. I believe it was the United Kingdom who said that you can't do the surgery and the sedation. And then when you go to America and the hospitals, that's a law. I can't remove your appendix and run the IV. So in American hospitals you have to have an anesthesiologist and a surgeon. UK, it's that way for everyone, including the oral surgeons, and the only people who step outside that norm predominantly are your professional oral surgeons where you all do the sedation and you all do the surgery. What do you think of that discrepancy?

Andonis: Well, I think it's a great model, and I think that we -- because it's been able to open up being able to provide a lot of care at a lower cost to patients, and it's a proven model that's worked very well for so many years. Because our training is really second to none when it comes to actually getting anesthesia training. But I do see the times changing and I think at some point it's going to go away from our profession, partly because there's been, again, a dilution of some education. Even in oral surgery curriculum in some programs there's been a dilution of basic dental teaching in dental school. But at the same time, there is a different kind of standard. We're dealing with patients now who have medical conditions that maybe they didn't have twenty years ago. We're seeing more obese children now in our offices. That's an airway risk that we didn't have to face as much say in the seventies and eighties, now with this obesity epidemic that we have. We're seeing kids who are on a lot of recreational pharmaceuticals. Things beyond what maybe they were doing in the sixties, seventies and eighties, and they're coming in now and these are all anesthetic risk challenges that we may not be picking up on and there has been an uptick in off the space mortality and morbidity that that has occurred. Fortunately, most of it is not actually in oral surgery offices, but we all get lumped into the same group when it does happen and it's sensationalized in the media as well.

But if you look at how many millions and millions of anesthetics are done every year safely in oral surgery offices and there may be 20 deaths or thirty deaths in a year across the country, which is tragic and it's heartbreaking, and it just kind of wrecks the career of someone who's taking care of a patient that they really care about what they do, but on a scope of what that is, statistically, it's --

Howard: -- less than the amount killed by lightening. Fifty Americans are killed each year by a television falling on them.

Andonis: There's less people that die during sedation during medical procedures basically. But I do think it's going to go away at some point. There's not enough dental anesthesiologists, there's not enough medical anesthesiologists who would feel comfortable working in a dental operatory sort of environment. And there's not a way to make it efficient to be able to take patients to have them sedated for treatment. And unfortunately in this country, people want sedation and they don't want to be done under local anesthesia. And there's nothing necessarily wrong with local, but the expectations are such that there's a very high demand on their practitioners and it's just the state of the society that we're in right now. They want sedation, they want it done, and sometimes people push the envelope. In my practice, I was very fortunate because I have hospital privileges and I have also ambulatory surgery privileges where I was working in private practice. If there was somebody that it just didn't feel comfortable, it didn't make me feel safe that I would be running their sedation, running their general anesthesia in my office, I would very easily tell them it's local anesthesia if you're willing to do it this way or we go to the ambulatory surgery center. If you're not comfortable with that, I can help you find another surgeon that may be willing to entertain that idea.

Howard: And ambulatory means?

Andonis: Ambulatory, meaning like a center where maybe an orthopedic surgeon or plastic surgeon would do outpatient surgery.

Howard: Ambulatory means walking in, walking out?

Andonis: Yeah, walking in, walking out sort of deal. But it's a surgery center with operating room, but they have a full medical staff and anesthesia there and an operating room to take care of the patient. Let somebody else deal with the anesthesia. At that point I just walk in to do my surgery and they're responsible for managing the anesthesia.  It's more expensive, it's significantly more expensive.

Howard: I posted a map today on Dentaltown and it's quite --

Andonis: I actually saw it was the one with the population, where they live? I saw it this morning.

Howard: So there's two debates when you look, as far as these - when you look at the fact that half of America lives in the shaded areas. I grew up in Kansas, so I'm completely sensitive to the flyover state. If you ever turned on any news, it's Miami, New York, LA, San Fran. No one ever talks about Kansas and Nebraska, North and South Dakota. No one ever goes there, they only fly over it. But let's look at -- half of America lives in the nineteen thousand and eight small towns. And a lot of those guys sit there and think, "Well, you know what? My population, when I tell them they need to drive two hours into town, they say fricken pull it." So a lot of them want to learn to place implants, they want to learn anesthesia. I always say, "My gosh, just go find an oral surgeon or periodontist to come to your practice one day a month and save up all your wisdom teeth and implants." Same thing for anesthesia. A lot of them say, "Oh, I want to learn sedation." I say, "Dude, I've had four kids, they were all in the middle of the night. When they wanted an anesthesiologist, they just did the Motorola Pager, the guy was there in five minutes. And I said, "Where were you?" And he's like, "Sitting at the Ihop, sitting at the Waffle House." I always say, "Just have someone come in and do it and split it with them 50/50. They've done ten thousand."

So my specific question is: do you think these rural dentists should learn how to place implants or do you think a specialist should come in one day a month and split it 50/50?

Andonis: I think the key is treatment planning and learning to be able to identify which ones they should do and which ones they should require a specialist to do. Bringing a specialist into your office, it's always an interesting dilemma to deal with because we can never function in a dental office the same way we can in our own specialty office. It may look a little bit similar, but it's not. The workflow is different, your assistants are different, the setups are different. The available instruments that you may have. That one time you may need some special instrument that's packaged on a shelf to use in this one case, you're not going to have it there. The dental operatories are not very set up and I find it difficult to be able to work in some of these operatories. And the idea of, say, I could never put a patient to sleep in my buddy's office working out of that chair. Maybe I'll go and take out a tooth under local anesthesia in that chair and I still feel crammed sometimes in that operatory, or even where the suction reaches from or having to use the dental hose that's off the dental chair versus a wall suction. Even that restriction of the assistant holding a suction makes it more difficult for us to work than if they are using a surgical suction on tubing that's loose and passive where they can move it around and not fight the tug.

I think what's important is that every dentist, no matter where they practice, they get continuing education. They look for mentorship, especially if you're in a rural town where you're going to have to be able to pull a tooth, do an incision and drainage. And the key to all of this is treatment planning. You can identify the cases that are slam-dunk cases that the risk of a complication is low and these are the implants that I should be doing. This one's maybe a little bit beyond my skill set or a little too risky for this patient, based on their medical history. Maybe it looks like an easy implant, but maybe there's some complications and things that can arise from the other direction, where maybe I'm not comfortable managing this patient's anticoagulation medicines or so forth. But there has to be a balance somewhere in between.

There's simply not enough oral surgeons to manage all the extractions that need to be done. There's not enough oral surgeons and dental anesthesiologists to provide sedation and analgesia and comfort for patients. And quite frankly, we can't place all the implants and take out all the teeth. There's not enough of us to do it and it's hard to make a patient drive two, three hours, they have transportation issues. But I think that we need to, as a profession, embrace the fact that there has to be a give and take with this. And some people, they say, "I want to do everything in my office to keep them." Because they look at it purely from a financial and business standpoint. Maybe that's not in the best interest of the patient either. 

Howard: So, she just graduated from dental school. She's $350,000 in debt. And the first thing she going to say is, "Dude, we didn't place one implant in school. We didn't do one sedation course." Where would you recommend her to go for training to do surgery and sedation?

Andonis: I want them first to actually get really good at crown and bridge. Because they came out of school and they still got to know what their bread and butter is. Their bread and butter is doing fast, efficient, aesthetic, functional, crown and bridge first. If they can do that, then they move on to the implant stuff. You've got to have a foundation. They barely know occlusion coming out of school. So I don't want them dealing with implant occlusion really until they can do crown and bridge well. And if they can do crown and bridge well, they're also going to pay off that debt fast enough, and then you got a little spare cash to start saying, "I'm going to get into more." Maybe a year or two, maybe three years in, that's maybe the time you want to start. You've got to be seasoned as a dentist. First you got to learn how to run multiple chairs, which they can't do. So to get into an implant procedure where they got to have a sterile setup and they've got to place an implant as efficient, as fast as an oral surgeon or periodontist can in fifteen to twenty minutes or an hour depending if it's multiple implants. They've got to hit that record first. If they can do that and they can run it schedule and they know now that: yes, I've got a two-hour time slot that I can dedicate to placing the implant for Miss  Jones, great. Because now they've understood the rest of the treatment planning. Because if they're just looking at a space and saying, "I want to place an implant here." But what about the adjacent teeth? What are you doing for those adjacent teeth? Are you going to need to crown those later? Do you need to provisionalize them? Are you thinking about opening the bite first? I think they'd have to get into that mindset first before they start doing surgical things that are irreversible.

And I see that for my AGD residents that come in. Our AGD residents come in and they place anywhere from 50 to 100 implants each before they leave our AGD residency. They restore probably over 100 implants in that year, along with comprehensive dentistry that they're getting trained on. But they have to have some background first. And I think it's important that -- especially if you didn't get that great a background in dental school. I think the first thing they need to be thinking is: you know what? Suck it up for another year and go do a residency somewhere. Get a general dentistry residency: GPR/AEGD so you can get your speed up a little bit and get your treatment planning mind in focus first. And you'll probably get more implant experience by that point. To set the foundation to say, "Okay, now, I did fifty implants so I can go to this guy's course maybe: a Misch or a Garg sort of course. Maybe I'm at the point where I'm ready to go ahead and pull the trigger and spend another ten grand and go to the Dominican Republic and do some live patient cases. Or maybe, you know what? I want to go take a few more CE courses, regular ones, or join a study club first and learn a few more fundamentals before I'm ready to pull the trigger and go spend another $50,000 or $100,000 on implant instruments to worry about that part yet.

Howard: My dental office in Phoenix is right down the street from the Arizona cardinals headquarters. On my street there's a lot of coaches and players where I live and in my practice we have a lot of coaches and players from the Cardinals. And young boys always ask them, "What advice would you give me to get into the NFL?" They said, "Well, in college just focus on a block, a tackle, a pass, and a catch. Just nail those four fundamentals. Don't worry about all these fancy plays and all that stuff. Just, when that ball's coming to your numbers, catch." So when you come out of dental school, you're going to need two, three, four years of your basics: fillings, crowns --

Andonis: You have to learn how to talk to a patient first. You can't sell an expensive implant case to someone if you're so wet behind the ears right now that you still have difficulty being able to explain why they need to have a composite. Get them ready for whatever else they need. It's comprehensive treatment planning and I think that that's lacking. Because there's not enough time to get that taught, not enough time to get that experience.  And technology's changing so fast too. They come out, they get bombarded by wonderful products, but how much of it is really necessary if you can't get the fundamentals set. And once they start realizing the use of dental materials, they understand when they're going to do an E-max crown versus - look, I'm an oral surgeon, I'm talking to you restorative dentistry stuff now. They got to know the difference between when they're going to use a zirconia crown versus an E-max versus a PFM. Whatever they're going to plan to do they have to understand that relationship with a patient. They got to understand occlusion. They got to understand the bite first before they start putting things in that are not going to have a PDL and be immobile. That once it's integrated, it's in. And then once it's integrated, maybe that's fine, but what about the other teeth on the other side of it that maybe we should've had some other plan.

Howard: And I just want to remind you - we did a podcast yesterday with Gordon Christensen, and we're talking to him, he lectured here, but one thing I just want to - when you come out of school, don't read into all those different types of crowns, also. There's nothing wrong with a PFM. E-max is gorgeous and you can use it on molars, there's no big fracture rated E-Max on molars. And as far as a Zirconia goes, only Glidewell's BruxZir is holding up under all this long-term research. All these new zirconium things -- the one thing that I want you kids not to do that I did, is when I got out, I got all caught up in all these marketing and advertising and courses and tried all these new materials. I did a thousand Dicor crowns, cemented with Durelon that I learned at a course. Guess what percent of them fractured?

Andonis: No idea.

Howard: All of them. And guess how many I got to redo for free? All of them. Then Heraeus Kulzer came out with art glass. Within three years the art came off the glass.

Andonis: Are people doing those Captek crowns at all anymore? Do you remember Captek? When I was a GP we had Captek as well, and I did maybe a couple of hundred of them because I was pushed in the company I worked for to be doing the Captek crowns. And I always wonder how they held up over time.

Howard: They did really well. But I'm just telling you, kids, the old guys always say, "Well, let the dental kindergartners come out. They'll get all excited in a seminar and some Nascar speaker -" I call them Nascar speakers because in Nascar they have all the logos of the stuff they're selling or being promoted by, but in the dental lectures they forget to put on all their badges. And then you buy this stuff then it all fails. Ivoclar's Targis Vectris, that all fell apart.

When you're fifty-five, when shit comes out, you say, "Let the idiots do it for five years." Because there's nothing wrong with E-max, there's nothing wrong with BrixZer. There's nothing wrong with zinc phosphate cement. There's nothing wrong -- So when you've got some -- like I still use empergum, you know why? It started out as a German company SP, and then 3M out of Minnesota bought it and I've been using it since I think 1984. It's perfect. So someone will come up to me and say, "Well, you need to try this." Why? This has been perfect for thirty fricking years and you want me to try something else? So don't be that bleeding edge. And also a lot of you think that markets are efficient. They always teach that in school, they always teach economics. So if markets are efficient, then explain why sometimes the stock market -- in like March of 2000, Nasdaq was at fifty-eight hundred and the next thing you know it's eighteen hundred. That doesn't seem very efficient.

Adam Smith said that two people evaluate -- I want to trade my cup of coffee for your cup of milk, or whatever, and trade is very efficient. Trade is no longer efficient because businesses spend a billion dollars a day marketing to you, clouding your judgment, giving you emotion, giving you all this stuff and it's 20% off and buy now,' it's the convention special. And you just make a lot of really bad decisions. So I would say, "Slow down Spanky, slow down." Tell me something new, I want to watch it five years.

Speaking of new, can you categorically say sedation is safer in 2018 than it was in the eighties, nineties. It seemed like in the eighties a lot of sedation was narcotics, where the only antidote is slowly wearing off. And then they came out with Versed, and Re-versed. Are the pharmaceuticals you use today safer than in the eighties?

Andonis: I think they are. We've had a shift. In the eighties, a big use was Brevitol and Methohexital was the medicine that we used, in combination with a benzodiazepine like Versed. But the Methohexital had certain issues with it; it was more prone to giving you a laryngospasm, having airway issues and desaturations. Most of us in the younger generations have moved on to, say, Propofol. Propofol is a very safe drug, has a very safe --

Howard: That's not what Michael Jackson said.

Andonis: Well, Michael Jackson also had it administered by somebody that wasn't monitoring him and he wasn't monitored while he was getting it. But Propofol as a medication has very low side effects. And I worked in a practice with a phenomenal surgeon, my partner who preferred to use Brevitol because it worked well for him for all these years. But I noticed the difference. I would hear his monitor go to the B-set and he'd have to stop and hold the airway up, open longer to kind of get the patient back to breathing during that time. That never really happened with my Propofol. But I might have to re-dose the Propofol more often than he had to do the Brevitol. But for him, that stopping in between to do a re-dose or re-bump of the medicine was enough to say, "You know what? I'm not going to deal with that. I'm just going to go ahead and just do it the way I do efficiently this way versus stopping to re-bump."

So everybody has -- it's a balance. I think we are safer in the sense of technology. We have more monitors and more monitoring requirements. I think the educational requirements and residency programs have increased as well, when it comes to it. But there's a tip side to it too, again. There's a lot of diseases we're seeing in younger people now that we didn't have before. We're seeing patients with more sleep apnea issues, obesity issues, recreational pharmaceutical issues, which may lead to underlying cardiac issues. That's things that we can't necessarily always predict or protect from. So it's a balance. 

Howard: Is the legalization of marijuana, which is getting more -- I live in Arizona, it was the only state at the last presidential election -- I think seven states voted, six put it in, Arizona still held out. Is that going to increase more health history concerns for the average general dentist, people coming in?

Andonis: I really think it will. I think that maybe there is a therapeutic place for it in the spectrum, in terms of the medicinal side of it, but I think we already deal with that a lot. I mean, I see that a lot in the college kids already. They all admit to it, that they use marijuana. The question is --

Howard: But no, I mean in a dental plan. What if they smoked right before their appointment and they're coming in for a root canal?

Andonis: I'm not happy to treat them at that point, because sometimes these things are laced with other medications and other drugs in them as well and there could be an issue. So for me it's a concern. If someone is high and that they're not able to maybe recall what they were signing an informed consent for, or that they're not going to follow post-op instructions or that they're just going to be uncooperative. I mean, I've seen that happen, patients will come in and they were nervous and maybe they smoked a joint in the car before coming in for their sedation. But if they don't seem right, I don't want to give them more medicines on top of it that may have some sort of interaction with it. I'm very happy to cancel the case and I don’t have to do that case.

Howard: I'm in Phoenix, which is a retirement community. I'm sure Florida, huge retirement community. A lot of the old guys self-medicate when they have anxiety at the dental office. They have a couple of belts before they come in and you can smell it on their breath. Where do you draw the line? Where does that bother you and when is that  acceptable?

Andonis: It's a balance, and it comes with some experience. It comes with time. If I think that the patient's able to sit through a procedure - and I look at it, I say, "Okay, am I just pulling one tooth on you under local?" I'll probably tough it out and go with it. If I need something that's going to be for a couple hour’s worth of work on them, I may not feel so comfortable giving them medications over top of whatever else they might have in their system, and we can always reschedule. And I tell them -- I'm very honest with them. I say, "Listen, I'm concerned about your safety. You come back, we'll reschedule you next week, or whatever and we'll deal with you at that point. But you cannot: seventy-two hours." I tell them. In the hopes that I'll get twelve hours out of this. Honestly, I tell them seventy-two hours in the hopes that I can get twelve hours of them not being on whatever they're on. And for me, a bigger concern is something like cocaine or an amphetamine, not necessarily marijuana. But we have a big methamphetamine problem in a lot of states now and a big cocaine problem. If they come in and they're strung out, they're just not going to get the cake. I don't have to do it.

Howard: We are in the state, the home of Miami Vice. Do you remember that show or were you too little?

Andonis: I do.

Howard: That guy was from Wichita, Kansas. He went to East high school. He's the only famous guy that made it out of Wichita.

Another question. She's just got out of school. If you go to the internet or the IDF meeting in Cologne, Germany, it's the largest dental meeting in the world. They meet in Cologne. America has a very fragmented meeting market. All 50 states have a state meeting, then you've got the ADA, you got the Hinman, the Yankee, the CDA. But Europe, it's very consolidated. Cologne, Germany, which is -- Anita said it was the furthest outreach of the Roman Empire; they still have the wall around there. It's the only place you can get really good Italian food in Germany, it's just the greatest city. Anyway, they have a meeting there every other year, minimum a hundred thousand dentists show up. The whole city knows that they're going to be invaded by a hundred thousand dentists and all the locals help you get on the trains and everything. It's just so cool. But gosh darn it, there were over two hundred implant systems for sale. And she's like, "Okay, I want to learn how to place implants, but I can't evaluate two hundred implant systems. Can you shorten that list for her? 

Andonis: Yeah, stick to one of the major companies that has good local rep support. Period. Titanium is titanium, yes. But you're fresh of school, you need help in ordering parts. You need a rep that can be there that's knowledgeable in your system, that can make sure you get the right parts, that may be able to show you how to do something. A major company that can help get you to CE, get you to study clubs.

And so, for me, that's like basically saying the Straumann's, the Nobels, Biomed, Zimmer, 3I. I think you have to stick to one of the major companies. Horizons. I think the major, larger companies that that we work with, they're the ones that are more prone to have more research behind them as well, in terms of the product you're using. The standards may be higher, maybe not. I mean, there are obviously good companies. Dentaltown is very happy with Blue Sky Bio, great. They have a wonderful product. A wonderful line of products. The problem is is that it's all on the Internet. It's not that you have a local rep that's going to support you and when you are fresh out you need to be working with known systems. You need to be working with systems that have a history of having components available later. I can't tell you how often I see patients now that are coming in with implants, 20, 30 years old that need a new abutment. They need something different and we struggle and my prosthodontist struggles to find parts. And if they can't find parts to restore that case, I'm taking out some old implant that was placed in the 1980s, that's done well, but they need to have a tooth replaced in that place and they can't find parts for it.

Howard: You said something so profound. I'm always telling them, "When you get out of school, why are you sending your lab case for a crown in the next state?" You need a lab man. He just said it with implants. You need local support.

Andonis: You need a good local lab, somewhere where you can actually go to and watch the process behind it. It's not second year dental school where you're in the lab casting, which they don't do anymore anyway, from what I hear, they're not stacking porcelain. And we didn't do much, we processed a couple of dentures in school just to get the understanding. But there's nothing better than taking a day off and spending it with your lab guy to see other cases coming in, see how other people's preps and margins look and see the process. Especially now with the digital workflow, so you can understand what they're doing on the back end of this crown that you're receiving. You understand that, you become a better dentist.

Howard: So the average dental office collects $765,000 a year. The average lab bill is 10%. That'd be $76,000. Divide that by twelve months. See, the average lab is getting $6,300 a month from a dentist. So they're never going to tell you anything's wrong because they don't want to lose your account. If they say, "You need to reimpress this," and "I don't like your prep." If the dentist says, "Screw you, I'm going to another lab." They just lost $6,000 a month. If you're an orthodontist, that's an Invisalign case every single month. It's annuity, so you have to establish with your lab that he's safe. You have to sit there and say, "Look, I want to learn. I'm humble. I'm as humble as Howard pie, help me."

My guy was Wolfgang, and the Germans are the only country that make -- I mean, they make Porsche and Audi and Volvo. Their education for a crown and bridge guy is  as long as a dental school. And there was a guy out there in Phoenix, his name was Wolfgang, and he was a very old German guy and really, really tough guy. And I kept telling him, "Wolf, tell me, tell me," And when I was right out of school he said, "You need to come down here." Because it was his way of saying, "You're horrible." And he was showing me all these -- 10% of all of his cases -- Then he was calling them and fixing me up with them to go meet them and have lunch. I did the same thing with a local endodontist. You fly to San Bernardino to go see Cliff and Buchanan and these endo geniuses. Well there's an endodontist across the street from you that's done ten thousand molar root canals. Why don't you go pull up a chair next to him? It's free. You've got a friend, he's in your hood. You do a root canal someday, you get in trouble, you got a buddy that can help pull you out.

Andonis: That's the thing. You have to build relationships. I have never had a problem with the general dentists coming and spending time to watch us do a case for work. You got to send me some patients too, on top of this, because I don't expect you to learn everything in two visits or watching YouTube or perusing the threads even on Dentaltown all day long. That's just setting the foundation to get you thinking, to ask the right questions and then say, "Okay, what do I need to do next? Where do I need to look under next and what's the next step in my education to do this part?" You know how to do that? You build a relationship, you build a partnership, and then then at that point that I know: okay, fine, you're going to go and you're going to do some cases and you're going to get upside down at some point and you're going to call me and I'll take care of you.

But if you've only come in to watch me and then you go do everything and I never see another patient from you, I'm not invested in you. You're not invested in me at this point. There's no skin in the game for me to say, "Yeah, it's 4:00 on a Friday. I'm going home. You can deal with them since you haven't worked with me." And unfortunately, that's the way it is. But if you're someone who shows an active interest, do you want to learn? You come to be part of our study clubs and things like that, yeah we'll teach you how to do things because we can't do everything. And maybe I don't have the time to see Mrs. Jones because I'm out of town at this point. But I want you to still be invested in my practice. I want you to know that you have someone that's here that can help you with this. There has to be a relationship building and I tell this to our residents all the time as well.

It's like, look, just because I'm teaching you guys to place implants and you're doing pretty advanced cases here, doesn't mean you're going to do all these cases when you get out. You're still green. You're still wet behind the ears, even after a year of residency. Your job is to get your name established in the community and it's not by being the guy that's going to come in and place another hundred implants next year. You've got to set the foundation. Your owner doc that's hiring you is going to expect you to do good crown and bridge. He is going to expect you to make the right decisions about which teeth you're going to pull, which ones you're going to refer. Same thing with endo: which endo you're going to get involved with, which endo -- maybe you're not going to do that endo retreat, maybe that one you're going to send it to the endodontist and you're going to be prepared on the back end to do a nice core and crown on that tooth. It's all treatment planning. At the end of the day, it all comes down to treatment planning.

Howard: And I'll tell you another thing: every single general dentist I know -- I always tell people, "You wouldn't want to go to a doctor who didn't do that procedure once a week." And as an MBA, as a dentist with an MBA, I tell you, you're not profitable if you don't do that procedure every week. So when you learn sleep apnea and you do one case every three months, you're not faster, easier, higher quality, lower cost. You're not in the profit zone. If you learn to place implants, if you don't place one implant a week, it's cheaper to refer. Ortho, especially. I look at general dentists, they'll schedule a half an hour for an ortho to change the wires in the bracket. Okay, your orthodontist, that's a fifteen minute appointment and he runs a 50% overhead, so you're doing a 30 minute appointment, you're at a 100% overhead.

Andonis: And they have assistants that are going to do the majority of that treatment, which your assistant probably in a dental practice is not going to be doing that, adjusting wires, you're going to be doing it, really.

Howard: Yeah. So our Megagen wrap, do you like Megagen? Is that a good one? 

Andonis: I think it's a good implant company as well.

Howard: Is that one of the big ones for you?

Andonis: I don't know what their local reps are like. There are companies -- like, we have a great Nobel rep here. I've got friends in other parts of the country that they don't have good representation or to get a higher turnover. So it's hard to say. My old practice partner used to say, "Sooner or later one of two things will happen: either the product will fail, or the rep will fail you." It's one of the two that may be the issue that makes you make a change in your practice decision, and it's either the rep or the product, and usually the product hands up is fine.

Howard: And if the rep disappears, he'll end up at a different dental company. They never leave dentistry.

Andonis: Very rarely.

Howard: But our Megagen rep will say -- you'll get a group text, saying, "Hey, we're all meeting at the sandbar Thursday after work at 5:00." So you'll go out after work and have drinks with your buddies, but you'll be sitting there with six of his dentists and then you might sit there and say, "God, I don't work Friday." And then he's sitting there saying, "Well, I'm doing this case on Friday." So when they're in the operatory, so many times there'll be sitting there coaching your assistant, the setup would be a lot more efficient this and this. But again, local lab, local support, local specialist. You need relationships in the hood.

Andonis: You got to play the long game here. You really have to play the long game. It's not just about what I'm going to do now that sounds really cool, then I'm going to just do this. This is a patient's life we're talking about here. This is their long term health and you have to approach every patient in the same way and say, "Okay, if this is my mom, my dad, my wife, my sister, me, how would I want to be treated with this?" And you'll see the gamut of what's available to be treated, by what your skillset -- but you have to be just be brutally honest with it. Am I efficient, am I fast enough to do this? Am I really comfortable to do this? And at some times you're maybe not, but you'll build that skill set up if you don't rush to the finish line and you take the time to get the training along the way. Then you can be a really competent, very successful practitioner who has the right tools to fall on when they need it and they have the right backup with their specialists. You know, over time.

Howard: Okay, this is dentistry uncensored. I know what all the politically correct noise you're supposed to say, but I know where I see a discrepancy between people's words and people's actions. Okay? So when I talk to anyone who's placed over two thousand five hundred implants, they never use a surgical guide, almost none of them. And a lot of them are still on panos. And when you talk to the millennials, you have to have a CBCT and a surgical guide. So why are all my fifty five, sixty -- I got sixty-five year old friends that have placed ten thousand implants and still use a pano and have never used a CBCT. I'm not saying which one's right or wrong, I'm just saying there's this huge discrepancy. The old folks said, "I placed five thousand implants before they even had a CBCT." And they don't use surgery guides. So where do you weigh in? Because you're not an old guy and you're not a millennial. What is your age?

Andonis: I'm thirty-eight. I'm the tail end of Gen X, right? So 1980.

Howard: You were born in '80? That was when I graduated high school.

Andonis: So that's the tail end of really, Gen X sort of deal. And everybody's talking about - by the way, I'll tell you this - everybody's talking about millennials now in the news and everything, but these kids from the whole shooting thing, they're not millennials. These are not millennials, that age group anymore. The millennials are done. The youngest millennials are already well into their twenties or late twenties at this point. So this is a generation alpha. These kids born now.

Howard: So what's after the millennials?

Andonis: Oh gosh, I don't even know. My wife would probably kill me for saying this now, but the millennials pretty much were -- after millennials there was like a generation Zeta, I guess now. And then there's the Alphas and there's a whole different group. But they keep talking in the media about millennials this, millennials this. Millenials are done.

Howard: Millennials is slang for the next generation.

Andonis: The kids starting college now are not millennials. They're not. And they keep being referred to as millennials. These kids in high school now are not millennials. They're whatever, generation Alpha or whatever they are now.

But I would say that in terms of the CBCT scan, just look at the rest of the way we practice and the things that we do in our day to day life. You don't want to go have an angioplasty procedure performed by someone who's not going to use a CT angiography and things to do that now, and they're just going to go up by feel and do a balloon stent for you. You want the best technology out there and the diagnostics that are there, You don't need it to drill a hole, it's routine. You've done ten thousand implants, it's routine at this point to drill a hole in bone. But I personally feel much more comfortable using a CT to plan my case.  I know much more predictably where I want to go, what adjustments I want to make, what I want to shoot for. And I take a post-op CT as well. I take a pre-op CT and I take a post-op CT after that implant's in. And sometimes I find out: boy, I was way off on that one, or I hit it where I was. But every time I do it, I learn something. And I think it makes you a better dentist by being able to say, "You know what? I would've done this differently." And there has been one occasion where I've gotten a post-op CT and I said, "Boy, I really missed the mark on this one." I'll take it out and reposition it right then and there, because it's a lot easier for me to fix the problem right then and there than to send it to my restorative dentist later and say, "You know what? Figure it out for me. I'm sorry I messed this one up."

Howard: So if I have them take a pano and they're holding a cat, is that technically a cat scan?

Andonis: It could be. But I'll show you - it'll be hard to show you here - but I'm going to show you an incredible example I have on my phone of what looks like a perfect two-dimensional implant and when you see it in 3D --

Howard: So what cat scan, what CBCT -- is it okay to just call all CBCTs just a cat scan.

Andonis: Well, to call them a cat scan, I mean, it is definitely different. Cat scan is obviously computer tomography. In our dental offices, it's really a CBCT. It's a cone beam, it's a volumetric CT scan that is a lot less radiation than a traditional medical grade CT scan. And there is a gamut of quality that you get from different companies and what's available. Me, as a maxillofacial surgeon, I need to see the whole head. I want to see the whole face. I want to see the structures that I work on from here to here basically. So I can follow all my follow ups when I want to see them without necessarily having to get a medical CT for some of these cases. So I want to plan zygomatic implants --

Howard: So what do you use?

Andonis: I'm a big fan of both I-CAT and of the Carestream, like the nine thouseand three hundred.

Howard: Okay. That's what I had, the Carestream. When I'm talking to patients, nobody knows what a CBCT is, so I just tell them we're going to take a cat scan.

Andonis: I tell them it's a 3D scan.

Howard: Do you tell them it's a 3D scan?

Andonis: Yeah it's a 3D scan.

Howard: Is it not right for me to say I'm going to have Jan take a cat scan of that?

Andonis: Yeah, I mean, I tell them it's a 3D scan, it's a CT scan. I think they get it when they see it in 3D and I show it to them.

Howard: Just say a 3D scan. Because I don't like the word CBCT because the patient looks at you cross eyed.

Andonis: My notes say CBCT, in terms of my notes. So we're going to get a panorex, which is the traditional one you may remember that goes around your head, or a 3D scan. I just call it a 3D scan because I show it to them in 3D and I actually let them see, during my consult I may plan out their implants.

Howard: Okay but we both have the Carestream. But, the surgical guide.

Andonis: Okay. I'm a big fan of surgical guides. The last two years that I was in private practice before I went to the VA, I converted probably 95% of my entire practice of implants to fully guided surgery, even for single tooth implants. It was rare at that point for me to even have to get a patient -- unless it was a guy that came in and said, "You know what? Do this extraction, then I'm flying out of town for the next month." For me to do an extraction, do an immediate implant and freehand it, it became rare to do that. And I didn't have a patient say no to me in my specialty practice on a guide. And I just passed the cost of the guide onto them. I said, "Listen, I can do a case guided for you. It's going to cost you about another 400 bucks to have a guide, but it's going to allow me to make a smaller incision on you. It's going to allow me to place the implant with more precision and a lot faster on you. And you'll be in and out the door and we will already have the plan in mind of exactly where we're going. It's going to make it easier for Dr. Jones or somebody who's referring you to me to restore it." And in some of those cases we actually had a screw attained provisional pre-made. So it was an anterior case, I would plan the extraction, the guided implant into a screw retained position, immediate with a prefab mill PMMA crown that I would deliver at the time of surgery, that I would just screw right into the implant if we had enough primary stability. Pack my bone around and I'd send the patient back to the restorative dentist to have the access foreclosed and the restorative dentist would charge them for that premade, milled crowns that have given them a flipper or an essix. Great service and we're maintaining the papilla and developing soft tissues from day one.

Howard: Do you see yourself implementing a 3D printer to make your own surgical guides?

Andonis: I think it's a great idea. I don't know if I have the time to do it. I think it's absolutely wonderful that dentistry has moved to the point where now it's even affordable to have one. I would like to have one, but I see things are moving in two directions. One: I can't see that that 3D printer, which may give you some great accuracy and still be pretty phenomenal and gets you close in the ballpark, cannot compete with say the 3D printers that they have at Nobel that are bolted to the foundation for less micro movement inaccuracy, that are actually bolted into the foundation.

Howard: Where are you sending for your 3D surgical guides?

Andonis: Well I do them through Nobel. Nobel guide, Nobel clinician. And I also -- when I was in private practice, I did a lot through MIS with M guide, which I thought was a phenomenal --

Howard: MIS - make it simple. Out of Israel, bought by Straumann?

Andonis: They were just bought actually by Dentsply. Their guides, I was a huge fan of their open guides that they had called the M guide. Phenomenal guide system. And those guys in New Jersey were really great to work with. But I think primarily in my practice, it's really the Nobel Guides.

Howard: You're here in Florida. And when I was little, it was 3I dental implants and it was bought by Biomed and then it was swallowed up by Zimmer. And now Zimmer put up their whole dental implant division for sale. They want to exit that, which I think that's kind of weird. And then Straumann bought one of the largest ceramic dental implant deals. And then on Dentaltown, lots of periodontists are starting to question -- they're seeing 20%peri implantitis on implants at five years, and at six to nine years are seeing 46%. And there's a lot of people starting to wonder that maybe titanium is not so inert, and maybe that has something to do with the inflammation around it. And some people are swearing by it and it's anecdotal and they claim there is some research that ceramic implants are going to have a lot less peri implantitis. Is that Hokey Pokey, too far out there, need more time, bleeding edge?

Andonis: I think you need more time, to be honest.

Howard: Does your gut think that's true? What does your gut tell you on that?

Andonis: I don't think there's a problem with titanium. I mean, look how many millions of implants have been placed that are still functional today without that problem. Maybe we're seeing it, but that might be the result again of prosthetic design, who's placing them. Maybe there's something to do with some of the different surface coatings that we're dealing with now too on them. I don't have enough experience to tell you. I am seeing more ceramics coming out. Nobel's coming out with one of their own ceramic implants as well this year. Maybe it'll be the way of the future, but I think that we've got a good thirty years of osseointegration with titanium now that seems to be doing fine for most people.

Howard: I'm not slamming, because the Fran family reunion out of Parsons, Kansas and Nevada and Missouri -- the people giving the majority of All on fours, most of them aren't yoga instructors who are vegan who ran a bunch of marathons. I mean, I'm in Phoenix. Most of the people needing extraction implants, they're hard living. They're smoking, drinking, eating their cheeseburgers. So it's kind of a skewed population, you know what I mean? We're not going to randomly just choose a hundred Americans and place in implants. There's a lot of reasons why these people need a denture.

Andonis: They're in a terminal dentition for a reason. It may have been financial costs over time and lifestyle changes, lifestyle choices basically. And then it's compounded. So it's multifactorial usually.

Howard: So the next one's lined up, I've got to go. But last question: again, dentistry uncensored. I'm not saying I'm for or against, I just like to ask where there's controversy. There is a lot of - and maybe dentists confess too much to me while they were out there at the bar - there's a lot of dentists who believe when they extract a tooth, that the suturing is wicking and that that's where the bacteria in the mouth get on the suture, go down there. And there are dentists who almost never suture after any extraction. And then there are others who spend more time on the suturing than they do the extraction --

Andonis: That's probably me.

Howard: -- and sew down like a mattress. So again, I'm putting out a huge schism. Why do a lot of people never ever suture, ever. And a lot of people like you -- I've seen your cases where it had to take more time to suture than extract. So is suturing wicking? Talk about suturing.

Andonis: Well, wisdom teeth: I typically place two to three sutures on a wisdom tooth case for my incision.

Howard: On all four?

Andonis: No I don't suture the tops typically.

Howard: Okay. So you don't suture maxilla wisdom teeth.

Andonis: I don't usually suture maxilla wisdom teeth unless I've got an anterior release for them. In the mandible, I will typically place two to three sutures for that area. And that's only for me because I felt that I had a better stabilization of my clot, where I put my gel foam or whatever else in and that I didn't have to deal with as many post-op bleeding issues. And for my patients, I felt that most of them anecdotally, from what they would report to me is that they were more comfortable. My partner who had been doing it for almost 30 years, only one suture on the lower, just behind the second molar. And that's where he did it. And that's where his comfort zone was. Whenever I did it that way, I felt like I got a higher dry socket rate than if I placed more. So it's a crap shoot. I have no idea why one works versus the other. But for me, I felt more comfortable having in a couple extra sutures.

Howard: Is the three most common variables for dry socket still smoker, woman and on birth control pills?

Andonis: That's what we say. My dry socket rate was pretty low. We tracked it --

Howard: But is it usually one of those three things? It was a smoker --

Andonis: And an older patient. The older they were, the more likely they were to have an issue.

Howard: I always wondered -- when I was in school and Matthais (inaudible 01:11:19) oral surgery, Charlie White, I don't know if you know him. He's at (inaudible 01:11:14) and Brett Ferguson.

Andonis: He's president of the AOMS this year. Phenomenal guy.

Howard: He was my oral surgery instructor. Loved that guy. God, he was so amazing. What I loved about him is he wouldn't help you until you did your thirty minutes. "Howard, you've only been in there ten minutes. You already given up? Get back in there." Love that guy. But when they were telling us that -- Brett Ferguson, Charlie White, Matthias Horgan, that it was a smoker, a woman, or a woman on birth control pills, it really means that -- you think estrogen is a big part of that clot?

Andonis: It may very well play some sort of molecular level in that clot stabilization, but you would think it's almost the other direction, because smokers and people on birth control have a higher tendency to form clots. That's why they have higher risk of getting a DVT.

Howard: A DVT?

Andonis: Deep venous thrombosis. They actually form clots, so why would we they lose a clot in the mandible, in the bone socket? And there's probably a greater role, I would say, maybe with some sort of bacterial, clot lysis, basically from having colonization of the clot. There's something in the saliva for some people and just getting bacteria down into that clot that may cause that.

Howard: Are you using resorbable guts?

Andonis: 3-O chromic for 90% of my intra-oral procedures.

Howard: 3-O chromic.

Andonis: 3-O chromic is what I use for probably 90% of my cases.

Howard: So you got to get them back to take it out.

Andonis: No.

Howard: Chromic is gut?

Andonis: Chromic gut, yeah.

Howard: 3.O chromic gut, who makes that?

Andonis: Almost every company, but I heard they're not using it in Europe anymore. They've stopped using it in Europe, but 3-O chromic is the reabsorbable suture of choice for me. And I use that for, I'd say 90% of my patients. The other 5% may get some sort of vicryl and then the other 5% I'll get something like proline or nylon or maybe like a cytoplast cortex suture.

Howard: Well, I'll tell you what, seriously, Dr. Andonis Terezides. That is Greek, Greek and more Greek. So are you a big Greek food fan?

Andonis: I am.

Howard: Final question was: My Big Fat Greek wedding, did you find that racist or funny?

Andonis: No, I found certain parts of it that everybody can relate to and even cross cultural, a lot of cultures can relate to it there. I think it's more eye rolling because, like, it's the stereotypes that you still see -- we all knew people that had family, people that were like that, but I think they didn't really apply to my family or my wife's family so much.

Howard: Have you ever used Windex on a patient?

Andonis: No, I have not, but Paradex all the time.

Howard: Hey, seriously. Huge fan of yours. It's a couple of guys like you that take Dentaltown from an amazing website to world class.

Andonis: You've done a pretty incredible thing with Dentaltown and it's been pretty cool, I've made a lot of good friends over the time. My oral surgery buddies -- and there's a group of guys that we talk to on Dentaltown, we have our own little text thread and we just -- middle of the day we may throw something inappropriate to each other on a text message or shoot a case and get a second opinion really quick on the fly. Take a CT scan and scroll through and be like, "Hey, what do you do? This guy's in my chair." And it's not even going through the Dentaltown because we really got to get to each other, find out how to manage kind of an interesting case in the hospital or something.

Howard: Well I can totally say that if you're not on Dentaltown and you're not seeing his -- I mean, it's world class material I've never seen in any type of a textbook or anything, and if you had a textbook, remember, it takes five years to write a textbook and then to get their money, they sell it for ten years. You post cases that were done --

Andonis: I was very lucky that I had great teachers all through school, from undergrad all the way through dental school and especially in residency. I mean, to train under people like Bob Marx and (inaudible 01:15:01) and Michael Pelig and Danny (inaudible01:15:01) Vishy Broumand and Ramsey (inaudible 01:15:01) And those were my faculty people at University of Miami. These are the guys that write textbooks, they pioneered a lot of the techniques and they imparted that knowledge on us and they beat us daily into submission to learn to do things their way. And I think we're trying to slowly, slowly carry that legacy forward with them.

Howard: Well you're doing it in spades, buddy.

Andonis: Thank you very much, Howard. It's been a pleasure.

Howard: Thank you so much for coming on the show.

Andonis: Really great talking to you.

Howard: Thanks for doing an article last month on Dentaltown magazine, and thanks for all the world class cases.

Andonis: I got a couple of people recruiting, some of my prostho colleagues said they'll write some more for you guys, so --

Howard: Thank you very much.

Andonis: Thanks Howard. Have a good one.


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