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Howard:
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It is a huge, huge honor today to be podcast interviewing Dr. Edward Feinberg, DMD in Scarsdale, New York. Is that up by Syracuse or Albany?
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Edward:
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We’re 17 miles north of New York City.
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Howard:
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It’s really a suburb in New York City.
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Edward:
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Yeah.
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Howard:
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You got a long bio and I want to read every word of it. First of all, Dr. Edward Feinberg is a graduate at Tufts University. That’s in Boston, right?
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Edward:
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Correct.
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Howard:
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And has practiced dentistry in Scarsdale, New York for more than 35 years, is a successor to a unique tradition of restorative dentistry and was trained by a master and pioneer in full coverage restorative dentistry, Dr. Elliot Feinberg, who is his father. The techniques used by Dr. Feinberg have documented clinical evidence and a library of 100,000 pictures taken during the past 66 years. Dr. Feinberg is a nationally recognized lecturer and a noted author of scientific and educational articles for dental publications and a textbook, an amazing textbook, The Double Tilt Precision Attachment Case for Natural Teeth and Implants available on his website, www.edwardfeinbergdmd.com.
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He is also a reviewer for the Journal of Oral Implantology. In addition to educational activities, Dr. Feinberg has also served on four councils of the American Dental Association and is a past president of the Ninth District Dental Association, a component of the New York State Dental Association with 1,600 members. Dr. Feinberg is a recipient of the Ninth District Dental Association, D. Austin Sniffen Award, the Paul Harris Fellowship Award and the New York State Pierre Fauchard Academy’s Award for Distinguished Service. The Americans all think that G.V. Black is the father of dentistry but the French would tell you that 100 years before him was Pierre Fauchard.
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I want to read about your book first because this is really an amazing book. Title of the book is The Double Tilt Precision Attachment Case for Natural Teeth and Implants, a Time Tested Alternative to Fixed Bridgework. I’m guessing 99% of the dentists listening to this don’t even know what a double tilt precision attachment case is. That’s why I’m so honored that you came on the show to talk about it. This book is designed to provide instruction on the philosophical basis for the precision attachment case as well as clinical technique. It presents all of elements that are required for health longevity and supported with numerous case examples documented with X-rays during the past 64 years. All the cases were prepared in the same manner even though different materials were used. This range of documentation is an extreme rarity in the dental profession. What’s rare still is the inclusion of precision attachment cases fabricated on implant abutments during the last 20 years. The ideas outlined in this book should challenge the reader to adopt an entirely new paradigm of thinking. Practitioners and patients alike have been conditioned to think that fixed restorations are always better than removables and the decision to create fixed bridgework cases often have more to do with emotion than reason.
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The precision attachment apparatus consist of a male and a female. Any male fits any female with equal precision to .0001 tolerance. There is no locking, gripping or clasping mechanism. Retention is achieved with a double tilt. The case is surveyed with two tilts so that the direction of insertion and withdrawal is different from the pull of musculature and gravity. If stress is applied to the removable, it can move slightly to relieve the stress but it cannot be dislodged. Destructive forces are dissipated instead of being transferred to the abutment teeth. The result is that the double tilt precision attachment case works on some of the weakest teeth imaginable.
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Clinical examination and X-ray evaluation of patients during the last six decades clearly demonstrate that the double tilt precision attachment cases created according to the procedures outlined in this book generally last longer than the fixed bridgework cases. As a restorative choice, the double tilt precision attachment case is the equal of fixed bridgework on implants and it should be presented as such. In many cases where implants have a poor prognosis, for example, the double tilt precision attachment case is really the superior option.
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The double tilt precision attachment case requires minimal maintenance, occasional realigns and no paste is required. It is rare to replace the metal component of the attachment even after two decades of continuous 24-hour a day of function. After all that, my first question is going to be what the heck is a double tilt precision attachment for natural teeth and implants? What are you talking about? I know that’s what my homies are thinking.
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Edward:
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The precision attachment itself is a male and a female and there’s no retentive mechanism at all with it. The double tilt is the angle of how you take the partial in and out. It’s tilted in two directions and this tilt is different from the pull of the muscles and gravity. If a stress is applied to the removable, it can move slightly to relieve the stress but it can’t come out. There’s a little trick to teaching patients on how to take these cases in and out. This whole concept was invented in 1906 by this guy, Chayes. Nobody listened to him so he jumped out the window and killed himself.
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Howard:
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Are you serious?
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Edward:
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I’m serious. Dentistry has a really amazing history.
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Howard:
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Where was he living? What part of the world?
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Edward:
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I think he was an American but I don't know much about him and his history. Then, the real history begins in the early ‘20s when the Sterngold Company patented the number 7 attachment which it was basically a male and a female. That whole concept was applied very early in dentistry’s history because my dad got this from his teacher, Dr. I. Franklin Miller. That’s where this came from. It goes all the way back to then. The earliest case that was done in our office was done in 1950 by my dad. That case lasted 31 years. The males were never changed.
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A lot of modern attachment components, you have to keep changing different components like vinyl sleeves and things like that. With this concept, there is practically very little maintenance except occasional realigns of the partial. That’s really the only maintenance in addition to hygiene. That’s really the only maintenance even after decades of continuous wear because the patients are instructed to keep the partial in all 24 hours a day and only remove it when they brush their teeth. It’s pretty cool.
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Howard:
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It is very cool. I hope that someday, you create an online CE course on this so everybody listening can see it. On Dentaltown, we put up 350 courses and they’ve been viewed over half a million times from every single country on earth. Looking at all the pictures in your book and all this, listening to it on a podcast is good but I think seeing an online CE course, it would be better. I think reading your book would be the best. How much is your book on your website?
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Edward:
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It’s around 200, I think 225, something like that. I don’t remember the exact fee. Believe it or not, I don’t remember.
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Howard:
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What’s crazy is they don’t blink at buying $250 roundtrip airline tickets to go to some course but then when they see a dental book for 250, a lot of them will balk at that. That is absolutely the lowest cost way to learn the most information. Even if you were going to see a course, like I remember before I went and saw Carl Misch, the first thing I did is read his book A to Z so you get the first round in the book. You can go back, whatever, so that when you went to the lecture, you would learn so much. Reading books is still the street smart way to learn the best dentistry. The most expensive way is flying across these countries and staying in resorts to go to these institutes.
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Edward:
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Also, it takes time to absorb these concepts. You're right, even just attending a course, you wouldn’t necessarily get everything all in that course. The book helps reinforce it and something that you could continually refer to. It’s very interesting. My dad, we gave courses here. He gave demonstration courses on patients for 40 years in this office. I sat in in a lot of the courses that he gave. Typically, he would take a patient and he would prepare teeth for fixed bridgework. That was one of the courses, and show every step on a patient to about 10, 12 doctors in about seven sessions. He also gave a precision attachment course and did the same thing.
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I was here every day and I learned something every single time because there was always something that I missed. I would say to my dad, “Hey, dad. Why didn’t you tell me this and such? I’m here every day.” That’s what I got from him. I know how hard it is to absorb everything especially when it’s a new concept and you're not familiar with it. It takes time and study in order to really grasp it.
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Howard:
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That is so cool. How many children did your dad have and how many of them became dentists?
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Edward:
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I have one sister who lives in Arizona.
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Howard:
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Really?
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Edward:
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She’s not a dentist. I was just out there to visit her.
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Howard:
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Where does she live in Arizona?
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Edward:
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She lives in Scottsdale.
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Howard:
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Next time you come by, you got to tell me. We’ll do dinner here. You can come by.
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Edward:
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I would love to do that. That would be great.
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Howard:
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I would love it. I’m in actual Phoenix but everybody down here calls it Ahwatukee because it was annexed by Phoenix. When they annexed Ahwatukee … It’s the southernmost part. When you go to the airport, there’s a big South Mountain Preserve south of it and Ahwatukee is the section of Phoenix … It’s about 10% of Phoenix south of the mountain and that’s where my dental office is, my home is, Ahwatukee but yeah.
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If you’re ever doing dentistry on your sister but you just need some … like you do it all or whatever or you need a dental office or you want to adjust something, come by. A lot of dentists say, “But I’m not licensed in Arizona.” I tell them these laws are just suggestions. They’re not real. They’re just suggestions. What do you think the state is of removable? Do you think because of implants, do you see removable declining? How has implants changed precision attachments, removables in your career?
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Edward:
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I think it's a misconception to think that implants can do everything or any one particular treatment option can do everything. I think that there are many places where you can't put implants in and patients who have all the financial means can’t have implants if there's not enough bone to put good implants in. I feel strongly that if you can't put good implants in, they shouldn't be done. The precision attachment case gives those patients an option to have the full arch reconstruction without putting implants in areas where they're likely to fail. I’ve been using implants with precision attachment case and I think it's a great combination because by doing that, I avoid all the bad anatomy, I don't have to get involved with sinus lift surgery and the most predictable place to place implants is in the anterior region of the mouth usually.
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Also, the patients can bite into anything because they have fixed bridgework in the front so there's also no anterior posterior tipping forces that's common with overdentures. I think too with removables, most of the concept comes from dentures. When they do implants, the whole concept of screwing a denture in where really, implants, it's more akin to fixed bridgework and fixed bridgework procedures. I don’t view the implant abutments as being different from the natural tooth abutments or where they should be treated differently because in a lot of cases, the implant abutments are actually stronger than a natural tooth abutments that support precision attachment cases for decades.
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Howard:
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I always also think that one of the errors that the young dentists have that they slowly lose over 20, 30 years is they think treatment planning a removable would be crazy because they're thinking for themselves, they would want all fixed and they think that the consumer, the patient, the customer would not want anything removable. The truth of the matter is I'm out here in Phoenix with a lot of retirees. I can't tell you how many people who have full dentures in my practice come in and we talk about implants. They say, “Well, I don't have any problems with my denture,” or they’ll have partial. I say, “Well, does it bother you that your partials come in or out?” They’re like, “No.” I think there seem to be a young dentist bias to treatment plan all fixed because in their own noodle, in their own mouth, in their own walnut, they’re thinking I wouldn't want removable. What do you think of the patient satisfaction of removable?
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Edward:
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I think it puts well, a precision attachment case you can't compare to any other kind of removable. It's a very high satisfaction rate. When you present all the facts to a patient and you let them choose, you’d be surprised a lot of them choose the removable. What I always do is, because if a patient never wore a removable before, you don't want to just start out and make them a permanent case without them experiencing what a removable is like. I will always incorporate some kind of temporary removable in the treatment plan.
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Let's say I've had a couple of patients who said, “You know what, I don't like the idea of a removable and I'd like to change the treatment plan.” I could do that. Everything is step-by-step all down the line so that I'm not going to have an unhappy patient or somebody who had unrealistic expectations about what a removable is. The best removable there is, is the precision attachment partial denture. That's the double tilt precision attachment case.
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Howard:
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You're just saying that because that’s your book.
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Edward:
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You see, the problem is that the clasps and all of the other types of attachments are usually locking mechanisms that grip the abutments. These pass along destructive forces. Teeth could take vertical forces but they can't take lateral forces so they function laterally whereas the double tilt precision attachment case first functions vertically. The destructive forces are dissipated. I can show so many cases where you have very weak natural tooth abutments and it supported this removable partial denture for many years. You ask yourself how could this possibly work and yet it does. I think that has a great deal to do with it.
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Howard:
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How could I bribe you to make an online CE course on this for Dentaltown?
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Edward:
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You don’t have to bribe me. I’ll be glad to do it. I’d be happy to do it.
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Howard:
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I’ll give you my son if that's what it takes. Ryan’s sitting right here next to me.
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Edward:
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That’s great. I worked with my dad and it was a fabulous relationship. We had a great relationship. I’ve been actually working in this office since I'm 16. My dad and I practiced together as dentists for 23 years. I think it's great that you're with your son. I think it’s special.
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Howard:
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Ryan, you got to stay at least 23 years. You got to beat Edward here. You can’t let him win the battle, Ryan. You got to beat him. In fact, we can also do something. I think it’d be almost like an introductory to your book. I hope this is an introductory for everyone listening, an introductory to your book because this is a great service and also, General Motors has a high-end Cadillac. Save a little money, get a Buick, a little more money, Olds, a little more, a Pontiac, save the most, a Chevy. These double tilt precision attachment removable cases are significantly less than going to ClearChoice and paying $25,000 an arch for all-on-four, correct?
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Edward:
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That’s absolutely correct. That's correct. Some things about all-on-four cases that worry me is that some of the implants are put in on angle and are being asked to absorb all these forces and how that's going to hold over time and what percentage will hold up over time, I don't know. I've had a chance to see how these cases hold up over decades and the precision attachment cases hold up on the weakest teeth you could possibly imagine over decades. That concerns me. We've been doing implants here since the early ‘80s and I've seen them fail even after 20 years. I've seen cases last for 20 years and that was it. The implants went. Part of it was because of the type of implants that they used in that era but we don't know how things are going to work out.
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A lot of what's being done has to really conform to good principles in engineering because there are so many things that we don't know the answer to. Putting implants in that aren't long enough, that's the same thing as if you're building a building and you don't have the foundation that’s strong enough to support the building. That's exactly the same so that’s what worries me. If I could put three good implants in the anterior region and make a precision attachment case, I know that from an engineering standpoint, that's a really sound case that's going to last a long time.
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Howard:
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If you ask any economist, say what's the number one variable to trade, they would say price. You might say the best car in the world is a Mercedes but they’ll tell you you're going to sell a lot more Ford Tauruses than Mercedes just because of the price. What is the price difference between like a $25,000 all-on-four versus what you just said, three implants and a fixed precision attachment partial to fixed anterior? About what price range would that be?
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Edward:
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That would be less. I’d say we’re doing them here in conjunction with our surgeons for like about 20,000 to restore a whole arch but a lot of it depends on what materials you're using, what your overhead is so the price by itself can vary. It's the quality of how it's done that's really important and how likely it is to last. We're judged by patients. Sometimes, they want to compare us all. We’re all doing the same thing and they want to compare us all according to price. There's no doubt about that but really, they don't find out how good you are until at least five years. I mean anything less than that doesn't mean anything, I think.
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If let's say I have a patient and I have patients where these precision attachment cases were done and they have that case 30 years, that's the best investment that patient ever made and by far, the cheapest. I think that's an important consideration that patients should be thinking about. How long is this going to last? You can't guarantee anything but what percentage lasts? I could show those cases on some of the really weakest teeth ever imaginable and show how they lasted over 30 years with minimal changes in the X-rays. That's really unusual. I know when I present something to a patient, I'm really standing on solid ground with a real track record behind me.
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Howard:
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We’re talking about solid ground. In your experience of decades and 100,000 photos, do you think a lot of implants are failing more from engineering principles or from peri-implantitis?
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Edward:
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I think engineering principles. There are people who are just sticking them in all over the place and they're not correcting the things that are wrong. One of the signatures of a piecemeal approach to dentistry is the single tooth implant because I think a lot of dentists don't have confidence in their crown and bridge skills but they have a great deal of confidence in their implant skills. When they put these implants and they’re ignoring a lot of what's going on around this implant, you go to any implant lecture, you'll see that and you'll see everything falling apart around a single tooth implant.
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I've seen implants shear off below the bone level because destructive forces were being applied to them. I've seen other cases where the screws loosen all the time because lateral and destructive forces are continually being applied to these implants and that's why they loosen up. That's the reason. I think that a huge reason for failure is engineering considerations. You have to correct the bite. You have to make sure there's no neuromuscular problems that are going to interfere with the success of your case. Otherwise, you're just going to have major problems.
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Howard:
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You remind me so much of Carl Misch because the Carl Misch’s story was he started out as a prosthodontist making full dentures and he was seeing the other people doing these implant supported dentures. He saw the implants shearing off and he said these guys don't know anything about forces. They don't know anything about removable. They just think if they stick titanium in the jaw, they can put anything on top of it. He credits all his successes by mastering removable dentures first and then, adding implants to his curriculum instead of not understanding removable and just going into fixed implants.
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Edward:
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I think that's absolutely correct. A big problem is that people think that implants can solve every restorative problem, that they are panaceas but there really is no such thing as a panacea and there's no such thing as one size fits all. You really have to look at everything closely. I think if you can't put good long implants in, they shouldn't be done. When I send patients to my surgeon to be evaluated, I want to know if they could put good long ones in and if they can't, then I don't want them done. I know they're going to fail. I’ve seen a lot of implant failures. Most of them are for those reasons.
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Howard:
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For someone who’s been around the block with your father, a long career, it seems like the human condition is extremist like they'll just start learning implants so they'll never do a three-unit bridge again. Do you think the three-unit bridge is dead because there’s implants or do you think sometimes a three-unit bridge is a better scenario?
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Edward:
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I think without question, the three-unit bridge is a better scenario because what I just mentioned about the piecemeal approach to dentistry where somebody puts an implant in and the teeth all around the implant are failing or they have fillings and big crowns in them. If you know how to do good crown and bridge, you could do something good for the whole area with a fixed bridge that’s sound and that's going to solve that patient's problem for the whole area whereas a single tooth implant only fills a space. That's all it does. It doesn't address any of the other problems around it.
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I had one patient where he was seeing a dentist who believed in the implant theory of, “You know, when the teeth go, we’ll just put an implant in there.” That’s like supervised neglect. That assumes that that patient’s always going to be a candidate for implants and then, this patient is now 90 years old and can't have any more implant. What happens to that patient? That's not a fair way of looking at things. I think that's a bad concept or a bad model. There is no such thing as one size fits all. The perfect place for a single tooth implant is if you have a virginal mouth where the teeth are sound. You don't want to cut them down to make fixed bridgework but if they already have crowns and big fillings and they’re going to need crowns, it doesn't make sense to do implants. That patient would be better off with a fixed bridge.
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Howard:
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I want you to weigh in on this even though you'll be biased towards the dentist but I have a feeling you won't be biased because you've been around the block. I have talked to more than one ear, nose and throat or rhinologists tell me about this implant sinus lift nightmare and he’s saying, “I don't get it. All that dentist had to do … You already had two teeth there. All you had to do is put that missing two hooked onto those two adjacent teeth but they went in and they buried into my sinus and packed a [inaudible 00:25:54] bone and titanium and then, they're telling me that the complications …”
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Do you think that dentists are emotionally biased to save enamel because we're dentists and we don't give a crap about what the ear, nose and throat or the rhinologist has to deal with whereas an ear, nose and throat might be more emotionally biased to leave the sinus alone and you go work on other teeth? Do you think we're biased towards blow up the sinus and save the teeth because we’re dentists and ENTs are biased at, “Stay out of my sinus because I'm a rhinologist and you're a dentist”?
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Edward:
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I don't know if it’s that. I think that people end up focusing on some areas where they excel. For example, some people, if they could do great implants, the answer to everything becomes implants. The bonding people are that way. They could do great bonding. The answer to everything is bonding. The truth is that they all have limitations and the better you are … See, if you could do good fixed bridgework, if you could do good implants, if you could do good precision attachment case, you could do good bonding, you could pick what's right for each individual patients.
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For example, my mother gets sinus type migraine headaches. I don't want to do sinus lift surgery on her. She's already got lots of troubles. I would try to avoid that. I think too many dentists become emotional and put themselves, “Oh, I wouldn’t like to wear a removable so therefore, I don't want to recommend a removable for my patient or I don't have confidence in my removable because most patients don't like them because they move.”
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Then, they end up sticking their neck out to do these treatments which can be disasters or have disastrous results. I think you really have to really sit down and look at everything. If you have that patient who wants it and they're willing to go through all this stuff, I have no problem with that. It is their choice and my job is to give them choices and then help them pick what choice is best for them so I want them to have all the facts.
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Howard:
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My favorite Aristotle quote was it is the mark of an educated mind to be able to entertain a thought without accepting it and the condition of the human is an extremist and everyone, as they get older and wiser become a moderate. It’s either no three-unit bridge, all implants or just … I still don't understand what these dentists advertise on their website, they’re metal-free. What does that even mean that you have a metal-free practice? Do you fly in metal-free airplanes? Do you drive metal-free cars? Is your house void of metal? Why is metal all of a sudden bad? Then, you look in their office and they're using metal anyway but everything's all good.
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I want to open up a whole another can of worms. Mini implants, some people are using mini implants for removable attachments. What are your thoughts on that? Someone has a loose denture. They're putting four or five minis down there with O-rings. What do you think of minis? Do you think there's a place for them?
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Edward:
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I don't know. I think it’s experimental. I wouldn't stick my neck out to do things like that. I really would rather do something I can hang my hat on that has a track record and let other people do the experimentation with these things. That's my feeling.
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Howard:
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I want to ask another can of worms because you said the word neuromuscular twice. There are two camps in occlusion. One is you know Dawson-Pankey CR. There's another camp, neuromuscular and a very specific question that we get to this podcast is, “I'm out of school. I want to learn more about occlusion and these institutes are expensive like LVI and Kois and Spear and Scottsdale Center. They're all expensive,” but there's clearly neuromuscular occlusion camps and there's CR Pankey-Dawson. How would you answer that question? She can't afford to take both of these courses. Would you ever start CR or neuromuscular? The only reason I ask you is because you've used the word neuromuscular twice.
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Edward:
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I have to say I'm not an expert in all those areas. However, if you have a new patient and they come to you and you … I’ll take a full series of X-rays and study models and I look at the study models and if I see the midlines don't line up, if I see there's abnormal wear, if I see evidence of something going on, I want to know what caused that patient's problem. I put them very often on a diagnostic appliance which is nothing more than a Hawley bite plane with instructions that they are to wear it 24 hours a day. Eat with it, sleep with it because every time the teeth come together, the teeth send a message to the brain where the jaw should go. If that's not in harmony with the muscles, that's where all the destruction happens.
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The purpose of putting a diagnostic appliance is to eliminate those messages and let the muscles relax and tell the jaw where to go. After four to six weeks, I examine the patient and if the teeth come together in a different position. Then I know that the bite that the patient has is different from where the muscles are comfortable. Then, I can take some kind of a wax bite to put the models together and analyze what would have to be done to correct that patient's problem so that you eliminate all of their bruxism and the grinding and all of the destruction that's occurring.
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That's really how I do it. I got that from my father who got this from this Dr. Berliner who in the ‘60s wrote a whole textbook on the subject. I still think there's a lot that we really don't know about occlusion. When I restore a patient, I always think in terms of restoring them to an ideal occlusal plane to eliminate a lot of the lateral destructive forces. That's how I do it.
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Howard:
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Your book is 220 pages. How long do you think it would take a dentist to read that and comprehend that and get it? I mean is that a weekend read? How many hours do you think … I actually was curious about my book. I sat down and read my book. I mean the audiobook, it was five and a half hours. How long do you think it would take to read that, your book?
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Edward:
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I don't know. It depends on the level of knowledge that the dentist has and then also …
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Howard:
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[crosstalk 00:32:35]
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Edward:
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Yeah. I really don't know. Also, too there are a lot of new concepts that would be new to most practitioners and that sometimes takes time to absorb. You might have to read it more than once. I wrote this very carefully. There's a lot in it. All, everything that I said in it has meaning and is important. I know even from attending lectures and from reading myself that very often, you miss things on the first go around or maybe you're not attuned to what you're really reading so it doesn't register and you have to go back and re-read it in order to really fully comprehend it. Once you start doing a case, then some of the stuff takes on new meaning because you're more familiar with it.
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Howard:
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What advice would you give? The bottom line is you're on a podcast right now and only 5% of Americans have ever listened to a podcast and all the data shows they're all under 30. You're talking to a lot of people, probably 20% are probably juniors and seniors in dental school and the other 80% are probably been out of school five years. What advice would you give them? It's a very different environment than when you got out of school or think of when your father … When your father got out of dental school, they didn't even have dental insurance. I think the first dental insurance was 1948. When did your father start practicing?
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Edward:
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He started practicing in 1948.
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Howard:
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That was the first one. It was a New Jersey Longshore Islander’s dental insurance. Even when that came out, 99 % of Americans didn’t have it. Now, dental insurance became massive fee-for-service when you and I got out of school. Now, it's all changed to PPO. What advice would you give them? Do you think you can do this level of dentistry that you're talking about in a PPO practice?
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Edward:
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I think it can be done. I don't believe in that insurance should be dictating what we do. It’s not insurance even. In dentistry, it’s payment assistance. I think that's what the big problem is. It's like a big deception. The patients are all fooled into thinking that they have something that they really don't have but you have to sit down and talk to people. You're not going to reach everybody but you can reach some people who appreciate the big term picture and what they're going to get.
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Let's face it. You could live with dentures but is that good quality of life? I’d say the best quality of life is that you hold on to your teeth. Everything about what you do, you smile, you eat 24 hours a day, that's the best investment that you could make in yourself. We have to try to communicate that to people. I think they'll be happy to pay the extra cost in order to have the better work. There are lots of people who want good quality work and we're here to give it to them.
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Howard:
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What would you say to someone, they're graduating and they say, “Dr. Feinberg to graduate from dental school, we only had to do 15 units of removable and I want to learn more about removable from complete two partials to precision attachments”? What would you recommend to learn more about removable?
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Edward:
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Read my book. Also too, dental school can only give you a very rudimentary foundation. Everything I learned was after dental school. I had a great mentor. I would say attach yourself to a good mentor, somebody who’s doing really good top quality work in your area and see if you can befriend them and let them become a mentor to you, somebody you could go to and ask questions of, somebody who will help you, point you on the right direction. That's what I had. Then, you are responsible-
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Howard:
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Are you talking about your father?
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Edward:
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My dad, yeah. He was my mentor. Everything I am is because of him. He was a genius.
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Howard:
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That is so cool.
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Edward:
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He was absolute genius. As I said, I have 100,000 pictures of cases that go back to 1950. Nobody will ever match the sheer volume and quality of the work that he did in his lifetime. It's a treasure and I hope that I can go through because I haven't even touched a quarter of what's there in that collection, all the slides. They held up over all those years. When I get presentations, I like to show the old with the new because that's what gives validation to this whole approach to dentistry. I’d say to the young people, you are responsible for your education and what you got was a rudimentary foundation. Now, it's up to you to continue to educate yourself and become better so that you could become the best person you could possibly be in dentistry.
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Howard:
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You graduated from Tufts in 1977. How many years ago was that?
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Edward:
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I don't even want to calculate that.
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Howard:
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1977 … 39 years ago so you're coming up on your 40th.
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Edward:
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I know. That is so hard to believe. It goes so fast. I can’t even believe it.
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Howard:
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Dude, you look amazing. You look younger than I do. My dental school, I graduated ’87 so next year is my 30th and you look younger than I do. Tell these dental students because they might not believe this but what percent of everything you learned in dental school 40 years ago is basically extinct?
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Edward:
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I’d say most of it like 90% but they gave you … You see but that’s all true in all professions. I think all they can do is give you a very rudimentary foundation. That's all that could be expected from them. They can't show you everything. What bothers me about a lot of them is I think they close a lot of minds and they make people think that their way is the only way and the best way. Very often, that’s not true at all. They had to show you a way in order that when you got out of school, that you would have some proficiency but that’s it. That’s all they should be expected to do. I think they're doing their job. What they should do better is make students understand, we gave you were rudimentary foundation. Now, go out and take all the courses you can. Build your knowledge and skills and become the best dentist that you can be.
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Howard:
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Now, you don't make those precision attachment partial dentures. A lab does. Can you share a lab that does this?
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Edward:
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That is not entirely true because I do all my own preparatory work. I pour all my own models, make all my own dies so that everything that's going to be made on those models, then I could send it to a technician. I have one guy who does the metal work and I have one guy who does the porcelain work. Otherwise, I do everything else myself. I even process the teeth on the partial. You have to-
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Howard:
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How long is your presentation on this? If you were just going to rant from A to Z on all your presentation, how long would it be?
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Edward:
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It could be hours.
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Howard:
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You need to do this. You really need to do this. You know what's really cool about the online CE, is when I go to dental schools in Asia and Africa, their textbooks are 20 years old and those courses on Dentaltown are just everything. It's their only way to connect with the-
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Edward:
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I’d love to do it because I feel very strongly this was given to me. I fell into this. I was born into it and I feel very strongly that I’m obligated to give this back. I want to do all of that so I'd be happy to. Just tell me what I have to do and I'll be glad to.
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Howard:
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I’m howard@dentaltown.com. The person in charge of online CE is Howard Goldstein in Bethlehem, Pennsylvania. He’s a dentist in Bethlehem, Pennsylvania. I’m howard@dentaltown.com. He’s hogo because we already have one Howard, so H-O-G-O@dentaltown.com, is hogo. How far are you from Bethlehem, Pennsylvania?
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Edward:
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Probably not that far. I’ve been all over Pennsylvania. I gave all these courses for the University of Pittsburgh in their outreach continued education program so I’ve been all over Pennsylvania.
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Howard:
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That’s a great dental school there. I did Carl Misch’s curriculum at the University of Pittsburgh but my fondest memory is that the … It was like seven three-day weekends but the last three-day weekend there just was playing. All this old fart dentists were [inaudible 00:41:14]. I think that was one of the most fun nights I ever had. Then, for some reason, I couldn't go to class for an hour late the next morning. I don't know why that was. That's a joke but so you talked about labs. Is there a brand name at these precision attachments that you use?
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Edward:
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There’s only one male female. In my book, the original number seven attachment is no longer made but it's the concept that's important because we've made them with different versions of male-female attachments. The only that’s of around is this thing called latch attachment and the latch doesn't really work which is good because the latch consisted of a little semi-circular ball in the female and a depression in the male. I used to wipe away the little ball without a little inverted cone bur because I did not want any kind of retention but it doesn't function in a very short period of time so now, I don't bother doing that. It's a simple male and a female and that's it.
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The thing is, is that if you are working with a technician, most technicians only know how to do one tilt so if you only do one tilt, then the partial is likely to come out all the time. Then, you’ll have to put some kind of either redo the whole case or some kind of lingual arms or whatever on it. That defeats the whole purpose of the precision attachment case because you're applying lateral forces to the abutment teeth. They have to know how to do a double tilt so they should check the wax steps on the surveyor and check everything on the surveyor before anything is made so that they make sure that the double tilt is incorporated into the case. You really won't find out until after the patient is wearing it and then, you have a problem.
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Howard:
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You went to Tufts in Boston and Sterngold is Attleboro, Massachusetts. Was that a suburb of Boston? Did you ever go to Sterngold? Did you ever work with those guys directly?
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Edward:
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I call them up all the time. I’ve actually never been to their place. I never have.
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Howard:
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Is it outside of Boston?
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Edward:
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I think it’s not too far from Boston but I've never actually been there.
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Howard:
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That's the only the recommended male female. You're basically saying it's really the only one.
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Edward:
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Yeah. It's the only one I know of because it's the concept that's important. I don't know anybody else who makes anything like that.
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Howard:
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That is so interesting. What other advice do you recommend on removable in general, and any other removable advice? The bottom line is if we go to the ADA Convention, there's just a ton of courses on CAD/CAM, implants, cosmetic dentistry. The removable section isn't the hot and sexy section. They don't seem to be a lot of [inaudible 00:44:25]. What other good information could you share with removable in general?
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Edward:
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I think these are the best cases. The reason why this is called a precision attachment is you have to have a precision mindset. Everything, every step along the way has to be done with precision. This is real precision dentistry which is really cool. I mean if you were really a meticulous precision-oriented dentist, somebody who wants to do real good quality work, then this is the kind of case that's going to make you really happy or really challenging. Most people are not really being taught how to have that kind of mindset. They want to put something in a hurry, make it look white, make a quick buck and the patient’s out the door and not worrying about what happens down the road to these patients.
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When you think about what we’re asking dentistry to do, precision becomes very important especially when you realize that the best we can really work at is the tenth of a millimeter level and bacteria or nanometers and we're expecting our dentistry to function 24 hours a day underwater in an environment loaded with bacteria and under forces and that we get anything to work is a miracle. The precision approach is critical to a high percentage of success, very, very critical. Most people aren't being taught that.
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I think in the past, they were taught more with different techniques like maybe gold foil to have precision attachments, to have a precision mindset. They do everything meticulously step-by-step and that was important. Today, the way things are being done, it looks like it's less important. The people who are going to be most interested in this kind of a case are people who want to do high quality, high precision work.
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Howard:
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Now, is there any demographics or people who are getting this, is there a certain age range where they most fit? Are they more likely to be grandma or grandpa? Do you see any demographics? What demographics do you see in getting this?
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Edward:
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My patients are mostly older because in order to make a removable, you have to have you missing teeth where you can’t make fixed bridgework but I have younger people now who lost a lot of teeth who are great candidates for this. It really is less age-dependent. I’ve made precision attachment cases on implants for 90-year-olds. Age is not really a factor in this at all and that gives me tremendous advantage because I can make this case on three implants and I put them in the easiest areas where they’re most likely to have success. I can make that case. They’re great cases. Those patients can eat anything, bite into anything and don't have to worry about using paste or anything like that.
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Howard:
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If I ever lived to be 90, the only thing I’d want on my 90th birthday is for somebody who loves me to come up and hit me over the head with a shovel and you’re saying you have patients who still-
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Edward:
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Yeah, but when you talk to people who are 90, they don’t think that way. I have patients who are in their 90s who were skiing. They want to live and they want to have a good quality of life. I think everything is relative. I think maybe 90 is the new 40. Wouldn’t that be great?
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Howard:
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I’m in Phoenix and there's all these retirees and it blows my mind. I’m 53, fat jogger and I have many, many patients that pass me out on the road that are between 80 and 90. This morning, I got passed by one of my patients who’s 86 years old and he always pinches my gut when he passes me. He always looks over, grabs my belly. It is true. It is amazing how they are breaking so many age barriers. Would you say that the teeth and implants last longer with removable because they can get in there and clean better than if it was all fixed and nailed down? Do you think the implants and teeth last longer? Like in all-on-four, do you think it would last longer if it came in and out of your mouth versus was screwed down, fixed?
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Edward:
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I can't comment on how all-on-fours are going to hold up after 20 years. That, I can't comment. What I can comment-
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Howard:
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Fixed over removable.
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Edward:
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This is what I can comment on. One of the things that we do is we check our patients at our hygiene visits. If you are really paying attention, year after year after year, you will see that the cases that last the longest are the precision attachment cases. I’ve had patients where maybe one arch is fixed bridgework and another arch is precision attachment case. The fixed bridgework will have to be replaced long before the precision attachment case has to be replaced. I think that's pretty amazing but that's typically what you see. The precision attachment cases last far longer than the fixed bridgework cases maybe because the loads are dissipated better with the precision attachment case. Maybe weak abutments are not really part of the case or used in such a way that they’re not part of the case for the precision attachment case whereas with fixed bridgework, they have to support the bridgework.
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Howard:
|
You went to Tufts in Boston. Massachusetts has three dental schools, Tufts, Boston and Harvard School of Dentistry. Is that right, three dental schools in Boston? I want you to go on record and rank those three dental schools, first second and third.
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Edward:
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Both of them?
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Howard:
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All three. Which one’s the best? Tufts, Boston?
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Edward:
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I only have experience … There is no one-
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Howard:
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I just want to get you in trouble.
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Edward:
|
There’s no one single best. I think that's, as I said, they can only give you rudimentary foundation so I think they're all basically the same except certain schools are a little bit better in some areas, in other areas. For example, BU, they excelled in endo because of Herb Schilder. I went and took all those courses and he was an amazing teacher. I learned a lot from him. I'm sure this is true in most of the fields where there is somebody really special at one of the schools and they have a program in a particular area which is unequaled by all the other schools. In that area, that school would be the best but I don't think any school is necessarily any better than any other.
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Howard:
|
Let me ask this question. What are we up to? 64 dental schools now or …
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Edward:
|
We’re getting a new one here in my area. The Touro School of Dentistry is only maybe five miles from here.
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Howard:
|
What’s it called? Touro, T-O-R-A?
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Edward:
|
T-O-U-R-O. They're going to accept their first class this year. Never in a million years would I have thought that could ever happen but …
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Howard:
|
Are you going to get involved with the school?
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Edward:
|
Absolutely, yes. I would love to.
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Howard:
|
It’s T-O-U-R-A?
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Edward:
|
T-O-U-R-O. They actually-
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Howard:
|
T-O-U-R-O Dental School.
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Edward:
|
They actually have … Touro College has schools all over the country and they wanted a dental school so now they have one.
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Howard:
|
Now, what is the mother school? Is it an osteopath school or an MD school?
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Edward:
|
It’s New York Medical College is part of Touro College and that's here in this area.
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Howard:
|
Nice. Are you excited about that? Do you think it's a bad idea?
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Edward:
|
I think it's a good idea. Dental schools can be a bad idea in that if they take patients away from the practitioners in that area or they don't have a good relationship with the people in that area. They really reached out to us. I think we're going to have a great relationship. I think it's going to be a win for everybody. I’m looking forward to it.
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Howard:
|
Of all the dental schools, how many of them do you think right now teach your double tilt precision attachment technology?
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Edward:
|
Zero. I think that almost nobody knows anything about it which astounds me because it comes from the very roots of the profession. I think when I went to dental school, we had one precision attachment in our kit and we were never shown how to use it.
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Howard:
|
Do you think it’s because older dentists always complain, “Well, they didn’t teach us those. They didn’t teach it.” I’m like, “Come on, dude. They take 100 kids off the street and in four years, they got to give them a license to treat the general public. They can’t teach them everything.”
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Edward:
|
No, they can’t and they're not ready to absorb that. They have to get their feet wet. They have to do conventional removables before they can jump into doing precision attachment cases. They're not wrong but I think unfortunately, it's been neglected. This area has been neglected and very few people know anything about it. These are the best cases that may come from the very roots of the profession. That's why I had to write the book. If I didn't write the book, all this would go by the wayside. I think that would be a tragedy.
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Howard:
|
Yeah. I'm just honored that you would be on my show today. You're telling thousands about it today and I really hope you do an exhaustive online CE course. I think it'd be great marketing for the book because I think when they hear the podcast, that's going to make some buy the book but if they see it … A lot of people driving to work right now in their car might not be seeing exactly what you're talking about.
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|
I think if you do an online CE course and everybody that takes it will tell you their name and number and email and hopefully, I'm sure if you keep referencing your book enough times, they’ll get your book because I think it's a great service. I do believe that as you get older, you become more moderate. If your only tool is a hammer, everything looks like a nail, that’s where implants are going. An implant will fix anything and it’s just not true. There's still a big piece of the pie, a big part of the puzzle to help all your patients. It’s still going to involve removable gold, amalgam, glass ionomer. If the average dentist has 2,000 patients, you need a portfolio of treatment plans, not just three things in your toolbox.
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Edward:
|
Absolutely correct.
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Howard:
|
I think you're an amazing man. I think you have an amazing book. You're just a neat guy that's so cool, how you idolize your father and he was your mentor. That is just so damn cool. That was a big healing for me. My dad was my idol and on the business side of things and he had nine restaurants. When he died, I cried for half a year and it felt like someone was standing on my chest. Then, one day, I woke up and I thought to myself, “Why am I making this all about me and crying about my loss? I got four little babies back there. I need to quit thinking about my loss and start to turn around and look at those four boys and trying to get it so when I pass, they’d think the same way of me as I thought of my old man.” That was the only way I got through it. How did you deal when your dad passed?
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Edward:
|
It was hard being here … He worked almost until he passed. Until two months before, he was here in the office. It was difficult because I had somebody to talk to. Now, here I was all alone. It was difficult. I also had a lot of problems to deal with that were kind of dumped in my lap with his passing. It was a very, very difficult time for me but I miss him a lot. He was really a genius. I really grasped right away that he was something special. As I said, nobody will ever match what he did and he practiced in a different era where the things that he did, there were no implants. There were no things like that and the things that he did were simply mind-boggling, real miracles. I was blown away by it. I think he was blown away by it too. All these things really came from him. He was influenced by his teacher who also was really an amazing human being, amazing person.
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Howard:
|
Is that the one who jumped out of the window?
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Edward:
|
No. That was Dr. I. Franklin Miller, was my dad's mentor.
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Howard:
|
I. Franklin Miller. Who was the one who jumped out of the window? What was his name?
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Edward:
|
His name Chayes, C-H-A-Y-E-S.
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Howard:
|
C-H-A-Y-E-S.
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Edward:
|
Yes.
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Howard:
|
What did you credit him with?
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Edward:
|
He’s developed the double tilt concept with the male and female.
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Howard:
|
He developed this. If I read this book-
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Edward:
|
It’s his idea.
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Howard:
|
If I read this book, will it increase my chance that someday I'll jump out the window? I’m not worried. I only live in a two-story house.
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Edward:
|
I don't know why he jumped out the window but I always say in my lectures, nobody would listen to him so he jumped out the window.
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Howard:
|
That's why I only live in a two-story house, so if I jump out the window, I'll just sprain an ankle. I won’t go splat but hey man, seriously, thanks so much for being on my show. Thank you for your commitment to all this work that started … What year did you say when Chayes started this?
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Edward:
|
1906. When you think about this, it's mind-boggling that something came from that era when they barely even had anesthesia.
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Howard:
|
When was the germ theory? When did they even discover germs?
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Edward:
|
That was in 1800s. It wasn’t maybe what, 50 years earlier. Dentistry really came a long way in a very short period of time. It has a really fabulous history.
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Howard:
|
Yeah, and so did the American economy. In just a little time out of nowhere, it was the steam engine, the light bulb, the electric motor. I mean it was just all this massive stuff right out. I always wonder if the next century will be like the last century.
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Edward:
|
I think a lot of it depends on people's attitudes. I don't like some of the things that I see and I hope I can make a difference and change them. That's the most important thing, the mindset and the attitudes of people and one of the reasons why we're having all these problems is because of that. There's no question about that. There's other factors too like they sent all the jobs overseas. If we can get that back, I think we could have what we once had.
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Howard:
|
On that note, we’re out of time. It’s an hour. Thank you again for all that you've done for your patients, all that you've done for dentistry, your D. Austin Sniffen award, your Paul Harris Fellowship award, getting in the Pierre Fauchard Academy, getting involved with this new dental school. Seriously, thank you so much for spending an hour with me today. I really appreciate it. I hope these dentists listening can see your online CE course someday because you can see it on your … Now, it's even on your iPhone. Most of these people are watching … Here's the iPhone. You just hit the CE deal and there's 350 courses and they're sitting there listening to these …
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The thing that us, older guys don't realize is you think of a big screen TV or you go to a lecture and you have that big PowerPoint, that big screen up. You take your iPhone and you hold it in front of that screen and you pull the iPhone back until you can no longer see the screen at the dental convention or your big screen TV and it's basically just four or five inches in front of your face. Now, what's really exciting is they just released two weeks ago the Oculus virtual reality goggles. It's not going to be long before on Dentaltown online CE, you'll just put on those goggles and you won’t see anything but your presentation.
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When you're looking at the TV, so much your peripheral vision is the ceiling, the wall, the carpet, the cat on the floor. You're seeing all this other stuff but as you pull it closer and closer to the eye … That's what Google has been saying. Google's been saying it's not how big is your screen. It's how close is it to your eye. This online CE is really going to be a game-changer from here to Kathmandu. I’ve watched dentists taking these courses in Tanzania, Ethiopia, South Africa and Namibia. They love it. They just absolutely love it. They even tell you they could never afford to fly to Europe or United States to see some of these courses so look forward to your online CE course and thanks for all that you've done.
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Edward:
|
Thank you so much too. I really enjoyed this. I really did and I will definitely make that course for you. I hope that we get to meet sometime. I’d like that very much.
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Howard:
|
Next time you visit your sister in Scottsdale, you got to come see me. I'm in the port part of town, Phoenix.
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Edward:
|
I will be there. My sister’s not too far from you. I know she lives close to the airport so it shouldn’t be far from you.
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Howard:
|
I’m 11 minutes from the airport.
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Edward:
|
So is my sister. She's got to be very close to you.
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Howard:
|
Right on. I can’t wait to have dinner with all of you.
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Edward:
|
Great. Same here. Thank you.
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Howard:
|
Okay, bye-bye.
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