Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard Farran:  Well, I’m very excited for this next interview today with Dr. Mike Kelliher, graduate of Tufts University back in 1993, um, you’ve been doing this for 21 years and you’re probably most known for, uh, not just CAD-CAM, but um, CAD-CAM with E4D…

Mike Kelliher:  That’s right, yep.

Howard Farran:  So, um, I’m really excited. I want to talk to you about CAD-CAM, I want to talk to you about, uh, what, what, what is the population of your town? Would you say you’re more major urban?

Mike Kelliher:  No, a small suburb of Springfield, Massachusetts. 

Howard Farran:  Okay, and how many, how many people are in Springfield?

Mike Kelliher:  Oh, I’m not sure about Springfield, uh, the town we’re in is probably under 20,000 though.

Howard Farran:  But, but when you leave your town, would you not know it that you’re in Springfield or would it be…

Mike Kelliher:  Oh yeah. No, Springfield’s a pretty good-sized city, so it’s the third largest city in Massachusetts. 

Howard Farran:  Okay. And so, I, I, I’ve been liking to start all my podcasts off with just the, the general question of the fact that, uh, for a guy like me, graduated in ’87, been doing this, uh, 27 years…wow, this last recession was a whammy. 

Mike Kelliher:  Yeah, it was tough.

Howard Farran:  Yeah, I mean, I’ve lived through several of them, and the one thing they all had in common is they were about 18 months of, uh, pain and misery, and then it was back…

Mike Kelliher:  Yeah.

Howard Farran:  …back going again, and this one, 2008-2014, a lot of the dentists on Dental Town are just crying that, uh, My city’s economy is flat, huge unemployment, lots of people aren’t getting approved for financing, and  uh, so, um, guys like you who’ve been doing this for two decades…

Mike Kelliher:  Yeah.

Howard Farran: …share with these listeners from, uh, not just around the United States, but around the world, um, what are you excited about in your practice and what makes you excited, and what’s growing your practice? Where do you find enthusiasm and passion?

Mike Kelliher:  Well, I mean, we’re, I mean, I’m a big technology guy, so anytime we put technology in the equation, it seems to be, uh, the fun stuff, it’s the toys. So, we enjoy that. But, basically, we’re a bread and butter dental practice. We do kind of the general stuff, so um, enjoy just taking care of the patients every day and seeing a broad, uh, spectrum of procedures and types of patients all day long. So, that’s, that’s the…

Howard Farran:  And what procedures do you do? I mean, do you pull wisdom teeth, do you do molar endo, do you…

Mike Kelliher:  No. No, we do pretty much everything except I don’t do a lot of surgery. That’s about the only thing we don’t do is surgery. 

Howard Farran:  So, you don’t do…you don’t place implants or remove wisdom teeth, but you do molar endo.

Mike Kelliher:  Uh, yeah, do some, do endo, but just about everything except the, the surgery, yeah.

Howard Farran:  Okay, and what made you get into CAD-CAM, how long have you been doing CAD-CAM?

Mike Kelliher:  Uh, we’ve been doing CAD-CAM for about five years now. Uh, we got into it, uh, yeah, almost exactly five years ago. Uh, well, we had been looking at the technology for quite a while. It interested me quite a bit, uh, to be able to bring that technology into the office, and so we’d been kind of watching and watching, and finally the thing that set us into doing it was waiting for the materials to mature. So, when we started seeing, I started seeing e.max cases, actually on Dental Town from the CEREC users, and seeing that, boy, these guys are getting very good restorations, uh, the material quality seems to be good, the e.max had been around in press version for a while before that, so, you know, once we saw a, a good quality material and saw that the technology had matured to the point where we could get a, a good quality restoration, then we started really looking heavily at it. Um, I have a practice with, with two partners, so for us, it was, uh, pretty much a no-brainer to, uh, bring that technology in because it really did cut out laboratory expenses tremendously, so we were able to, uh, to uh, cut our expenses a lot, and especially like we were talking about in the economy, uh, being able to control some of your costs, uh, that way was a big help, especially seeing where laboratory expenses have gone in the past few years with the prices of metals going up and all that sort of thing. 

Howard Farran:  So, your statement of income on your lab bills, was it before CAD-CAM, was it 10%, and what it drop to?

Mike Kelliher:  Um, well we ______...

Howard Farran:  Where did it start and where did it drop to?

Mike Kelliher:  Uh…um, numbers-wise, I’m not sure. I know we’ve dropped it by over half because we’re doing almost everything in-house in terms of, uh, you know, all single units are done in house, most of our, you know, one or two…you know, two or three cases, and we’re even starting to mill bridges and stuff in the office as well now. So, most of that is in-house now. We still will send out obviously, uh, a big bridge that is, uh, something we can’t mill and removable and stuff like that, but in terms of all, virtually all the single units are in-house now. 

Howard Farran:  So, so what initially got you the most excited was that it was technology; number two, was it to lower the lab bill or was it the…?

Mike Kelliher:  Yeah, more into…

Howard Farran:  Or was it the patient, um, one-day experience? I want to…I want to remind…I’m 52, I want to remind the, uh, these young kids that when I was a little kid, I remember I, one of the saddest summers I had was my best friend broke his glasses, and back then, it took six weeks to get into the eye doctor, and then they sent the prescription out. He basically couldn’t see all summer.

Mike Kelliher:  Right.

Howard Farran:  And then, we saw the birth of, uh, Lee Optical, EyeMasters, Pearly Vision where you just walk in there and an hour later, you walk out with glasses. Was that a big part of the equation – same-day crowns?

Mike Kelliher:  That was definitely a big part of it, um, to be able to provide that. You know, one of my least favorite, and I’m sure everyone’s least favorite emergency phone calls to get is the temporary came off on a Saturday afternoon phone call, which we all had to deal with, uh, to not have to have that, and you know, the patient experience is great to be able to provide the, the service in one visit is a big one. So, it was a combination of a lot of factors, but you know, seeing where, where the technology had merged to it and the materials had evolved to, it just made a lot of sense, so everything kind of gelled together to be able to provide that in the office rather than having to send all of that stuff out, so…

Howard Farran:  And there’s also…I’m hearing a lot that, you know, a temporary, you, you tried to make it well, you try to do everything well, but bacteria leaking…

Mike Kelliher:  Oh, absolutely.

Howard Farran: …is… we’re seeing a lot less endo in same-day restorations. 

Mike Kelliher:  Yeah.

Howard Farran:  Would you say that’s true?

Mike Kelliher:  That is…absolutely agree anecdotally. And it’s not something I’ve tracked, so I really couldn’t say percentage-wise, but it’s very, very rare nowadays that I will send a patient for endo post-crown where it wasn’t super common before, but enough that you’d know it was there, so it’s rare, very rare that we’re doing that, and that is a big advantage being able to cut that prep and within about an hour, you’re sealing that restoration with the resin, and it’s not having any time to take bacteria in, so…

Howard Farran:  And what resin are you cementing your CERECs with…

Mike Kelliher:  Uh…

Howard Farran: …or CAD-CAMs?

Mike Kelliher:  CAD-CAMs, I’m doing with…

Howard Farran:  ______.

Mike Kelliher:  Uh, yeah, with the, uh, SURPASS Apex materials, uh, in an Anchor. 

Howard Farran:  SURPASS and anchor?

Mike Kelliher:  SURPASS bonding agent, Interface, and Anchor, yeah, the usual. 

Howard Farran:  And who makes those?

Mike Kelliher:  That’s Apex Dental. 

Howard Farran:  Apex Dental, so, say it again, SURPASS?

Mike Kelliher:  SURPASS, Interface, and Anchor. 

Howard Farran:  Interface and Anchor, and those are all three from Apex Dental?

Mike Kelliher:  All three from Apex Dental, yep…

Howard Farran:  And what made you choose those?

Mike Kelliher:  Well, I had been using the SURPASS bonding agent for a very long time, uh, and I’ve had fantastic results with that in terms of low sensitivity, and the anchor is a core buildup material and a resin cement, so  I had that in the office, as well, so it’s kind of a nice way to be able to keep inventory relatively minimal and not have to have a special resin cement, uh, and it’s products that I knew had worked very well for me, as well, and it’s, you know, there are other CAD-CAM users having good success with that combination of materials, so a combination of…

Howard Farran:  And that’s a dual, that’s a dual cure?

Mike Kelliher:  It’s a dual cure, yep, absolutely. Dual care, so it’s, uh, you know, you, um, you place it, let it gel, and clean it up. It cleans up real nicely and, uh, like I said, very, very low sensitivity, so it’s a…

Howard Farran:  Now, you’re, you’re part of three dentists in one office?

Mike Kelliher:  Yep, three dentists in one office. 

Howard Farran:  So, have you all intellectually agreed to use this so you don’t have ten different, three different bonding agents, or…

Mike Kelliher:  Unfortunately no, and you know how this goes with, you know, its three partners. I’m the youngest of the three, so, you know, getting things changed isn’t always, uh, as easy as I would necessarily like it to be, but um, it, it, everyone has their favorites, and you kind of, if you get very comfortable with something, then you’re going to stick with it, and if you’ve had success, then…so, there’s no reason necessarily to change. It would be great if we all were using the same materials for everything, but that’s maybe not realistic to expect that.

Howard Farran:  Right, and, I, you know, a lot of dentists always complain about their supply costs being high, and they always want to blame it on, you know, on Patterson or Siner, Benco or Burkhart, but then you start looking at the details, you’re like, Okay, why are two hygienists and a dentist using three different kinds of gloves? Why…

Mike Kelliher:  Yeah.

Howard Farran:  Why…and you know, and then when you ask them to make the painful decisions that would lower their supply costs, and they say, Never mind, never mind.

Mike Kelliher:  (Laughs) Yeah, I know.

Howard Farran:  So, I want to talk about, um, let’s go to your earliest decision, so we have, um, two major players in the market – E4B, uh, and Cerona, and at the last, um, Cologne meeting in Germany, which is the big international meeting, 100,00 dentists go to that every other year…looks like there’s a lot of CAD-CAM players…

Mike Kelliher:  A lot.

Howard Farran: …coming from Korea and Japan, um, what made you, um, go with E4D, what other CAD-CAM companies are, do you see coming down in the future and, tell us, walk us through that decision.

Mike Kelliher:  Yeah, I mean, when we, when we were looking five years ago, there was only the two basically that were involved, and uh, quite honestly at that time, so, my partners are not as computer savvy as I am, and we really wanted to make sure the software was very, very user friendly, and at the time, the E4D software was a lot more, um, easy to use than the Cerec software, that version of CEREC software. Um, we also liked the fact that all of this, all the E4D materials were manufactured in the United States, they have kind of an interesting, um, you know, corporate structure where all of the, um, manufacture, R&D, education was all done down just outside of Dallas, Texas, so they’ve got an interesting setup there. Um…

Howard Farran:  I’ve visited the plant and had dinner with the founder and his wife, his wife’s name was Dotty?

Mike Kelliher:  Mm, not sure. I met the wife where Basil was the founder, but never met his wife. But, um, yeah, it’s a very interesting way that they had structured it. So, we were, we were very impressed with that, um, you know, the milling technology they seemed to have in place looked to be very, very good, and uh, like I said, we really liked the software and the responsiveness of the company, so, uh, you know, that was for us a good thing. And then, like, like I said, the big issues for us were what materials were available and, you know, thankfully the e-max, which is what we’ve been using as our workhorse was available with the, um, with the E4S systems, so it seemed to be a very good fit, and we’ve been happy with the decision. Ever since, they’ve supported us very well, they’ve handled, um, the upgrade path, I think extremely well. We’ve been through now, in five years, three different new durations of the, uh, the camera software, and they’ve been very fair. We, um, you know, we had to pay for one camera upgrade to go from the first camera to the second camera, and when they, uh, the Neva, which became the Planmeca PlanScan came out last year, they actually credited us back the money we paid for the, um, the second camera upgrade towards the, the PlanScan, so I thought that was pretty fair the way they handled it in keeping the costs in line. They also had a kind of interesting, kind of profit structure where they get a royalty on each block of purchased instead of making a lot of money on the hardware, seemed like they were very interested in making sure their users were successful, because they had a vested interest in us producing a lot of crowns and selling a lot of blocks, so I think that was an interesting concept what their company as well.

Howard Farran:  Basil is a class act…

Mike Kelliher:  Yeah.

Howard Farran: …and in, in so many ways, whether it be family, marathon runners, I mean, he’s just a hell of a guy. 

Mike Kelliher:  Yeah.

Howard Farran:  I love that guy. 

Mike Kelliher:  (Laughs)

Howard Farran:  I really do. 

Mike Kelliher:  It’s an interesting group down there now, and of course, he’s moved on from E4D in the past year or so and, you know, with Planmeca coming in, it’s been a lot of changes in the past year with E4D, but, um, I think the Planmeca, uh, you know, merger in has been a big help. They’ve brought a lot of manufacturing expertise and, of course all of their knowledge in imaging and software, uh, has really kind of jump started…we’ve seen a lot of changes just in the past six months or so with how the software and the hardware is being handled, so really looking forward to see what happens in the next, you know, coming years with the company for that sort of stuff.

Howard Farran:  So Mike, I want to ask you this question. 

Mike Kelliher:  Sure.

Howard Farran:  Um, before CAD-CAM, a dentist takes an impression…

Mike Kelliher:  Yep.

Howard Farran: ...hands it to a lab man…

Mike Kelliher:  Uh-huh.

Howard Farran: …doesn’t see it for two weeks. The lab man makes the entire crown.

Mike Kelliher:  Right.

Howard Farran:  Two weeks later, walks in the door. But, it seems like a lot of dentists, when they get CAD-CAM, decide that, um, now they’re a lab man. 

Mike Kelliher:  Sure.

Howard Farran:  Not their assistant, they, they optically scan, they’re milling, they’re staining, they’re glazing and all that stuff. Do you, are you now a lab man with a CAD-CAM or does your assistant do this, or do you just…

Mike Kelliher:  Yeah, well, yeah, and it depends upon the cases, but we do, uh, sometimes the assistants will do the design and the stain and glaze, sometimes the docs will, kind of depends on the timing and the type of case we’re doing. Uh, but that’s one of the nice things about CAD-CAM is you can train up your staff and delegate stuff to them, which will save you time. It’s also a nice way to kind of empower those staff members to do something different instead of, you know, just being chair-side and, you know, working all day long doing that. It gives them something new and a new challenge, so, and sometimes some of your staff is a lot better at staining and glazing than, than the dentists are. They see color sometimes a lot better than you do. So, I don’t know if I’ve necessarily say I’m a lab man, I mean, for the kinds of things we do, I think we do a very nice job, uh, and we’ve gotten to the point where we can get a very nice result out of, out of a Cerona block in the office. If I have a very high end cosmetic case, I still am going to send that and have a, a dental technician get involved there because, you know, there’s an artistry involved with that in terms of layering porcelains and stuff that we can’t do in the office, but for a monolithic restoration which is another big part of, not just CAD-CAM, but part of what’s changed in dentistry in the past five years or so, the monolithic restorations, uh, I think we can do a pretty decent job with those in the office and get a very nice result. Um, you know, it’s always a tough question as, you know, are you taking the job of the dental technician and bring it into the office and, you know, there’s a lot of training skill that goes along with that, but for the simple restorations I think that this works out very, very well, and you can get a very, very nice result. 

Howard Farran:  So, um, basically on Dental Town, I’m on Dental Town all day every day, and uh, what, um, what are you seeing growth in your practice? I mean, what are you doing to this flat, anemic blah economy?

Mike Kelliher:  Yeah, I mean, for us, we’ve been fairly fortunate. The bread and butter kind of dentistry has held pretty steady for us, and the stuff that has kind of gone and faded back has been more of the cosmetic-type cases, um, but you know, we haven’t seen anything we necessarily can say we’re going to grow in this area, we’re just trying to, uh, provide as much service to our existing patient base as possible, making sure we, uh, you know, keep the patients in there for their active recalls and making sure we’re diagnosing, treating all of the routine stuff…dentist, and that seems to have held pretty steady for us. We’ve been fairly lucky. I would hear we haven’t been hit quite as bad as some areas of the country. So, yeah, we haven’t added a lot in, although one of the things we’re going to look at, uh, is probably maybe to start placing some implants in the office, uh, as a different, uh, avenue to have, and again, this kind of ties back into the technology with the, uh, cone beam and the CAD-CAM to be able to do some of the guided surgery procedures. I think that will make it, uh, a little more attainable for general dentists to be placing some implants, probably not all of them, but at least placing some implants in the office.

Howard Farran:  Now, would you, would you go with a, uh, Planmeca since they now, they, do they own E4D, did they buy E4D or…

Mike Kelliher:  They, they bought a…the way it was described to me was it’s a noncontrolling interest in E4D, so they, they, they’re co-developing products now. Um, you know, we actually, before I even got into CAD-CAM, we had a Planmeca Promax Pan that can be upgraded to CT, so that would be the logical thing for us to do anyway would be just to upgrade out pan to CT capability, and it will happen to play well. Um, the one thing that’s nice about the E4D system is that it is open-source and the Romexa software that Planmeca has that they’ve integrated the E4D, um, software into is all open-source. You can pull anybody’s cone beam into that without any problem at all. It’s ______...

Howard Farran:  Okay, Mike, Mike, a lot of our viewers, um, don’t understand the difference between open-source and what’s the opposite of open-source? Can you talk about that?

Mike Kelliher:  Yeah, well basically, I mean…

Howard Farran:  What’s the opposite of open-source?

Mike Kelliher:  The opposite is closed. Um, when you look at…with Cerona in particular and so many manufacturers, they basically make it so that, uh, it’s more difficult for you to import and export, uh, files in and out of your system, so if you have, uh, say a Cerona or a CAD-CAM system and you want to use cone beam with it, uh, you kind of do have to use a Cerona cone beam with it to make it…it works a lot easier that way, and uh, it’s not so simple to do, um, to bring in another cone beam. Same thing if you want to export outfiles out of, out of a Cerona system, uh, it’s not quite as simple. You do have to have a special laboratory version of the software and pay a little bit of a fee, whereas some of the software, E4D and a lot of the other ones have an open-source which basically means that you can export a, a .STL file from your CAD-CAM system. Essentially it’s a JPEG version of your, uh, of your CAD-CAM files so it’s universal and can be brought into any other software. So, if I, for instance, were to send a, uh, scan of one of my cases, um, that I don’t want to manufacture in the office to a laboratory, uh, in the STL format, they can then pull that STL file into a 3Shape software and mill it on a 3Shape mill if they, if it’s something big, or if it’s any other piece of software, any other mill they want to use. 

Howard Farran:  Now, are you doing that with, um, um, like do you do that very often or do you do that with bridges instead of an impression or…?

Mike Kelliher:  Yeah, sometimes we will. Uh, not every single time, but, uh, a lot of times we will send that kind of stuff via a STL file to the laboratories and do it that way. If it’s…

Howard Farran:  What, what lab are you using that accepts that, the file?

Mike Kelliher:  Right now, um, I’m using a lab down in Texas called Cosmetic Advantage Dental, that uh, a guy name Jimmy Fincher runs down there, and so we send stuff down to him, um…

Howard Farran:  So cosmeticadventure.com?

Mike Kelliher:  Cosmetic Advantage Dental.

Howard Farran:  Cosmeticadvantagedental.com?

Mike Kelliher:  Yep, yep.

Howard Farran:  Okay. 

Mike Kelliher:  Yeah, and, but again, where it’s an open file, I know that, you know, you could send it off to a big lab like Glidewell or Microdental or any of these other labs, could take those files and can open those up and work with them, as well. So, it’s very simple for the user to take an open file from their CAD-CAM and send it off to anybody whereas you have to do some conversion process, um, when it’s a closed system. So, it’s a little bit more of work to do it that way, but so I’m a pretty firm believer that, that your CAD-CAM, if you’re using a digital impression from CAD-CAM system, it should function the same way as, uh, a physical impression. So, if I take an impression with Aquasil or Impregum, it shouldn’t matter. I should be able to send it to whatever lab I want. It should be the same with your CAD-CAM. If you’re taking a digital impression, I really think you should be able to just send it off to the lab and let the laboratory technician and you decide how that, that you’re going to use that digital model, uh, to take care of your patients, so, rather than having to jump through a bunch of hoops. So, that’s why I think the open-source thing is, it’s gaining steam and you see most of the newer systems that have come out in the past year and you talk to Buddall the systems that are coming. They’re are having some version of a .STL export kind of built right into the software now.

Howard Farran:  Yeah, and tell us about some of these systems, names for our viewers.

Mike Kelliher:  Uh, Carestream is probably one of the bigger ones that came out, which is the remnents of the Kodak company, they had sold off a few years back, they’ve got a, a scanner that’s hit the market about a year or so ago, that book’s pretty interesting. Um, 3Shape Trios has got a very, very nice scanner as well, probably one of the more expensive scanners on the market, but one of the nicer scanners on the market. Um, that one has been very nice. Koda…er, 3M, uh, has had scanners for a while. They’re one of the, actually the first company to have a live video scanner and they have a, a new version actually coming out, I think this fall, over there, their scanner as well, um, so that’s something interesting to look forward to, as well. So, there’s a lot of companies, and what you’re seeing is that a lot of these major manufacturers, in fact, when you look at Planmeca when they, they were distributing E4S over in Europe for a while because they didn’t have a scanner. They all seemed to want to have one because they see that the future of impressioning is digital. It’s not going to be physical impressions probably a whole lot longer, uh, at least for a lot of things, so…

Howard Farran:  And why is that? Tell people why you think that It’s going to go from physical polyether, polyvinyl to optical scanning?

Mike Kelliher:  Yeah, well, it’s faster, I mean, and all…when you look at laborites right now, laboratories have converted to a digital, uh, work flow already, so when you get your case interview send a stone model off the one of the big commercial labs now, they’re taking that and scanning it in and then going ahead and either doing a CAD version of your restoration or they’re printing or, um, milling out waxes to, to go ahead and do restorations that way if they need to cast or press or something that way. So, the technology’s moving that way on the laboratory side. On the dental side, it’s much faster. I mean, I can…the scans are pretty quick. I can get scans done very quickly now, probably quicker than the impression material takes to set, it’s more comfortable for the patient, they don’t have to have the impression material in the mouth for, you know, two, three minutes, whatever the set time is, and now I can digitally send that, uh, file off to the lab right away. It’s going to be there in, you know however long it takes to upload the case, rather than having to ship the case both ways, so you cut your shipping down, um, and it, so, it’s overall a lot nicer, and you can also get feedback immediately if I…if you take that big bridge impression and, you know you got maybe six abutments you’re trying to pick up, and you take a physical impression you get a bubble right on the margin, well, you’ve got to take that whole impression over again, whereas with digital, if you go back and you see, Oh, I missed a little bit of data on, you know, this particular abutment, you can just go back and scan a little bit more in that spot, add that data back in and you don’t have to retake the entire impression, so there are a lot of advantages to it. Um, you know, being able to manipulate those digital molds, plus you’re also now able to save those models. Uh, none of us are saving every model from every case we ever do because we’d need to have warehouses attached to our offices, but with the harddrive space, you know, becoming extremely cheap and a small, you know, unit, uh, you can actually save all  those digital impressions for however long you want to, and be able to go back to them in the event you need to. So, there’s a lot of advantages to the digital impressioning. I think though, the real power is to have the chair side in the office, in conjunction, because the, they return on investment for the dentist, I think really comes when you’re able to do the chair side, uh, you know, same day dentistry in the office because that’s where you’re going to…you realize the savings in the laboratory bill and, uh, the one visit for the patient, which is a bit of a marketing opportunity for you, uh, so those you’ll have with the, the um, the milling in the office, but you won’t have that necessarily just with digital impressioning. So, uh, you know, different, uh, different ways to go about having that technology in the office. But, do think you’re going to see the, the change, it’s just, when you see all of these big manufacturers lining up and all introducing similar products, you know that’s, you know, some writing on the wall there. They’ve done market research, they see where the market is going, as well.

Howard Farran:  So, you’re…initially you said you don’t do surgery, you don’t do wisdom teeth or place implants, but then you alluded to the fact that you’re thinking about…

Mike Kelliher:  Yep.

Howard Farran: …making, well, I assume that’s, um, CBCT surgical guides to where it’s a lot easier to place them.

Mike Kelliher:  Sure.

Howard Farran:  Can you talk about that?

Mike Kelliher:  Yeah.

Howard Farran:  Where’s your mind at with that decision now?

Mike Kelliher:  Yeah, right now, I, I’m probably just about to pull the trigger on it. Um, you know, I definitely, you know…this is something I think that we’ll see a lot happening in the next couple of years because, you know, general dentists, they do need to add procedures, and implant placement, you know, isn’t really, really hard if you have a well-planned surgery, from what I understand, so the, the ability to have…if you have the tools in the office, if you have the, the CAD-CAMs, you have the cone beam, uh, I think the key thing is, one of the things that kind of always, um, concerns me whenever I’m doing implant cases is, sometimes you’ll get those cases back from your surgeon and they’re not, you know, ideally placed, and I’ve always been a believer in that they, um, the placement of that implant really should be driven by the position of the final restoration. So, to be able to take your CAD-CAM and design that final restoration prior to surgery, use the cone beam to be able to see where that bone is and can you place this implant in a position that will allow you to, uh, to have this restoration and then make your tweaks and make all that planning ahead of time, so there’s no surprises three months later when you uncover that implant, you know exactly where things are going to be. Um, and if you have, if you’re able to,  you know, do all this and have a surgical guide, uh, that’s going to prevent you from kind of getting yourself into trouble, and you have cone beam so you’re able to really see in three dimensions, you know, that anatomy and making sure you’re not going to be close to a sinus or a nerve or something that’s a concern. I think that will ______ (audio cuts out/choppy) maybe isn’t so surgically-oriented to place at least some, some simple cases where you’ve got plenty of bone and you’re able to, uh, to locate those implants in a good location without getting close to any vital structures. So, I think that’s something that we’ll see, more and more general dentists becoming involved, because the technology’s just going to make it a lot, a lot simpler and safer for them to do it much more predictable. 

Howard Farran:  And you say you’re about ready to pull the trigger on, exactly what – the software or the…what are you…

Mike Kelliher:  Uh…well, probably to upgrade our, to our Panorex to, uh, to cone beam, to get the upgrade done. I’ve already, I’ve gotten quotes and we’re, I think we’re just about ready to move on that in the next year. We’ve got an interesting setup – I’m in a professional building where we have, in our building, a periodontist, an oral surgeon, and orthodontist as well, part of why I don’t do a lot of surgery is because I’ve got a great surgeon right upstairs, but um, we also, we actually, uh, share in on the, the Pan, we’ve networked that Panorex into, a digital Panorex into multiple practitioners’ offices, and we’ll do the same with the cone beam, we’ll be able to do that and share the cost of that, as well. So, it makes it much more economical for all of us to have the technology without having to invest, you know, full, you know, put the full amount of money into it, but we’ll all have access to it for a pretty reasonable cost. So, that, uh, we’ll probably try to get that done by the end of the year and get that taken care of and it’s just a matter of finding some training courses and getting comfortable with, uh, an implant system. 

Howard Farran:  And have you, have you, um, found any training courses, some hands-on training courses that you’re looking at?

Mike Kelliher:  I looked at a couple, I mean, there’s, it’s interesting. It seems that there’s kind of two different…some of these interesting courses I sees online where they take you down into, uh, you know, down at the island some place, Dominican or something, and you place like a boatload of implants over, about a week period at a time, that looks very, very interesting. I think something like that…that might be as well…

Howard Farran:  Are you talking about…are you talking about Aron Garg down in the Dominican Republic?

Mike Kelliher:  Yeah, exactly.  That, that one looks pretty interesting.

Howard Farran:  What, what’s his website? What’s his company’s name?

Mike Kelliher:  You know, I’m not positive on that. Um…

Howard Farran:  Okay, well I’ll find it and add it to the podcast notes.

Mike Kelliher:  Yeah.

Howard Farran:  And what, what’s the other school?

Mike Kelliher:  Um…

Howard Farran:  Are you thinking about a classroom lecture?

Mike Kelliher:  Yeah, there are different, there are different lectures and um, you know, a more classroom-based kind of stuff with some hands-on, and I’m just trying to debate whether it’s…because, you know, it’s fairly expensive to do the, the week-long course, so I’ve got to see if I can find something that, that will meet my needs without having to go that far, but we’ll take a look. That’ll be, you know, the next step is just kind of figure out the training aspect of it.

Howard Farran:  You know what that reminds me of though, being 52?

Mike Kelliher:  Yeah.

Howard Farran:  Remember back in the day, um, when RK came out and everyone was afraid to do it on an American who, in a country with one million attorneys?

Mike Kelliher:  (Laughs) Right.

Howard Farran:  So, everyone was flying to Moscow. 

Mike Kelliher:  Yeah, yeah.

Howard Farran:  And there was a guy in Moscow that, I mean, I think he did like 40, 50,000 of them before anybody had done 10 in America, um, because he didn’t have the legal…

Mike Kelliher:  Environment. Absolutely, it does make a difference, doesn’t it?

Howard Farran:  Yeah. 

Mike Kelliher:  Yep.

Howard Farran:  So, so you would be optically scanning, sending the file to a lab and milling out a surgical guide, or would you be milling out your own surgical guide?

Mike Kelliher:  No, they, they, that would go to a laboratory. We don’t, uh, yeah, in fact, no body’s really necessarily milling out a surgical guide right now. You can mill out components to them, and there’s still some hand, hand work even with some of the in-office guides that I’ve seen. Uh, so no, this would be sent out to a laboratory with the, you know, with a metal sleeve and, uh, you know, drill stops and all that kind of stuff so we would be able to be real precise what we’re doing, so yeah, there’s several different, different laboratories that are out there, and the prices aren’t ridiculous – about $200 is what I’ve seen on average for a surgical guide. I’m betting that price is probably going to drop a little bit as you get more and more dentists getting involved wsith the technology and placing these, but, uh…

Howard Farran:  And what, and what’s also…

Mike Kelliher:  I think that will…

Howard Farran:  What’s also amazing is many of the oral surgeons I know that are legendary…

Mike Kelliher:  Yep.

Howard Farran: …have now gone to 100% surgical guides because their referring doctor, they say, you know, if I place 100 implants for you and 15 of…just 10% aren’t quite right, you’re only going to remember the 10% that’s not right. You’re not going to remember the 90% straight on…

Mike Kelliher:  That’s true.

Howard Farran: …and so they would rather just bullseye every single one of them so you’re always happy. So, they’re doing this…even though they are phenomenal surgeons.

Mike Kelliher:  I’d agree. I mean, in the days when CT technology was, was very uncommon and you maybe had to send the patient to the hospital and get a CT done there and the radiation dose was really high, and it was harder to justify doing that for every single patient, but uh, where the technology is, is there, the radiation dose is low, it’s not, you know, it’s not going to add much cost to the procedure to get that reliability and predictability seems to make an awful lot of sense to me to go, you know, go guided with all these cases, so that’s something that I’ll definitely be looking to do with my surgeons as we go forward. 

Howard Farran:  Now, you’re um, I want to thank you, not only for all you’ve done for dentistry, but for Dental Town, uh, you’re an administrator on the Dental Town forum, talk about that.

Mike Kelliher:  Yes. Yeah, I mean, that’s, that’s interesting, I mean, it’s um, something that we’ve been doing for about, uh, two years. I initially was brought in to kind of moderate all the, the E4D, uh, forums and some of the other technology forums, Uh, but it’s interesting, it’s, you know, it…sometimes it gets a little hairy and crazy, but for the most part, I think since Howard Goldstein has kind of taken over and kind of set the rule out, um, things have been pretty calm, and we don’t have to do a whole heck of a lot anymore. In the old Wild West days when you had the endo forums going crazy and the E4D and CEREC people going at each other, there was a lot more where you’d have to edit and, you know, kind of keep things under control, but nowadays, it’s not too bad. Occasionally we get ______...

Howard Farran:  And I want, I want to, um, that’s fantastic feedback, and that is 100% my fault because when I started Dental Town in ’98, um, I was a registered Libertarian, I thought these dentists all have eight years of college, they’re all adults, it’s, I’m not going to go in there and police, and I didn’t really comprehend cyber bullying. And now, and now, um, you see them talking about that on the news, at the elementary school, the high school. I know in Phoenix, when you’re bullying another student that the teachers call the police. And, and, um, it just, just takes not even one-tenth of one percent of these crazy cyber bully people to go on Facebook or Dental Town or Twitter or whatever and just say the craziest, meanest things, and so we brought in Howard Goldstein, and he said, Look, you’re going to talk, um, the rules are that, uh, Dental Town is not the government – a lot of people say, It’s freedom of speech – no, freedom of speech on the Constitution is between you and the government. You don’t have your right to come into my house and have your freedom of speech, and Dental Town is my house, and you’re going to talk to each other like you’re at a party at Howard’s house…

Mike Kelliher:  Right.

Howard Farran: …and, and gentlemen can disagree, but they do it in a nice way, and if you’re not nice, go play somewhere else. And Howard Goldstein is really, uh, and he’s been there doing that for three years now.

Mike Kelliher:  Yep.

Howard Farran:  And it is a different environment. 

Mike Kelliher:  You can say it is a different environment, and I think it’s important to have that environment because you want to encourage people to be able to post and, you know, especially younger dentists who, you know, that they, they’re going to want to learn, and learning from your peers is great, so be able to post a case and say, Boy, I’m having trouble with this, and to get just some good constructive feedback versus, you know, a lot of negative feedback, I think, is helpful because I know that when people get that negative feedback as their first or second, you know, experience online, then they’re just going to go away. They’re not going to come back. So, you want people to be coming out and asking questions, feeling free to do so without having a lot of, you know, kind of crazy criticism, so I think that’s a very helpful thing, and it taught me a lot.

Howard Farran:  Right, and what I saw, and what I saw is like, you, you say you use Apex Dental, so what I like to see, if you have a question about Apex Dental, about how you’re using Surpass, I don’t want to hear nine people say, Oh, well, you should be using this product…and, one of the problems with that, with the E4D is that everybody who posts an E4D case, somebody would get on and say, Well, you should have bought another, another system. It’s like…

Mike Kelliher:  Right, exactly. 

Howard Farran: …that, that’s not the question. We’re past that decision, let’s talk about this decision.

Mike Kelliher:  Let’s talk about…yeah, so that was one of the things…when I first kind of got involved, we were dealing with, was a lot of that, and uh, Howard kind of came up with a concept of, we’re going to have one thread and one thread only where you can kind of compare and bash and do whatever you want, uh, between the two systems, but otherwise, we’re going to have two forums where you can discuss the problems and issues you’re having, and one of my points with the, you know, the folks from the CEREC posters, you know, early on, was hey, you know, once we get to the point of having this crown on the machine, we’re all doing the same thing. So, in terms of staining and glazing and bonding and characterization, all that stuff that, that goes on after you get past the mill, and also preparation and all that sort of thing, there’s a lot in common that we can help each other out with, so that was kind of my point, and that seems to have happened now, as where you see some cross-pollination where you get people using the different systems kind of commenting to users from the other one, it’s a question where there can be some import, because there’s a lot of commonality, I mean, it really…the technology’s a little bit different, but in the end, you’re doing about the same thing. 

Howard Farran:  So, I’m going, I’m going to get to some more details. So, are you doing a shoulder prep with 2-mm all the way around, do you like…is that what you’re liking?

Mike Kelliher:  Uh, I, I’m doing a modified shoulder, but not 2-mm all the way around, probably like 1-mm or so all the way around.

Howard Farran:  Oh, you use 1-mm.

Mike Kelliher:  Yeah, 1-mm is about all…that’s. that’s what the specs are for e-max is about 1-mm, maybe a little more, it depends on obviously what’s missing, if you’ve got a, a big cuspid has come off, you’re going to maybe shoulder out a little bit more where the fracture is. One of the nice things…

Howard Farran:  And how much, how much occlusal reduction?

Mike Kelliher:  1.5-mm.

Howard Farran:  So, one and a half on the top...

Mike Kelliher:  Yep.

Howard Farran:  And 1-mm all around?

Mike Kelliher:  1-mm all the way around, yeah, pretty much is in a…

Howard Farran:  And a shoulder, you said a modified shoulder?

Mike Kelliher:  A modified shoulder, so basically that’s just a shoulder, but the burr’s got a, the corner of the burr is rounded because you want to have all you internal angles rounded, so it’s just a, instead of a flat, straight cylinder, you’ve got a little bit of a rounding on the end of the, uh, end of the burr. So, it just modifies, rolls that out internal line angle from the shoulder. So, we do a lot of that, and you know, the, the, of course the nice, one of the nice things about CAD-CAM is you’re able to, to save a little more tooth structure, try to keep things, you know, supergingival when we can and, you know, do more, maybe a little more on-layer crown latech preparation so we’re not, uh, taking away tooth structure if we don’t have to. That’s another nice thing, stuff that you wouldn’t be able to temporize with a conventional crown and bridge. So, you’re able to do it same-day when you’re adhesively bonding right away. And some just…

Howard Farran:  And back to staining and glazing, um, okay, so what, what percent of the market would you say…America’s got 150,000 dentists, 30,000 are specialists, 120 are general dentists. Of those 120,000 general dentists, what percent of those do you think are already at CAD-CAM?

Mike Kelliher:   Oh, it’s probably, I bet it’s less than 10% at this point. 

Howard Farran:  Agree. So, nine out of ten don’t have one of these machines…

Mike Kelliher:  Nope. 

Howard Farran:  And you just said something that probably frightened a lot of them – you said staining and glazing, and a lot of dentists and saying, Oh my God…

Mike Kelliher:  Oh, I know.

Howard Farran: …I, I, I’m not going to stain and glaze.

Mike Kelliher:  That goes back to dental school. 

Howard Farran:  No, this is crazy. The…

Mike Kelliher:  Yeah.

Howard Farran:  What, what’s Mike talking about? Talk about staining and glazing. What percent needs staining and glazing? Is this something that you do? Does your assistant do it? How much time does this take you?

Mike Kelliher:  Yeah, it doesn’t take very long at all. I do a lot of it myself to be honest. I kind of enjoy doing it. It’s not that hard, I mean, it literally takes, you know, maybe about two minutes to stain and glaze a crown, put it in the oven. It’s really simple. We have, you know, the, um, uh, the stains are pretty simple to apply, there’s some nice spray glazes that are out there that are very, very simple to use, take you about, you know, a couple seconds to spray on the glaze and you’re good to go. So, you know, you, you’re able to do these, uh, with a little bit of practice, um, without too much trouble. So, yeah, it is scary, but, um, you know, we all are pretty good with our hands, and like I said, the other opportunity too, is if you’ve got a, a talented dental assistant in the office, a lot of times, uh, your assistants can be, can be trained up to be very, very good at doing stain and glaze as well. So, I wouldn’t that scare you. It is, it is one, whenever I, um, you know, get feedback from new users, that’s one of the things they’re always seem to be nervous about or having trouble with, is the stain and glaze part of it, but after you’ve done, you know, 100 units or so, it becomes second nature, it really isn’t that hard to do. We do much more difficult stuff every day with general dentistry. 

Howard Farran:  So, so you and I are different schools of camp because, um, I figured, you know, my, my first, you know, decade or so I sent a rubber impression to the lab, so they did all that. 

Mike Kelliher:  Yep, right.

Howard Farran:  And so when I brought in CAD-CAM, I, I had my four assistants – Jan, Yoni, Millie, Christina, um, they do it all. So, you say the difference between me and you, you just enjoy doing that more…

Mike Kelliher:  Yeah.

Howard Farran: …and I just, uh…

Mike Kelliher:  Yeah, I mean, it’s, it’s, that’s the nice thing about this. You know, whatever fits into your practice style, you know, everyone’s going to have a little different take on things in terms of how you, uh, incorporate this kind of technology into your practice, so for me, I like to do the stain and glaze, it takes me just a couple of minutes to do. Other guys, eh, they just as soon let the assistant do it, they, you know, they’re time they can be off doing something else that they’d rather do more productive, um, so you can, you can kind of do however you, uh, works best for you in your practice. 

Howard Farran:  Okay, more, more, more specifics from you. So, you personally, not your hygienist, how many chairs does Mike work?

Mike Kelliher:  I just work a single chair. You know, I only…

Howard Farran:  You only work a single chair.

Mike Kelliher:  A single chair.

Howard Farran:  So, if I, um, I, I’ve actually…(laughs)…I’ve had two crowns this year, and you’re not going to believe this story…

Mike Kelliher:  Yeah.

Howard Farran: ...I shouldn’t even tell this because no one will believe it. I went to my favorite restaurant, ordered the salmon with, and it has peppercorn on it.

Mike Kelliher:  Yeah, okay.

Howard Farran:  Bit down on a peppercorn and MOD – boom.  

Mike Kelliher:  Yep.

Howard Farran:  Same restaurant, same dish a month later, same peppercorn, another molar, boom, okay?

Mike Kelliher:  Oh my.

Howard Farran:   So, so um, so now I’m ordering without peppercorn, I’ve learned that, but so…

Mike Kelliher:  I would guess.

Howard Farran:  So, if I, if I was scheduled with Mike, uh, I busted, I had an MOD busted off a cusp…

Mike Kelliher:  Yep.

Howard Farran:  I’m coming in for a crown, how much time would you schedule me, and walk it, walk the 90% of dentists who aren’t in CAD-CAM, um…

Mike Kelliher:  Yeah, so…

Howard Farran:  How long did you used to schedule that person in a chair when you took a polyether, polyvinyl versus now?

Mike Kelliher:  Yeah, I mean, typically what I used to do was to schedule for a 9, 90-minute crown prep, impression, temporary visit, and then for 30 minutes for the insert, uh, you know, for a couple weeks later. Um, now what I’d do is…

Howard Farran:  For two hours.

Mike Kelliher:  Yes, two hours. Now, I’ll still schedule for two hours, but it’s all in one visit, and most times I’m probably done in about an hour and 45 minutes, uh, you know, between an hour and a half, hour and 45 is my average time for CAD-CAM restoration, and what we’ll do is, you know, we have, uh, your patient will come in, anesthetize them like normal, um, we’ll go ahead and…

Howard Farran:  What are you anesthetizing with? Lidocaine, Septocaine?

Mike Kelliher:  Sep, Septocaine most of the time.

Howard Farran:  Okay. What percent of the time is Septocaine?

Mike Kelliher:  Eh, probably about 90% of the time. Basically, the only time I’ll use something else…other would be is if I have a patient maybe with, uh, a uh, a sensitivity to epinephrine, uh, or if it’s a very short procedure and I don’t’ want to, I’ll use something with no epinephrine just to, so they won’t be numb as long, but the Septocaine’s worked really well for us, so we use…

Howard Farran:  Okay, so you’re going to numb with Septocaine…

Mike Kelliher:  Yep.

Howard Farran: …then you’re going to prep?

Mike Kelliher:  Uh, well, first, while they’re anesthetizing, we’ll go ahead and pre-op scan the opposing arch, uh, if we’re going to, uh, copy the existing crown or tooth, we can go ahead and scan the pre-op of the prep tooth and be able to kind of clone that tooth onto the ______ (audio issues) designing ______ (audio issues) tooth and drop it right onto the prep later one, so we’ll get those scans done ahead of time, and then go ahead and do out preparation.

Howard Farran:  Okay.

Mike Kelliher:  Yep.

Howard Farran:  Okay, sorry to interrupt, but what percent…

Mike Kelliher:  No.

Howard Farran:  …what percent of the time are you going to clone the existing tooth, and what percent would you not, and what, what, what is your, what are you thinking – clone or not to clone?

Mike Kelliher:  Right. My, my, if…okay, so if I’m going to clone it, it would have to be that I like what’s already there. So if I have, uh, an existing crown or existing restoration that looks decent, that fits the occlusion properly, uh, has good anatomy, then I’ll go ahead and clone it. It’s probably a very small percentage of the time though because usually when we’re doing a crown, it’s a tooth that’s got a big old MODL amalgam that’s broken off a cuspid ______  (audio issues) existing partial dentures ______ (audio issues) with CAD-CAM same day is that you can take the existing tooth – if you’re going to make partial denture that’s fitting to an existing crown or a tooth, you can go ahead and clone that, and it’s the best way we’ve seen for making an existing partial fit a new crown, so that, that 100% of the time we’re going to clone. If we have some odd ball anatomy, a lot of rotations or missing, you know, teeth or something crazy that we, that the library teeth aren’t going to fit well to, we’ll clone that, as well. That’s a small _______, so most of the time, it’s quicker and easier to use the library teeth and, and go from there, and it will come out with a better result, so um…so, it’s a pretty small percent. And so once we have the, the um, the pre-op scans, then yeah, just go ahead and prep like usual. Um, I still use a two-cord technique for, for a tissue impaction…

Howard Farran:  Okay, I’m going to back you up on the prep, um, because , because my podcasts are downloaded at all age groups from dental students that are at school all around the world, so walk through your prep. Do you use a, a different burr to break contact? How many burrs do you use, and walk us through your prep.

Mike Kelliher:  Sure, I, I use primarily four burrs. Uh, what I’m going to do first is to do occlusal reduction with a…and I’m going to use…these are going to be all microcopy, one use, uh, diamonds that I’m going to use, so I’m going to use…

Howard Farran:  Microcopy?

Mike Kelliher:  Yep, microcopy, the single-use burrs. Uh, so I’m going to use a, a football-shaped diamond to reduce my occlusion initially.

Howard Farran:  Do you use depth guides?

Mike Kelliher:  No, I don’t actually, I’ve got a diff…well, um, so what I use to check my, my uh, depth is, um, I use something called a Prep check Common Sense Dental makes. It’s a little rubber, um, wing-shaped deal, and they come in three different sizes. There’s a 1-mm, 1.5, and a 2, and it’s got powder on it, and the green is the 1.5, which I’ll use, and once I’ve got my occlusal reduction established, you place one of those in between the teeth and have the patient tap on it. Any spots where you’re not reduced by 1.5, it’ll leave a little green powder on the tooth and you’d be able to just prep away that one spot, so it’s ______...

Howard Farran:  Nice, and who makes that?

Mike Kelliher:  That’s, uh, Common Sense Dental.

Howard Farran:  Commonsensedental.com. Okay, so you’re going to use a football, reduce a millimeter and a half…

Mike Kelliher:  A millimeter and a half is actually…

Howard Farran:  Before, before you break contact? 

Mike Kelliher:  Yep, before I break contact, I’ll do that, and then I’ll go ahead and, uh, and use a, uh, my modified shoulder burr, usually like a .18 modified shoulder burr, go around and, and get the buccal and the lingual ______...

Howard Farran:  A point, did you say, uh, .8, or 1.8?

Mike Kelliher:  .18.

Howard Farran:  .18. 

Mike Kelliher:  .18, yeah.

Howard Farran:  Okay.

Mike Kelliher:  Uh, and then I’ll go down and break through the contact with a thinner, maybe a flame-shaped burr to break contact, and um, go ahead, refine the preparation, uh, get, you know, once I’ve got contact broken and a rough shape done, I’ll place, uh, maybe a size  one ultra-detonated cord, uh, to get the tissue out of the way, I’ll finish my, my shaping with the, the course burr, and then, uh, I’ll take a fine modified shoulder burr, uh, and just, you know, refine the margins. It’s one thing that CAD-CAM preparations, the margins need to be nice and smooth. You can’t leave kind of rough, uh, margins with, with, uh, chips on the edges of them. It has to be nice and smooth because mill, the mill can only mill to a certain level with the burr. The burr size dictates how small. It can mill too severely and leave a lot of irregular margins, you’ll have troubles with marginal fits, so you’re got to just smooth that down real nice, round over all the line angles and, so that’ll be the preparation, step there, but that, I’ll spend a lot of time, I’m probably a little slow at preparation, uh, compared to some guys, but I want to make sure that prep looks really, really nice so that, you know, the lab just, either the lab or the mill is going to have an easy time with it. Um, so that will, will take a while, and that’s…right now with my restorations, that’s the only part that tends to vary, so of that, you know, hour and 45 minute visit, you know, what’s going to dictate whether that’s a short visit or a long visit is going to be that preparation stage, and if you’re chasing caries…

Howard Farran:  You said…

Mike Kelliher:  Yeah.

Howard Farran:  You said two-cord, but you only mention placing the one-cord. What else have you done?

Mike Kelliher:  Right, so after I finish the preparation, I’ll place a #2 cord for tissue retraction before scanning. 

Howard Farran:  Okay.

Mike Kelliher:  So we’ll place that…

Howard Farran:  And, and are you doing this with, uh, your naked eye or are you wearing magnification?

Mike Kelliher:  Oh, no…Yeah, no, I don’t do anything with my naked eyes anymore. It’s 4X loupes with a, with a light. 

Howard Farran:  4X.

Mike Kelliher:  I’ve got a SurgiTel…yep, 4X, uh SurgiTels and, uh, the LumaDent light switch I’ve been using the past couple of years, which I like a lot. Um…

Howard Farran:  LumaDent lights?

Mike Kelliher:  Yeah, yeah, LumaDent lights are awesome. Those, those are, they’re very…

Howard Farran:  Now, you been…you’ve been doing dentistry 21 years…how many years of that was Forex? Did you start loupes at 4X, or did you…

Mike Kelliher:  Oh no, I started at 2.5 probably…maybe 15 years ago. So, I practiced without loupes for maybe five or six years, and then I, then I started…I got my first pair at 5’s and quickly jumped from 2.5s up to, to the 4s that I have right now, and I can’t even do a hygiene check without loupes anymore, it’s just…

Howard Farran:  I know, I just go into…I go into office after office after office and…what percent of dentists would you say do not wear loupes?

Mike Kelliher:  Geez, I, you know, I would hope it would be close to zero, but I’m guessing it’s not. (Laughs)

Howard Farran:  Oh my gosh, it’s just, it’s…yeah.

Mike Kelliher:  Yeah.

Howard Farran:  It’s hardly used. And then another thing that’s, that’s neat, that we’ve been doing this, uh, this many years is then seeing your prep. I mean, you’re watching 4Xs, but then you see your prep on a screen and you’re like…

Mike Kelliher:  Yep.

Howard Farran:  I, I remember when I first started seeing my preps on my screen, I was like, I was like, I sucked. 

Mike Kelliher:  Yeah.

Howard Farran:  Do you, do you remember that experience?

Mike Kelliher:  I absolutely do, and it’s one of those, those ah-ha moments where you look at it and say, Oh my gosh, I, I can do a lot better, and like I said, every time, well, when I went from…and they say, Well, you’re going to get this magnification, it’ll help you get better. What they don’t tell you is it’s going to slow you down a lot a little bit, too, because you’re going to see things you didn’t see before, and you’re going to spend time trying to perfect what you weren’t perfecting before, so…

Howard Farran:  And, and I’ve always wondered, I’ve always wondered how big, I mean, I know…I use 3.5 loupes, but how many X do you think we’re looking at on that screen?

Mike Kelliher:  Oh, it’s got to be 20 or 30X by the time you…because, I mean, you’re scrolling in and really, you’re marking your margins, you’re scrolling and blowing that up really big, so you’re taking it way, way up in magnification, so you’re seeing a lot. And it’s, it’s humbling. At first, you start looking, like you said, you look at your preparation and you say, Oh my gosh, my margins could be a lot smoother than that, uh, so it’ll force you to kind of slow down and take your time and make sure that’s done correctly, but that’s better. I mean, you’re doing a better job.

Howard Farran:  Okay, so…okay, so you’re done prepping with your diamonds, you’ve ______ cord…

Mike Kelliher:  Yeah.

Howard Farran: …um, do you go in there with a, say a Sof-Lex disk or…do you…

Mike Kelliher:  Yeah, a lot of times I will, you know, if there are adjacent restorations, I’ll, you know, go ahead and disclose adjacent restorations, make sure they’re nice and smooth. Uh, you know, if I’ve got maybe some, you know, undercuts or something on the adjacent teeth, I’ll…you know, you’ll take…you got a couple of minutes when you’re in there with that cord, so yeah, very often I’ll take some Sof-Lex disks and just polish down the adjacent teeth and make sure there aren’t any rough, ragged spots that, that need to be smoothed out, because you, you want nice, smooth margins, and you would have done that with any, whether you’re doing CAD-CAM or whether you’re doing traditional dentistry with that. 

Howard Farran:  And so, now, you’re going to optically scan. 

Mike Kelliher:  Yep.

Howard Farran:  And then…so keep going.

Mike Kelliher:  Yeah, so I optically scan the case, and probably for your average, uh, you know, uh, single unit case, that’s probably takes about a minute and a half to optically scan and get, you know, you’re going to scan the, the preparation tooth and a neighbor or two on either side just for the system to get the occlusion, about a minute and a half of scanning time to get up all that, that information, and so you scan the prep side and then, um, you’ll do a buccal bite from there. Basically, what a buccal bite means is you’ve got…you’ve already got the opposing arch scanned and pre-oped, you’ll scan the, the uh, the prep side, uh, during that, the next step, and then, uh, to get the articulation, you know, the patient, you know, bite down, and you’ll scan basically a digital scan of the teeth interdigitated, and the software uses that to line up the upper and lower modeling, give you the, um, the articulation. So, you get that done and , um, you know, from there you’re just going on to design…you’ll go on to mark your margins, uh, which again, you can zoom in and really look close with the E4D. We have a, a version of the model that’s called Ice, which is basically a real high-res black and white version, so you can really see the, the edge of the margin, and you’ll go ahead and mark that, uh, with a little tracing tool. And from there, it’s just a matter of, uh…

Howard Farran:  You’re mark…you’re marking the prep with that.

Mike Kelliher:  Yeah, prep, prep is marked in, and usually…

Howard Farran:  Before, before you optically scan.

Mike Kelliher:  No, no, no, no, marking…after your optical scans are done, that’s…you’re going to…just to mark the margin for the software. 

Howard Farran:  Oh, okay.

Mike Kelliher:  Yeah, so you mark the margins and, uh, you also want to set an orientation. Basically, the, the way these systems work is they have a library-shape of teeth for, for the different, uh, you know, tooth positions, and what happens is that based on the orientation of the model, like how you scanned it, it’s going to drop that, that model of the, the uh, the library tooth on top of your preparation model, so you’re going to orient the model so it matches up to the, um, to the library tooth so that everything aligns up properly, uh, and then you go ahead and drop it in. The software will then kind of give you a proposal design, and it’d probably take me about two, two to three minutes usually to take the computer’s proposal and modify that, get the contacts, the, the occlusion and everything proper, check the material thickness – which is another nice thing with the, um, the CAD-CAM is you’re going to check your material thickness before you mill, so you know right away if you’ve got enough space, uh, enough proper thickness for strength of the material. So, one thing I think most dentists…typically will under-reduce a lot of preparations, and you find that out pretty quick when you start doing CAD-CAM because now, the mistakes that your lab technician was covering for you with, uh, you know, in trying to have to make a restoration that fits into, you know, .8 mm when he really needs 1 mm or, you know, a millimeter and a half, you now have to deal with that. So, you do that enough times and you’re going to say, Well, wait a second – I’m not…that’s hard work having to make that restoration fit. I’m going to give myself enough reduction so I don’t have to do that again. So, uh, you know, you go ahead and do that, the design. The design is fairly quick, um, and then a crown will get sent, the proposal gets sent off to the milling unit through Wi-Fi, and it takes about 10 or 15 minutes to mill out the restoration from the e-max block. Uh..

Howard Farran:  So, you’re going to, you’re going to take a shade…

Mike Kelliher:  Yep, take a shade…

Howard Farran:  And how many, how many, how many shades of blocks do you have in your office?

Mike Kelliher:  We basically, oh, we have…it’s the entire Vita range basically, all the As, Bs, and Cs and D’s, a couple bleach shades, and different translucencies – you’ve got low translucency and high translucency depending upon the prep style you use…

Howard Farran:  So, it’s…you have only e-max blocks? Or…

Mike Kelliher:  We have e-max and we also have some, we have the Empress blocks; well, I use Empress a lot in the anterior. Empress is a really nice material for that anterior.

Howard Farran:  Now, e-ma…e-max is, um, also um, Ivoclar.

Mike Kelliher:  Yep, Ivoclar…yeah, e-max and Empress ______...

Howard Farran:  So, ______ and…I, Williams, Ivoclar, e-max, and Empress.

Mike Kelliher:  Yep, and Empress, yep. And occasionally I’ll use, uh, some Lava Ultimate, the 3M product, but only for onlays and stuff like that. I won’t use that for full crowns quite yet.

Howard Farran:  And why is that?

Mike Kelliher:  Uh, there’s been some issues, a lot of reports of debonding, uh, with the, uh, the 3M Lava Ultimate. It’s a, it’s a, it’s really a composite resin on a stick. It’s basically a Filtek Supreme is what it is, but it’s on a stick. There’s a lot of flex to it, or a reasonable amount of flex to it, which is good and bad, and the bad of the flex unfortunately is that if you put that in a full crown situation and put enough cycles of compression on that, uh, eventually that’s going to flex the bond and you’re going to…you’re seeing some debonds as a result. So, except for onlays and inlays, it seems to work well because it doesn’t come under a complete flex. You have the tooth in there, as well, a lot of tooth structure, and those seem to be holding up very, very well, but for, um, for full crown, full coverage crowns, I’ve heard enough stories of people having issues with the bond failing that I’m going to hold off on that for now, and e-max is a good material, too. The nice advantage to Lava though is you don’t have to fire it and you don’t have to stain and glaze it, it’s just, you just polish it right out of the middle so it’s a quicker process. So, uh, you know, there’s definitely advantages there, but uh, for me, full crowns – eh, still not quite there with that yet. But, for onlays ______...

Howard Farran:  And walk out listener through, when are you going with Empress versus e-max?

Mike Kelliher:  Yeah, Empress I, I like to use if it’s in the anterior because, uh, one, the Empress, they have the Empress multi-block which is a, you know, we talk about these mono…these are monolithic restorations, so it’s one shade of material for the most part with e-max, but they do have an Empress multi-block that actually has different, uh, translucencies built right into the block, so you’re actually able to, in the software, position, uh, where you want to cut that restoration out of the block so if you want more or less translucency, you can move the restoration within the block, and then that restoration’s going to have some built-in translucency, uh, towards the incisor ledge if you like it there, and also a gradation of color as you move from the gingival up to the incisal. So, for an anterior restoration, I think it gives you a better, a little better aesthetic. It’s not a strong, but it’s a material I’ve used in the anterior for a lot of years, a lot of good results, so…

Howard Farran:  So, give, give me some percentages. If it was a woman, um, four maxillary incisors…

Mike Kelliher:  Yep.

Howard Farran: …what percent of it would be Empress…

Mike Kelliher:  That would be 100% Empress multi-block for, for, for four anterior crowns, I’d use Empress every time. Unless I had really dark preparations I was trying to block out, in which case I would go with e-max, so with the LT e-max because that can block out a, say it’s an endo tooth in there that was discolored, then you’d have to use the, um, the e-max with that. But, it’s…

Howard Farran:  Okay, I want, I want to change gears now because I only have the luxury of you for five more minutes. 

Mike Kelliher:  Okay.

Howard Farran:  Um, so, you and I are both big CAD-CAM fans, big time…

Mike Kelliher:  Yep.

Howard Farran: …um, nine out of ten dentists in America don’t have one…

Mike Kelliher:  Right.

Howard Farran: …and uh, and of the two million dentists around the world, it’d probably be 99% of the two million don’t have one.

Mike Kelliher:  Probably.

Howard Farran:  So, so you’ve got, you’ve got four and a half minutes, tell them why they should go CAD-CAM.

Mike Kelliher:  (Laughs) Well, I think number one is that you, you bring control of the restorative process into the office. Uh, you’re able to, to get everything done in that one visit, you control the quality of the margin, you control the quality of the, the shape and, uh, the aesthetic of the restoration. Uh, it’ll allow you to do everything, uh, in one visit, which your patients are going to like and awful lot. Uh, they don’t like to have temporaries, they don’t like to have to come back for a second visit and get numbed up a second time. So, it’s a plus there. And you’re going to save money, uh, in terms of your laboratory costs. It’s just, there’s no two ways about that. Uh, another thing…

Howard Farran:  And does, does, does the saved laboratory costs make up for the payment on a, on a 60-month, uh, payment plan…

Mike Kelliher:  Yeah, a…

Howard Farran: …on a CAD-CAM?

Mike Kelliher:  For our office, it was a, yeah, easily. With three dentists, it wasn’t even a close call. Uh, for ever for a single dentist’s office, I think for the most part you’re going to see that savings. Uh, you know, it all depends on how many units of crown and bridges you’re doing a month that you’re going to be able to do with your CAD-CAM, what your laboratory cost was, you know, you’d have to sit down, every body’s individually going to have to look at that, those numbers, but I think on average for most practices, that you’re going to see that, that breakeven point, is going to be attainable. Um, you know, there is some changes to how you’ll practice, but you know, it’s a lot of fun. I mean, it does add something new to the practice. It gives you, uh, you know, it gets routine after a while. You know, you don’t want to be doing the exact same thing for your entire, entire career. It also is a nice thing for your staff. It gives them something new to do, as well. Uh, it energizes them, you can, you know, kind of give them some, some new tasks and empower them to expand their skill sets as well, which I think is really helpful if you want to have long term staff. Um, also it allows you to do things that you couldn’t do before. You have that patient, you know, that’s getting the…for us, the college kid’s heading back to school. Every, every year it seems like you have at least one or two of these college kids that had an endo in July, shows up in your office in August and says, Oh, now I need that crown on that endo tooth. In the past, that was a real pain in the neck. You’d have to temporize them and then hopefully get them back when they’re on break at some point and get their final crown in and hope they don’t lose a temporary while they’re at school. You’re able to get that restoration done right away for that patient. The patient walks in, you know, broken tooth and you’ve got an opening in your schedule, you just, you know, okay, boom, we’re going to go ahead and do a crown and get that done for you all in one visit. Uh, they, they really do enjoy having that, so it, it does, uh, it does change the way you practice. It adds a lot of capability to your practice, uh, so I, I think that it’s something that, you know, I know the big scare for most dentists is the cost, but believe me, that, that is, you know, you…

Howard Farran:  Well, I want to, I want to, I want to say one thing. 

Mike Kelliher:  Yeah.

Howard Farran:  You know, the cost on a balance sheet, yeah, you bought a big thing. 

Mike Kelliher:  Yeah, yeah.

Howard Farran:  But, on a statement of cash flow, if you’re already paying out $5,000 for a lab and now you’re just paying less money to a la…

Mike Kelliher:  And that…

Howard Farran:  But, but, but I want to…address another complaint. Um, I don’t trust those all-ceramics. I, I do gold or porcelain fused to precious or porcelain fused to semi-precious…

Mike Kelliher:  Uh-huh, right.

Howard Farran: …and these yahoos doing all porcelain like Mike and Howard, they’re crazy.

Mike Kelliher:  Well, I mean, that was, that was initially my whole back on CAD-CAM, too, was the materials, but I’ll tell you right now, we, I’ve had and we’ve had the restor…the CAD-CAM in for five years right now – I’ve had two e-max’s fracture in that time, and both of them were, were teeth early on that I designed a little bit too thin, and I had done and endo through. Those are the only two fractures I’ve had. The monolithic restorations, the e-max, you’re look at about,  you know, uh, strength in the 400 megapascals strength range right now. That’s really, really strong. When you’re looking at a PFN crown, that, the weak link on a PFM crown, which people will have no problem using, that’s 160 megapascals strength on the veneering porcelain of a PFM crown, and people don’t seem to have any concerns about using PFM crowns in the posterior. You’re using a much stronger restoration with a monolithic e-max, it’s just a better mousetrap. I place them routinely, second molar, you know, not a problem at all, and uh, it’s not just me. You can, you know, a lot of CAD-CAM users on Dental Town.

Howard Farran:  It is, it is, it is, they have to be reprogrammed because back in the day when I, when I got out of school in the ‘80s…

Mike Kelliher:  Yep.

Howard Farran: …you put an all-porcelain crown on a second molar, and…remember when ______ came out and it was all porcelain crowns, I mean…

Mike Kelliher:  Right.

Howard Farran: …it was bad news.

Mike Kelliher:  Right. 

Howard Farran:  So, it’s hard to unlearn those early…

Mike Kelliher:  Sure.

Howard Farran: …initial traumas that now, it just, it doesn’t even seem, it doesn’t even seem realistic that there are all-tooth-colored materials that you really can’t break. I, I’ve seen dentists on YouTube hammering them into a 2X4.

Mike Kelliher:  Yep. Oh yeah, no, you’ll see them running them over with cars and all kinds of crazy stuff. But, the proof is in, you know, like I said, five years right now of using the material and I’m seeing far less fracture with, with uh, monolithic e-max than I ever saw with PFM. Um, you know, to the point where, I mean, you, one ______ restoration I used to see a lot of fracture with, with PFM was implant restorations. Implant restorations that have no, no give to them, so they’re more, more likely to fracture. You put e-max on top of an implant and you have a much lower fracture rate than you do with PFMs, so it, it’s a…

Howard Farran:  And I, and I just want to end with one bizarre thing. All mine in my mouth are gold. 

Mike Kelliher:  Yeah.

Howard Farran:  And um, I um, I’m, nobody wants gold. They, they hang it on their ears, their wedding rings, their nose, their belly button, ankle bracelets…

Mike Kelliher:  Yep.

Howard Farran: …but man, people just won’t put gold in their mouth.

Mike Kelliher:  No, no, absolutely not. But, you know, that’s, that’s, uh…we…

Howard Farran:  Culture.

Mike Kelliher:  It’s culture and thankfully we have materials now that we can give them tooth-colored restoration, and if you’ve got a patient who you’ve got space issues with, zirconia’s a great option as well. So, if you’ve maybe got that second molar where you can’t get a millimeter and half of reduction, you can go about a half a millimeter with zirconia and, uh, I wouldn’t mess around with zirconia in the office, but you can certainly sent that off to laboratory and they can produce that for you, and that’s a very inexpensive restoration, as well. 

Howard Farran:  Well Mike, we are out of time. 

Mike Kelliher:  Okay.

Howard Farran:  And, uh, thank you so…are you sitting outside?

Mike Kelliher:  I’m outside.  I’m on my deck right now.

Howard Farran:  Wow. I’m looking at my background and, uh, Brady, I’m looking at my background and I’m looking at his background and it’s like, I’m going to do my next podcast outside. That, that’s amazing. 

Mike Kelliher:  Yeah.

Howard Farran:  But hey, thank you for all the countless volunteer hours you’ve done on Dental Town over the years…

Mike Kelliher:  No…

Howard Farran: …moderating the forums, sharing posting, uh, thank you so much for all you’ve done for dentistry and for Dental Town, it was an awesome, amazing hour. Thank you, Mike.

Mike Kelliher:  It was great, and thanks for having me. I appreciate it, and thanks for all you do. I mean, it’s…your site that set this stuff off, and I’ve, I’ve probably taken a lot more than I’ve given back over the year from Dental Town, so I appreciate it.

Howard Farran:  Ah, thanks buddy. Okay, if you’re ever in Phoenix, stop by, and if I’m ever in Massachusetts…

Mike Kelliher:  Definitely.

Howard Farran: …I’ll call you.

Mike Kelliher:  Definitely. Alright, good to see you.

Howard Farran:  Okay, good to see you.

Mike Kelliher:  Bye-bye. Alright.