Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1304 Peri Implantitis Treatment with Dr. Samuel B. Low, Dr. Gordon J. Christensen & Dr. Asle T. Klemma : Dentistry Uncensored with Howard Farran

1304 Peri Implantitis Treatment with Dr. Samuel B. Low, Dr. Gordon J. Christensen & Dr. Asle T. Klemma : Dentistry Uncensored with Howard Farran

12/3/2019 6:00:00 AM   |   Comments: 0   |   Views: 1074
Dr. Sam Low provides dentists and dental hygienists with the tools needed for successfully managing the periodontal patient in general and periodontal practices. As an associate faculty member of the L.D. Pankey Institute for 20 years and Professor Emeritus, University of Florida, College of Dentistry, Dr. Low’s many years’ experience training dental professionals is evident in his straightforward, informative, and entertaining teaching style. Dr. Low’s presentations focus on creating positive interactions between dentists, periodontists, and dental hygienists through communication skills and continuous quality improvement to enhance esthetics, tooth retention, and implant placement.

VIDEO - DUwHF #1304 - Sam Low

AUDIO - DUwHF #1304 - Sam Low

Gordon J. Christensen is Founder and Chief Executive Officer of Practical Clinical Courses (PCC), Chief Executive Officer of Clinicians Report Foundation (CR), and a Practicing Prosthodontist in Provo, Utah. Currently, he is an Adjunct Professor at the University of Utah, School of Dentistry. Gordon has presented thousands of hours of continuing education globally, made hundreds of educational videos used throughout the world, and published widely.

Dr. Klemma has been a lifetime student of dentistry. After graduation from Loyola Dental school he started private practice in a suburb of Chicago. He was an instructor at Loyola Dental school for 8 years. Besides the hundreds of hours of continuing education that he participated in, he has written 2 articles on aesthetic dentistry and 1 article on pulp protection using Thera-cal by Bisco. He is currently a Clinical Director for Heartland Dental and lectures on Diode lasers for use in hygiene and clinical Dentistry.

Having launched 1,300 (and counting) Dentistry Uncensored with Howard Farran podcasts, Farran Media is proud to open its recording studio to the public. Reaching a new audience and potential patients has never been easier as you partner with a sound engineer and professional equipment to create, host and launch your very own podcast and video content. Farran Media offers hourly studio rental, remote recording, podcast launch packages with custom logos and intros and so much more. We’ll guide you throughout the entire process to ensure your podcast is a success–click here to learn more or give us a call at 480-445-9699.

Howard: Man what a treat today I cannot believe I get the honor of podcasting Dr. Samuel B Low DDS MS MAD along with Gordon Christensen the god of dentistry whose mom and dad were Pierre Fauchard and GV Black and then Dr. As the real Dr. As. Dr. Asle Klemma, let's go through them all real quick, Samuel B Low receivers DVS and Masters of Science degree from the University of Texas at Houston he also completed his residency in perio at the University of Texas at Houston received a masters of education from the University of Florida he's a diplomat of the American Board of Periodontology and past president the American Academy of Periodontology. As an associate faculty member of the LV Pankey suit for 20 years and professor emeritus University of Florida College of Dentistry Dr. Low many years experience trading dental professionals is evident in his straightforward informative and entertaining teaching style Dr. Low was selected Dennis of the Year by the Florida Dental Association Distinguished Alumnus by the University of Texas dental school and the Gordon Christian lecture recognition award he has past president of the Florida Dental Association and past ADA trustee what a legend Dr. Low I've been a huge fan admirers I think you were you and Gordon were the first two people I asked to come on the show. Gordon this is his fourth appearance and this is your first appearance you had to let Gordon come three times. Gordon Christensen does not need an introduction I could read it for 40 days and 40 nights. So basically he's the founder and CEO of practical clinical courses a practicing process in Provo Utah his wife Dr. Rella is probably the most profound microbiologist in dentistry they're both cofounders of the non-profit clinicians report foundation previously named CRA there I mean my gosh Gordon Gordon's resume is 40 miles long. Dr. Alse T Klemma he a dentist at advanced dentistry he's the clinical director for Heartland dental which is the largest dental organization in the world they have over 900 dental office they're founder Rick Workmen's been on the show I think my gosh at it so you're out of Schaumburg Illinois right?

Asle: I am Howard, yes.

Howard: and who's my OOP my bisque Oh buddy been on the show BeYong Sung yeah my gosh what a legendary chemist. Well I don't even know where to begin so I just wanna I brought you guys on the show mainly I wanted you to come on the show is when I got out of school in 87 there's all kinds of periodontal procedures and we'd lay flaps and you'd send them to periodontist now this incense and I got to school about 87 it seems like starting in the mid 90s people started saying well you don't need to do all this stuff it's easier to treat it all with with forceps and start pulling all these teeth and replacing them with implants and after about ten years of that people start thinking maybe those teeth weren't so bad after all and now I have the biggest concern I have is these, you know if you listen to podcasters you're young a quarter of our listeners are still in dental school the rest are under 30 you can shoot me an email or leave a comment in the in the YouTube sections but they come back that they became a dentist because her mom is they go back into work or their mom her mom's placed you know hundreds of implants and they all have peri-implantitis around half of them and so they're confused because when you tell grandpa that his implant where he can eat bacon cheeseburgers he loves it there's no pain but then they've got five six millimeter hamburger around it and so peri-implantitis is a big issue so I thought let's get you guys come on the show so we'll start with Sam the incidence of periodontitis continues to increase and more so for the frequency of implant disease we know from the most recent well just talk all things implant itis and what would it what is a 25 year old need to think when she sees an implant that grandpa loves but there's five six seven millimeters or raw hamburger around it?

Sam: Well you're right on target this this you know all of us on this call have talked about this I've had numerous conversations with Gordon about it he mentioned to me not too long ago that when it's in front of audiences they're asking about implantitis is that little dirty secret that's out there that most people don't want to admit especially those who place implants the American Academy of Periodontology is now admitting it I and it's hard to get the numbers Howard but there's no doubt we're running between around twelve to twenty percent of all implants placed are gonna fail I don't mean implantitis I mean we're probably gonna lose and there are several reasons for that we're placing more implants there's one that maybe our training is not where we should be and there's one that maybe we're placing them in patients that possibly we should be keeping their teeth I'm not suggesting something from an ethical nature but as you know you've been around where we have hurting mentalities in dentistry just like every other profession the bottom line is this when you take someone you know I was in practice this morning you take someone's tooth out that they've had for thirty years you know what they say thank you thank you Dr. Low for doing that you take somebody's implant out you better run for the hills because it's a whole different deal because you don't really have alternatives and so this is where you know at some point we wanted to us to discuss about laser technology on where that may be not necessarily the panacea but close to it or managing this thing and you're gonna hear me say this over and over where we let peri implantitis get to the point that we extracted it to where sometimes letting implant I just get to the point that we cannot make it reversible so it's this whole thing as you know about early diagnosis so implantitis is out there it's not going to wait it's going to get worse before it gets better and we need to do something about it, especially in the area of the general practice.

Howard: So do you think I'm gonna go back to the cases that are filling of the twelve to twenty percent of implants are going filling I know the first thing the 13-under crowds gonna say is oh I bet those are the smokers or they didn't brush or floss what was it diagnosed was the incorrect diagnosing or they put them in two older people that smoked and drink and basically.

Sam: You know originally we thought that nicotine usage was directly now the number one risk factor in the loss of an implant is placing implants now you can avoid this but don't take risks it's actually a history of losing teeth from severe peri implantitis is the number one risk factor the rest doesn't help but the bottom line is we're also taking chances placing implants that we didn't do before the reason that we had such a great track router in the past is that you know we placed implants with a thirty millimeter wide thirty millimeter height thirty five-year-old male and the position of number nineteen you you could go to ace hardware get us stainless steel screws blindfold it put it in backwards and it would probably work that's not what we're doing now plus you know I just want to reinforce there has to do something also with training and let's face it we're reaching a point now and unless you have a CB CT and a surgical guide if it fails from a litigation standpoint you should have a good attorney. So I agree about the risk factors in the past but there is a thing of just not placing them correctly and sitting around for five years and then when they go south we think it's because of implantitis it may have been the original positioning of them so it's multifactorial.

Howard: Who's next dr. oz or God?

Asle: Oh God always first.

Gordon: You would all be interested in hearing what I'm going to say and you know we provide many hands-on courses in Utah from people who are well known in the profession in all areas and we elected last about January to Institute one on rescuing implants usually a course takes several months to fill up that one was still live in a couple of weeks and we had to start turning people away now john suzuki and i provide that course and in doing so well kevin suzuki too John's son in during that course it was very easy to see all the course had done implants for some years it is a fairly mature being compared to what we usually get we usually get about half young man it's up to five years at school these are hands-on courses we have models where they are simulated failures we go through the conventional orientation of implants salvage which is basically stage one that should be done by any general dentist basically the logs and scaling route planning etc the conventional I'm talking about not laser and you jump up one level and if it is enough loss of bone and obvious denudation whenever the threads gotta lay a flap with a conventional technique and Sam knows better than I and when you do that then you've got to clean the miserable thing up with the wire brush or were glycine or whatever and then suits you back sprinkle some bowel feathers praying a little bit and hope that it's satisfied in surveys a very nice even we're seeing only about a 50% chance of recovering with the conventional technique in that of course we also had and had been done of the potential of laser which and 30 want to get into later but the diseases there I agree completely with what Sam just said about the various causes chronic ongoing threat peri implantitis is one of the majors of course smoking is I'm seeing people I'm seeing people take large pieces of restorations offer articulator plunk them in the mouth cementum and never touch the occlusion occlusal load is a major failure situation wrong angulation is all on fuller frenzy that everybody is getting into now I think this and that 45-degree angle the fertilizer chess analysis shows that the negativity of that in about 20 factors I can identify right off the top of my head that will be influential in predicting failure and let's not throw out osteoporosis you know many people placing implants are in the fifties and sixties in the t score of over - bottom line is they're gonna fail too you stick them in where the bone is inadequate I asked this view who knows their t score I had one guy in the group bottom line is there's so many factors Rella was asked, my wife to do the micro on it then she turned it down because she said there's so many factors we'll all be dead before we can evaluate enough of them to get there good answer bottom line it's here we've got to do something about it.

Howard: So you said John Suzuki taught that course with you?

Gordon: Yeah

Howard: and you said his son helped?

Howard: His son Kevin and is a periodontist about 10 years out of schools in Seattle very fine person, yes.

Howard: One of the things I want to I'm gonna go to just the the finance side of it a lot of dentist took on an associate and and the number one associate turnover is you know that they get they can work at these big DSO is that they only last about a year and the only thing that's really keeping associates to stay maybe two years is if you give them a lot of CE and a lot of these people want to learn implants so they put a lot of money into these young kids to place implants they place four or five implants then they job hop after a year or two and then over the next five years they got to pay five six thousand dollars to have every one of these five implants replaced and redone by a periodontist and I just lectured to a DSO group here at Scottsdale a couple weeks ago and they're to the point where they don't want anybody even placing implants anymore unless they're a board-certified periodontist and some of them have got to that point with endo they're like yeah you let these kids come out of school and they do their first 10 molar root canals on your patients and then they go take a job somewhere else and guess who's gonna have to send everyone I'm to have a retreat. So do you think do you think that one of the problems with these failed root canals is that I mean if I was gonna get an implant done I wouldn't want to go to somebody who just did their first 25 implants I'd want someone who's done a thousand is that part of it or is it still you said the number one risk factor was I'm having a history of losing teeth from periodontal disease is high up on that list under trained young kids?

Gordon: Asle You're involved with that doing.

Asle: I do deal with a lot with that Howard.

Howard: and by the way you're with Heartland which keeps the associates the longest Heartland and Facebook are keeping their Millennials about two years whereas the rest of FANG Amazon Netflix Apple Google like Google they give them every perk in the world and their average millennial stays one year Amazon has the shortest it's about a year and when I look at the dentist when they come out of school when they get an associate job it doesn't matter if it's a private practice or whoever they're their average association ship job is a year but you Heartland keep them the longest in dentistry just like Facebook keeps them the longest in the tech industry and everyone that I've ever talked to you from Heartland say they're staying on with Heartland because of all the opportunities of continued education like learning how to place implants.

Asle: Yeah there's no question about that we really trained the dentist and and everyone graduated like Christensen and obviously and Dr. Low graduated before Howard and I but I as personally and I've spoken Dr. Low about this they don't get a lot of training in endodontics like we did I mean we have to do about 10 molar endos we could do probably 30 gold foils you know ten you know chest crowns that we had to do ourselves and I think the educational part we see that is coming out they've never done endo never extract the tooth except hanging there for periodontal disease so I think the education of the young dentist is now being put into the private sector much more than it was even 15 or 20 years ago, there's no question about that.

Gordon: As old as I am I keep teaching because what I see in hands-on courses is unbelievable and you just said it I'm seeing kids who have done two crowns getting out of school watch the denture being done I even hit one kid recently he did one canal on the three canal tooth and two other kids did the other two connect and then there are dentists just like me.

Howard: Yeah so is Heartland to the point now where they're thinking that you know what we're just gonna only let endodontists do endo and periodontist place implants are they approaching that or is that not even on the board?

Asle: Well speaking I don't wanna speak for Heartland I just know our educational system Howard is the world class we're actually putting more money and more time into educating them we've got a mentoring system now that is on board that is second to none that we can just about guarantee there at the end of the year that they will be performing root canals at a level that none of their I shouldn't say none but very few of their contemporaries that don't go into extra continuing education will not be able to do what they're doing so we're putting a lot of resources we're basically doubling down our resources in continuing education because they need it here in simple.

Gordon: Howard I strongly believe that post well is to not post graduate graduation CE hands-on is necessary we have a series of thirteen plus it's 26 days and it's almost embarrassing to me to say now there are all name-brand people that they probably get a better clinical education long dental school in 26 days if we take the average school now there's an outstanding good school and there's an outstandingly unbelievable bad schools so you get out of one of those mediocre bad schools they have to go post graduation CE I even...

Howard: Come on Gordon make the news who's the worst dental school in America?

Gordon: I'm not going to tell you I don't need any more dang  lawsuits.

Howard: Just text it to me then I'll say it. Okay well when I got out of school that was the first thing I did is I went up to Provo I took at least two years off Gordon's life I went up there with Mike DeTola we sat in the front room the front row of every course every month for a year and I remember every time he'd walk in there and he'd see us for like the tenth time he look us like oh my god oh my god those are the best days ever I love that shout out to DeTola. So there's I want I'm really confused about this 19000 health care is only 1% of the GDP there's no specialties one doctor does it all by 2,000 health care is 14% of the GDP the MDS have 50 specialties we have nine now it's almost 2020 we're up to 17 percent of the GDP there's 40,000 doctor journals every single month in the world you couldn't keep it up on and I see these dentists that want to they want to do it all they want to place implants there weren't any root canals they were doing this line pediatric dentistry they want to do it all and history has shown us that zatia is taking place and no and you know you're not gonna go to GM and say hey why don't you make refrigerators and washers and dryers. So what do you think about the modern-day love affair about this super dentist this mythical super dentist that's just gonna do everything does that even work?

Sam: I want to give you a counter with that and that is patience at this point expect everything to be done in one place and from a competitive standpoint I'm with you from the standpoint of standardization and bringing the level up but the bottom line is patients expect everything to be done in one place so it's not just about the dentist trying to learn everything the the pressure that's being put on them because when I do a CE course I asked is is the audience does anyone ask the patient ask you can you doctor I know you can do it you place those eight veneers I know you can extract those wisdom teeth on my daughter you know where the roots wrapped around the entire valveral nerve I know you can do it so there's a significant amount of pressure that's being placed on these practitioners so let me bring something forward and this is also something that Gordon and I've talked about let's take periodontitis right 98% of all periodontitis is managed by a hygienist in a dental practice we are still losing teeth because of that now part of that is because the general dentist does not know how to do moderate to severe cases and part of that is the perception of doing periodontal surgery for the most part if you go on YouTube and look at mucogingival surgery I mean it'll scare the heck out of you and in fact I was again I was in the clinic this afternoon and someone came in with their daughter we were doing a mucus enjoyable procedure the daughter who's 15 had already been on YouTube and saw a mucogingival surgery and was freaking out before we could even get her in the chair. So the bottom line is we have information transfer my position and I do believe that it so I want to just connect the dots for you Gordon and I believe that it's time for general practitioners to start doing some periodontal therapy besides non-surgical so that we can scrape the feet and to do that you can't be done with a blade and that's where this laser comes in and I would like As to speak to that because As is a prime example of a general practitioner who I believe did periodontal surgery well but now has got a significant number of car dental surgeries with a minimally invasive laser then I'll go one step further.

Howard: Was it a diode or a co2?

Sam: No it's a full-blown erbium all tissue laser that's the only laser that can it has to be a naught issue laser are you gonna burn the teeth burn the implants and he has he's acquired that expertise with the training he and his other colleagues at Heartland to make this happen so my point is is this it's what I call total solution everyone wins their cases I as is smart enough there are cases that he's not gonna touch but you're gonna be a heck of a lot more cases that he is going to touch now because those patients if he didn't touch them Howard you know what they'd do then leave and leave go down the street probably have their teeth extracted probably had the implants that we're tightening and so I'd go one step further the same thing with implantitís the only thing I can see right now to really manage an implant surface is going to be a laser and it has to be an erbium laser but it has to be done when you first start smelling it at the first at the first thread instead of waiting till the sucker is is you know it's what I call respiratory peritonitis is when you breathe the implants and teeth move back and forth so it's time to change into me that's what this podcast is all about that's why I wanted to be with your venue that's why I wanted Gordon that's why I wanted the practicality of As because it's time to make a change so that people can keep their teeth and if it's implants keep their implants.

Gordon: Often I've worked over my career with some name-brand periodontists including Robert Xiaohorn who have practice with eight years well we certain University Colorado there is Bailey here and is many others so I've always been heavily involved with periodontist even though it's a prosthodontist I've been quite a bit periodontal surgery and I've placed implants now for 36 years my original quarters in Brannamark himself so I am kind of a fetish about this I I often asked in a course especially when a lot of I James in there and dentists I'll say how many of you dentists have done up to you how many of you have done ten periodontal surgeries in the last 12 months get a group of 300-400 all have three or four hands that go up they do not know how nor do they want to lay a flap now doing conventional implant Salvage you have to lay a flap in a moderate case or one is getting heavy well along but in the earlier stages of very advantageous use of erbium laser does not require the use of the flap because the the energy now it's not just a minute in a straight line it comes out peripherally and although you can't see it once you've done it a few times you get the feel of it and you rotate it around whatever part of the implant is not really has bone over it anymore and that laser pops the garbage off the threads and then we follow up with conservative techniques and graphing necessary but the bottom line there isn't a necessity to lay a flap if we get it early enough, Sam how do you feel about that?

Sam: Well that's exactly and we have the science to show that but you're right if it's more than 20% you got to reflect a flap to see it but less than 20% but you know what we've been doing is the same thing we did and in sari preventing that's the same thing we did with periodontitis you were doing with implantitis we're watching it we're watching it the next and it's X potential and we've got to catch it when we see that very first bone loss that's are actually what we should be doing is watch is having our dental hygienists and this is you know my partiality to glyciner polishing we need to be doing something to prevent these implants from being lost but I'm with Gordon why don't we give As the tools for him to be able to save teeth without a flap. As has done several of them your opinion of where we are right now with erbium lasers?

Howard: Okay but just for the viewer they're still I'm confused they're confused you're seeing the erbium laser hard tissue is this something I can drill work on enamel for if you can do

Sam: It can do everything but it's expertise is in bone root soft tissue perio pathology implant pathology that's where...

Howar: What's the name-brand or number of the laser your talking about?

Sam: Biolace, waterlace technology

Howard: Okay so it's the Biolase waterlase you're talking about?

 Sam: Yes

Howard: Oh okay

Gordon: and they've been around now well the expresses is the older one who's been around for quite a while but that they are both erbium and they're all tissue lasers.

Howard: Okay Dr. As what did you want to say?

Asle: Yeah I just say a little bit to that I am a general dentist Howard but I do like doing endo, endodontic nut I love endo, so don't ever say dentists can't do endo cuz it is so fantastic.

Howard: I love it too.

Alse: Yeah so when I got out of school I was fortunate enough to have some friends that went to specialty schools one was periodontics and he would come out every Friday and all we do is perio I got out a little bit for you powered and we would lay flaps he would do one side I would do the other he would take all the money but I didn't care because I was learning. So I spent two years doing this with him so the first 10 years of my practice every Friday it's all I do is perio surgery we line him up for Friday every one of them and then you remember the Kies method came out and things like that and I started thinking as you said perfectly about a half-hour ago more conservative methods came around and I started seeing these long roots and these people you know big spaces between their teeth and I started saying myself you know what I just don't know if this is the best way to treat my patients to me when I look back at it now it was barbaric when I took a 15 blade and cut the tissue and made the distal wedges and you know it really was not a pretty sight to see so I again I love endo but I want to keep my patients healthy and we just happened to we knew Sam you know personally through Biolase and we've been to many of his lectures of such great lecture as you know and we just got together and as just a family dentist I said could we do a little program let's take three dentist or dentist and let's see how they do four general dentists and a I don't pilot project I don't want to call it a study because we didn't study anything we we did a little pilot project and Sam said okay let me work on that and we came up with a couple meetings and we said okay if we're gonna say for really high-quality doctors that can do surgery and we're gonna utilize this laser and see what we think and I was kind of excited because I'm thinking well I've got the greatest hygiene department in the world do you know how to have anything in there I might do some frenectomies these things like that well I was really challenged by Dr. Low to really sit down and he really asked me to probe certain areas I'm on my patients he said between two - number 2 and 3 14 15 18 19 30 31 you'll really sit down yourself don't let just your hygienist do it sit down yourself and take a look at these I sit down I get a little bleeding in a five millimeter pocket and what you said before you know we'd watch those implants well I didn't want to send my patients that periodontist for a five millimeter pocket and I really didn't want to use a blade on them I really didn't want to do that so lo and behold what happened through a six month period of time is those five millimeter pockets that I was watching maybe you know trying some arrestin which is I think works fine sometimes in some areas but not always I would have anesthetize the patient I'd had the Biolase Waterlase ready and lo and behold those five millimeter pockets were actually seven millimeter pockets that some of them actually had exudate on and this is a hygiene program and that I was extremely proud of and it's still very proud of them but I let it go I let it lacks a little bit you know I watched those five millimeters I watched those four that were bleeding and I ended up doing I don't know Sam might know numbers better than I do forty or fifty five years of surgery in five months and not quadrant not up to dude number seven or eight or something but I did a lot of two three fours thirteen fourteen fifteen and the great thing about it was I was able to do it like painlessly because the post doctor of pain was to me was unbelievably less it was when I did it with the blade we also get some photobiomodulation effect from the laser I believe so the healing as soon as you're actually making you know they're probings with the laser you actually start to get the healing process which is you know that's scientifically and that's known that's not guesswork but it really turned a lot of heads for us because we're thinking we're good clinicians how can we miss this much and what are someone who is what someone is not as careful as we are what's going on in their practice so it really started us thinking about hey you know we got a we have a change our thinking about this a little bit and also not to not to cut out our periodontist I'm gonna tell you my periodontist got more business from me after this little pilot project because I started diagnosing more and I found things you're absolutely right I didn't want to do better he does these than me I don't tell you it's teachable trainable Dr. Low can talk to it in greater detail but he calls it the perio repair system and it is wonderful I mean I'm not I teach lasers a diode laser I don't want to say I'm an erbium expert but he's kind of not a touchpad all you do is touch from step to step to step the step which to me he just made it so easy Howard again but it made it a simple process for a general dentist.

Howard: Well I want to sit there and say I would give anything if my buddy Fred Margolis was here today he was I called his podcast laser the Star Wars of laser pediatric dentists he was the first dentist who really took a hard tissue laser to pediatric and he always said my gosh the time it takes you to get a child numb I could have taken a hard tissue laser and just done the hole filling and anyway what you guys want to say anything about a Fred Margolis before we continue on perio?

Sam: Fred we miss him he was incredible he in his own way of being very humble and sharing we really missed him he was a pioneer in pushing lasers especially in pediatric dentistry so I really appreciate you bringing him up.

Howard: and so when you're talking about bio a salt issue ever if they actually get this machine though they can do what Fred Margolis was doing on enamel and they can do it on perio right and then I want is that correct?

Sam: Yes that is correct that is more technique sensitive but you know Howard where I go with this is called value-added procedures and if someone is not doing a particular procedure and you add that to and they're trained and to me that moves the quality of the practice it's not taking anything away from using these lasers for restorative dentistry but there is just so much more opportunity in using them for periodontics implant procedures frenectomy, newborn frenectomy with laser is an incredible opportunity with ten percent of all babies born having lactation issues so that there's just significant opportunities out there and that's what Heartland found.

Howard: Yeah one of the top three courses out of four hundred on dental town is pediatric dentist doing one on tongue-tied because it's just probably our generation probably had a lot of them but they didn't mom said no name well I get another clarity when you go to and you type in waterlace there's a waterlace Express and a waterlase iplus which what are you guys talking about?

Sam: Well the Iplus is a powerful device that works on not only what we've been discussing but also for your class 1 and class 2 's the express laser which is what As wanted is is also what Gordon has is a laser that you could do class 1 class twos but probably not as fast but you can do every single thing else plus as As mentioned it's all on a touchscreen a Samsung tablet that runs it but more importantly that laser is 27 pounds that will fit in the backseat of your car if you had more than one office and so it's the newest of the news forum Biolase the portability of it is attractive to many but all of the procedures with the exception of doing class one class two is fast can be done with the express laser.

Howard: and I just want to make sure everybody knows one thing this is not an advertisement for Biolase don't even go there these guys don't give me any money Gordon won't even buy me a beer and so these guys are just talking from their heart but so and I also want to say one thing on the price of a laser you guys there's you know there's three numbers there's a statement of income that's your profit and loss that's a report for third-party tax collectors like the IRS maybe your publicly traded it for a SEC there's a balance sheet what balances the cost versus the equity I paid in versus the liability I oh you don't manage the business with a where they with a balance sheet about you only use a balance sheet when you're trying to get other people's money or you're trying to split up your own money in the divorce. You only manage off a statement cash flow and so I don't care about if this laser cost a thousand ten thousand a hundred thousand I want to know what is the monthly payment in this month because I pay my bills monthly so if I have to pay this laser can I say I have to pay them $1,000 a month I need to know what can I do to charge out and bill a thousand dollars so on that exact question who wants to what is the lease payment a month and what are some examples of procedure I can do like what is that what is the monthly lease payment for waterlace express or waterlase iplus does anybody know?

Sam: Yeah I know you could the payment on an express laser would probably be around seven to eight hundred dollars a month the payment to you on one quadrant of periodontal surgery with the respective code is about twelve to fourteen hundred dollars one frenectomy is $500 if you did two frenectomy a month you would pay for it so in my mind I'm right there with you is called value added benefit with the return on the investment our guess what it's going to end up in your closet like everything else.

Gordon: Howard let me make a statement on that I played with lasers believe it or not since the early sixes and off and on off and on off and on, as these hard situations involved and there are several out there now we worked over the last while and since we don't want to make this a Biolase commercial we worked with the solium, Fatana and the Biolase and there are about 15 procedures that each one of the companies as you just said Sam if you if you were to take those stairs about half of them can be done with other modalities on the other hand to do the regulator is a changing and the overall office orientation you've got a blade of course we're dollar and a half you got a burr for a dollar and a half you've got a laser for whatever significant amount of money will it add to the practice and the answer is yes so somewhat of a mystique about laser I think it comes from from LASIK surgery because they see that in every newspaper they pick up and then the general public would think well it's better on eyeballs it must be good on teeth so there's already a sales pitch that you don't even have to make we're going to use a laser and well going back to my goal is in the child there an area where obviously gotta prep it's time we have to be with the solium laser it took me 45 seconds to cut a small blast it took me but through the auto setting as morning you guys said and therefore the procedure went rapidly of course I'm changing the energy you start slower that's why it takes a little longer you start slower until the mind is capable of tolerating the slight feeling areas and then once you get it up to the level of energy where it's supposed that you cut relatively fast so if you take as I said those 15 procedures I'd say half of them you could do something else but the mystique of laser the less pain that laser has is our value added certain things as Sam has said and there are good studies to show that the gross revenue of dentists using these major lasers is rapid once they use its various other orientations than just cutting teeth if I just had to cut teeth with laser I'll be candid and say I probably use a burr if that was the only thing it that is the only thing you does there's so many things that could not now let's just say I have a piece of tissue growing on under a bar a barn clip thing if I use the electric surgery on it basically burn the implants right out of the mouth no it's a person wearing a pacemaker I can't do that with with typical types of electric surgery and other modalities they're just quite a few things once you have a laser they can figure out I couldn't do that with other things without the dressing or having blood all over everything so we have to look a little broader than we have in the past and I've told Sam that I think plant Salvage will probably salvage lasers they've been around for 60 or 70 years there's nothing new but now there's a new need and that may allow relatively uneducated dentists to do a non-flap preventive sort of the procedure early on when that implants only about it's one or two or three threads denuded so I think we have a salvage done.

Howard: Dr. As, Sam said that Fred Margolis was a humble man but I imagine anybody who lives in Chicago and lived under the white socks for all those years you just have to be humble but I was wondering you went to you went too Loyola too and it was the way a big part of this I mean you you graduated in the world dental school in 1982 started pride price in Chicago and then Loyola closed down and what do they close out 93 ah yes 70th year anniversary but you and Margolis both Chicago people it was Loyola big into lasers is there a laser foundation from Loyola?

Asle: No absolutely not I attended several of his lectures tremendous man but no.

Howard: Was he a  Chicago Cubsfan?

Asle: He was a North Side guy so I would tend to think he was a cubs fan.

Howard: That's why he's humble they just lower their expectations zero they don't the only thing the only team worse that is the Minnesota Twins but we won't go there we're not gonna go that low on this show.

Asle: One thing I will add, I'm not hired by Biolase or anything Sam just asked me to be on this because we did that piolet just so you know but my I think it's seven months I had paid for my laser went using the waterless by the procedures I performed, ROI which I go by the ROI was tremendous so I can just speak for myself and I have a very nice practice again where I thought the periodontal tissue was really really good everywhere I mean I found enough and you know I'm happy for my patients not for myself I'm happy for them because I was doing them a disservice by not addressing at four millimeter bleeding five millimeter pocket so I didn't know surgery and I wouldn't even call surgery even though he'd have to legally I think by seven months I had done enough work to pay for my laser so just a little tidbit there on ROI on that Waterlase.

Howard: Sam I hate to be redundant but I am the I'm the one representing my listeners and a lot of them I know they're thinking well I heard just get a diode laser it's a lot cheaper remember a quarter my listeners are still in dental kindergarten school so what would you what would you say your sovereign dental school says I thought your I thought the cheapest one was a diode laser what would you say that kid?

Sam: A diode is a very acceptable laser if you're doing soft tissue as tropic to me a diode laser is like if I wanted to go I'm in Florida now I want to go up to Atlanta I could go with a smart car or I'd go in a Tesla the diode is the smart car the erbium is the Tesla. Number two first of all so there's a major difference in speed a diode works off of thermal and we all know that and actually unfortunately and Gordon has mentioned this before in his seminars and he's right on target many folks use a diode as if it was in the electro surge they they would be better off if they you know if they just used an electro surge and erbium is different and erbium laser can actually remove calculus remove the smear layer so with that we can get attachment it can degranule and you can never touch you can't really effectively even do in second stage implant uncovering with a diode. Someone came up to me I was lecturing last week he had tears in his eyes and he says you know I now know why I've been losing some implants I've been using my diode laser to the second stage uncovery, well what settings were you using he said well I was using what they told me not not the manufacturer but one of his friends which was like two watts continuous wave initiated tip which is an electric surge so that's really the implants are falling out so there that I don't take anything away from a diode but really it there's no other way to sing it Howard it's a poor-man's laser, sorry.

Howard: I also want to ask you your um I went through all Continuum's of the Pankey Institute and Key Biscayne you've been faculty there for a long time I think most people would agree it's probably the most prestigious name-brand Dental Institute how is the are you still at the Pankey and how are they doing, what's new at Pankey?

Sam: They're doing well one of the best things that we ever did was hiring Lee Brady, Lee Brady has changed everything for us first of all she represents where dentistry is going and our classes are now fuller than they were before she and I are talking I'm about ready to put a laser in her practice in Arizona but she has turned it around to where now Pankey is back where it was and I've always felt you know it's been a privilege to Dr. Pankey was one of my mentors I still use his euphemisms constantly in my lectures but but you know though Howard let's go back to the Millenial so and let's just be factual Millennials don't do CE like Xers and baby boomers did you have to go to them and I'm not trying to typecast all of Millennials but it's the same reason why you're not gonna see Millennials own practices in the future. We thought that Millennials would try a group practice and then say yeah you know I don't like it I'm gonna go I'm gonna go on my own no what we're finding are Millennials don't want to own a practice now please anyone on this call I'm not throwing every single millennial in there but I know our dental school class of the 94 that came out I think to set up their own practice 92 did something else and they like that they like working in groups we liked being independent they want to be in groups in fact they freak out if they think they're gonna go practice by themselves.

Howard: Dr. As even lectures don't practice alone he always says find two mentors and don't practice alone. I hired my first associate right out of school and I was so dumb he was as young as I am we both had just graduated like an hour ago because I wanted a buddy I wasn't spared I know I should add a mentor I just know I didn't want to be alone.

Sam: That's right and that's one of the things that I do kudos to Heartland for I knew Heartland but when we introduced lasers I got to know them more and As is one of those mentors it is amazing how much hand-holding they do on these practitioners I mean As you spend a great deal of your week looking at their cases talking with them by phone oh yes you know what this is about I'm not gonna get on this thing about dental education because I could and part of it has to do with standards and etc I would be the first to tell you we need to do some improvements but the comment that they leave they're probably not where they should be thank goodness there are the Heartlands out there that can take these folks and give them at least the practicality of Education.

Asle: Yeah I don't think that's absolutely true true when I got out I would see Dr. Christensen I would go see Dr. Dawson Harold Chevelle was really one of my main mentors I don't know if you know him but my gosh now at least even if they aren't as thoroughly trained as we are a lot of them still really want to be good and we like being there to help them become better it's all about education it's a lifetime it's an art dentistry is an art and you just look at Dr. Christensenand Dr. Low, you can't find two better examples than that is still working at their craft still getting better but still getting more educated and that's really the idea you know.

Howard: We talked about Fred Margolis the star wars of pediatric dentistry you just mentioned Dawson we just lost Peter Dawson this year in 1932 2019 yeah you guys want to say any words to what Peter Dawson meant to you?

Gordon: Peter Dawson was a very good friend of mine, we were together and they kind of aesthetic courtesy for many many years I have a respect for him and his influence in the profession particularly in occlusal. We treat three major diseases in dentistry we over treat carries every little pothole is treated we know that tario exists but we can barely spell it even though most of that a good course and we can't even spell occlusion so Dawson brought occlusion out of the closet and started to make it pragmatics started to make it to the point where it would actually generate money and made it a little more of the science is still alive for science is semi witchcraft but in the meantime the person who did that he and I developed a few things together and there aren't very many people who have done as much as even close to what he did and can't say enough good about him.

Howard: Sam what do you think you're at the Pankey Institute, a lot of people don't realize the Pankey Institute never competed with the Dawson Center, did they?

Sam: It's always been synergistic even though we were both you know we're both in the in the state of Florida i hardcore occlusion it was Dawson's comprehensive treatment planning and relationship building it Pankey and they still coexist you know the work that John Cranham is doing with with Dawson is extremely positive taking it in that direction but you know that'd be one of the issues I'll give you a very interesting observation because I am at the dental school today you know all of us on this call you here you remember waxing crowns remember even some of us go back to remember color different colors of wax, remeber the little cones that we were doing and all that stuff we were doing what we were doing that because we were the lab people because we did everything right?

Howard: Right

Sam: We had the sprues you name it now in our dental schools all the lab work is sent out and our dental students don't do lab work that's not neither here nor there but you and I learned occlusion waxing waxing. Unfortunately the dental student leaving as Nair has never really watched anything so therefore from that standpoint you know they are totally not in the occlusal vein so it makes it even more that they need to go to Pankey or they need to go to Dr. Christensen's courses or they need to go to Dawson or they need to spend time with As and I want to I want to say one thing that Gordon mentioned one of the areas that we are going to find out eventually with implantitis is going to be an occlusion you watch somebody is going to do the right study to demonstrate that bone is not concreat that it's viable but you know what happened see we get away with a lot because of a paradata ligaments you don't have a periodontal ligament in implants and that's when you begin to see screw fractures you know the cementation I am convinced that you better know occlusion or you should not restore implants.

Gordon: Ill ass something to that Sam if a person is placing implants and now it's around ten percent of general dentists placing implants I'll be in Israel next week it's about 80% there we behind other countries but with that many places people placing implants I strongly believe it's much like an auto mechanic who can't fix a motor person who is placing implants she'd be able to resurrect them and that's a lot of dentists that's at least 20,000 dentists in the US placing the influence and if they have to refer that that's like the auto mechanic saying I don't know how to fix the carburetor I'm going to send you down the street. They need to know how to salvage that and a laser has the potential to.

Howard: Okay the Millennials they love Shark Tank if they're gonna have their own business they love shark tank and if you were on on Shark Tank and you were on recommending this Biolase waterlase Mr. wonderful would say well who's your major competition so I guess that would be fotona so if a young kid was a CEO what's the difference between the fotona laser and the waterlace what would you guys say?

Sam: Well we could get down into the granular power the erbium YAG is a laser the erbium when it sees water it immediately stops the erbium chromium ysgg when it sees water it absorbs, personally we like because we are working with soft tissue we are working with hard tissue we would like a better depth of penetration so that is the difference between an erbium YAG and in the erbium chromium ysgg the other parts are the again like the icing on the cake it has to do with the training it has to do with the follow-up it has to do with the possibility by the way this just happened in the last two weeks Biolase secured an FDA clearance for removing crowns and veneers zirconium crowns off of teeth and we are the only company in the world that does that and that is incredible when you can take a veneer off in 30 seconds with a laser and the reason it works is because the energy goes through the zirconium finds the water in the resin causes micro explosions and literally pops that veneer off as a whole. So there there are some smaller differences but you know you know really what this is and I'm gonna take off a Biolase hat you know what the number one competitor is for any laser company its dentists that have not appreciated getting out of their own way and start looking at laser technology because our patients are expected they don't want to hurt they want minimally invasive and as Gordon says this is about lasix you know I'll bet you that if you and I interviewed ophthalmologist 25 years ago and said hey we have lasers you know what I think they would have said exactly what many dentists are saying today and I would never have my eyeball ever worked on without an optimist that didn't have a laser this is where I know this is going because this is what patients expect and this is where the value-added is going to occur.

Howrad: Okay so got a follow-up question so you're recommending this Biolase waterlase and their I know someone's listening is saying well what about what if maybe I should do Lanap instead compare waterlase and Lanap

Sam: There are significant similarities because Howard as a periodontist there are cardinal rules in anything we do that you can never try to violate there is one difference the periolase is a soft tissue laser it is not an all tissue laser it cannot remove the smear layer I don't want to overlook the smear layer unless you open up those dentinal tubules you're not going to get the kind of attachment we're talking about and I could probably buy two or three Express lasers for their cost of a ND Yag laser.

Howard: Right another question, when I tell you this fact statistics you're not even gonna believe me but at the cologne meeting last year there were 400 different dental implant manufacturers four hundred and you won't even believe this over half of them are just from the country of Italy alone but the question is do you think some implants have surfaces more prone to peri-implantitis than others?

Sam: Well you know that is well you'd like to be candid Howard here we go. Howard implant companies are in denial that there is implantitis, many people who place implants including my colleagues and my oral surgeon brother are in denial that there is implantitis it's only natural why would I admit failure when it's my business. However we have done studies implant surfaces are different, they're very different and the interaction of attempting to detoxify them are also very different now this is somewhat controversial to a certain degree but when you talk about detoxifying our decontaminating and implant surface you got to tell me exactly what you mean by that because I can take a cotton pellet filled with chlorhexidine and pretty well do a number on most implant services that's not what this is about this is getting towards corrosion this is getting towards titanium oxide this is now in refereed journals and this is where the laser comes in to make that surface like it was before when he came out of the package.

Howard: She just wants to know, look I'm coming out of school I want to learn implants just give me the name of one of the system, if you were 25 and you had $285,000 student loans and I mean because she when she goes to her periodontist oral surgeon they usually have five different systems she doesn't want to buy five different systems.

Sam: Correct

Howard: If she wants to buy one system what would you tell her?

Sam: I'm a Straumann guy I've been a Straumann guy I love the SLA surface it's done me well I know every single article ever written on it I love them as a company they've got and someone asked me when I was placing a lot of implants they said how come you used Straumann I said you know what this Drummond guy comes by every single week I need that company's support they are they you know some people will say they are industrial strength they don't restore as well as others what I mean by they don't have as many options they do now, bone level but for me if you ask me tomorrow what implant I would want in my own mouth are my wife Tessa's mouth it's going to be SLA it's going to be Straumann.

Howard: I just want to say one thing on Straumann, they are number one in units sold they sell more implants and what I also found interesting about them when I asked the CEOs of implant company - come on they run, Marko Gadola was on episode number 839 had thousand views just on YouTube that guy I said really you want to come on I was giving a lecture and I said you're gonna take questions from the he said I want to hear for my customers I want to hear from dentists good or bad. So the most successful people in the world make a religion out of availability, Gordon Christensen is absolutely the modern day living GV Black and he's come on this show four times and you know what you call some of these CEOs of smiles direct club, Invisalign and they run the other way and so kudos to Marko Gadola for coming on the show and he took some tough questions and from Canada of all the places I thought that'd be the nicest crowd in the world and the Canadian that were actually feisty up there. I want to go back to Dr. As real quick you always lecture about Dr. Lows repair technique what what why well explain what that is?

Asle: Well Dr. Low can probably explain a little better but there's really five or six steps and it's you use two different tips and one is a radio firing tip use that for the majority of the procedure it's basically lays the flap if you want to call it a flap down to the bone you would the degranulate the tissue you'll also then use the radial iron tip as doctor law said there's many different ways to remove calculus and erbium lasers one of them but he suggests using a just a some sort of hygiene scaler whatever works for you and then he goes back with the again this is his repair system we're using and again the nice thing is all on the touch screen just hit go from one step to the next and actually open up the dentinal tubules because really what we're trying to get is that long epithelial attachment that's he said we don't know those dentinal tubules that can be a problem we may not be able to get that at...

Howard: Can I just gave you some advice on Dr. Low's repair technique.

Asle: Yes

Howard: If you google Dr. Low's repair techniques you just pull up a bunch of pages of hernia repairs so you need to add the word Samuel.

Sam: Howard I am doing that too

Howard: and one last time what was the brand of Straumann that you recommended?

Sam: Oh no it's Straumann, I'm just talking about their their patented SLA surface.

Howard: So any Straumann with the SLA surface?

Sam: Yeah exactly, yeah that is a great great surface for us to integration for predictability and by the way we used the laser on many different lasers and many surfaces just to make sure it is appropriate for them.

Howard: Well I can't believe we went over an hour and I'm sure you guys got better things to do than talk to me longer than you have to but you know I would say that of all of all the 10 specialties don't you think periodontics has changed more than ortho, endo, pediatric dentistry, a public-house don't you think that that specialty has changed the most in the last three decades?

Sam: Well you want some more candor

Howard: Yeah

Sam: because I was with area residents this morning do you know what the first the average percent period on you know a paradigm is work week you know what percent of their work week is actually doing a managing periodontitis?

Howard: How much?

Sam: 30 percent, you see the problem?  You know what you're doing the other 70 they're placing implants and doing mucogingival procedures. 30% now how did that happen it happened because of trending I could go into it but you know the problem periodontists should be managing periodontitis and saving some teeth and I want to change.

Gordon: I so strongly agree with that I went Chicago Midwinter a few years ago I had a bunch of periodontists and I was chastised by them because I said almost exactly what you said one guy got up and said I do perio and I said congratulations we need to be saving teeth if we look at the overall life of cleaning and chewing we start out with teeth we get a few restorations they gradually going to crowns we start doing some endos and start jerking some teeth out and gradually you get into the necessity to do the last resort not the first resort that you're seeing out a lot of offices right now unethically but the last resort is the implant it should not be the first resort it should be that we should be saving teeth first and I'm finding that's a gross need in dental education at the moment there's more excitement to bore a hole and bow and screw the screw and then there is apparently to place a class-d resin or good crown we need to get back to basics.

Howard: Well gentlemen before you go these Millennials like to Google YouTube and watch an hour of course before they go off and make money and fly across the country and go see you guys lectures we put up four hundred and forty six one-hour online CE courses and it says they've been viewed four hundred eighty two thousand six hundred and seventy-six nights so a half a million times but those half million are the views of the 446 posted we've been putting course up since 2005 but most some were taken down after three years we've had over a million views if you left all the old courses up but they love that one our view and Pankey Institute you know they have a week-long curriculum so they put up an hour course to explain each week they said was the best marketing they've done. I'd love to have you guys each foot of course up there they so much prestige of dentaltown it transfers so much knowledge but then it turned people onto you and that that's why I do these podcasts because I think in the 32 years I've been a dentist that if I had to look at the one variable associated to who had a most successful career meaning they were happy they enjoyed dentistry they didn't burn out they had money I think it's connected to number of hours of CE. If you're talking a hundred hours of CE a year you're exposed to so much knowledge that you're gonna figure out a fun way to be successful and if you're just taking those minimum requirements to get your license redone so that that's why I started this podcast I thought okay you got an hour commute to work you're in the middle of nowhere Kansas or Iowa and driving down that highway instead of listening to you know talk radio you know I'll bring him Gordon, Sam Low and Dr. As right in their f-150 pickup truck for free but I hope I sure be nice if you guys put online CE course on this because when I look out at the dental industry in America there's a two hundred eleven thousand Americans with license to practice dentistry they build out a one hundred and seventeen billion when you go around the world there's right at about 2 million dentists they build out half a trillion for seven and a half billion homosapiens. So we know that dentistry is important I mean two million humans have dedicated their life just to be a dentist and treat these diseases it's not going away but when I look at the that that half a trillion dollars it's all just kind of growing one and a half two and a half three percent a year there's only two areas and this is my last question I want to have you guys weigh in on, You know there's only two areas with double-digit growth and that's implants and clear aligners and implants are growing ten eleven twelve percent a year and we just had this smiles direct Club and they just had an IPO and it was a disaster and I want to weigh on this because on the one hand they tried to do they tried to make orthodontics faster and cheaper but they decided to go around the orthodontist whereas Invisalign chose to incorporate the orthodontist with them but what did you guys think of the smiles direct Club trying to make orthodontics half-price going around the orthodontist, do you think they were trying to do the right thing by lowering the cost of ortho or do you think that was just failed doomed right out the gate?

Gordon: Don't you know this is a controversial, topic this is so controversial. ADA has expressed their thoughts on it orthodontic are hysterical, patients are doing minimal things adequately well other since they get into more moderate things the lawsuits are going to abound over the next while. As I look at this thing we'd be the first ones to investigate Invisalign our CRM aid and now that's the report by the way if you want some of our base I'll give you a website those are you listening will get you well hundreds of pieces of education if you want to search information you're going to go to clinicians, this big one long word but as we looked at Invisalign years ago i was very impressed because it was scientifically oriented they new how fast they could move a tooth they knew how fast they could move without degenerating bone and now one of the most disagreeable things that I see is my patients coming back from some orthodontist where the teeth has been shortened by three four five millimeters for going too fast there's an enormous amount of information out there about how fast the teeth can move and when you feedback you've got trouble and I'm more than happy to admit that the small amount of tooth movement can be done by almost any human as soon as they get a little more complex somebody has to tell them where to stop and I don't know who that's going to be.

Asle: Yeah I like to just add one a few things that actually because I look at x-rays in cases from hundreds of every day as part of my job and you would be absolutely amazed at when they come into one of our offices that there's doing smile direct and they have access to it type 4 periodontal issues they have decayed all over the place I mean I just don't see how they can move teeth when no one has said that the teeth or tissue is healthy enough to move that's really what I'm seeing I'm seeing it every single day.

Gordon: Yeah

Howard: So Sam what do you think about smiles direct club, how's your stock doing in smiles direct Club?

Sam: Well the background you know there is some link to the other company we've been talking about the bottom line here is...

Howard: What does that mean?

Sam: Well I mean there was a relationship between align and smile direct.

Howard: Right

Sam: and so my point is is that you know commercial is commercial as commercial I what we're doing is we're falling into the trap of allowing patients to dictate where we're going and we need to be the drivers of that instead of our patients being the drivers of that I shouldn't want to you know Howard I have Sam's you know they're need as Low's seven human needs I'm gonna give you Sam's five patient needs you ready, they don't want to pay, two they want to look fantastic even if their medicaid patient, three they want everything done now, four don't hurt him and five they want convenience. So those are the things they want our position is to at least listening to the things they want but not give them what they want. Do I believe that you're going to be able to go into Walmart and get your teeth cleaned yes do I believe we're gonna be able to stop that no do I believe that there was an optometrist that really loved me and took care of me yes and I find him now no did I know that there was a pharmacist that actually knew my family yes he's our pharmacist now no my position is owned by a hospital corporation but I would suggest to you and maybe it is not I do strongly believe Jim Pride said this Dr. LD said this there will always be patients who want us and that is the patients that I want and as long as that occurs there is still you know I just did a review I interview with News & World Report and they said is his dentistry still that dream profession and I said absolutely it's one of the few things out there where you can have a relationship with a patient the independent provide high quality of care. So there is a future out there but if you look at smile direct it's not gonna just be smile direct Howard you know that you can get veneers right now online they can send you the impression material you sink your teeth into it and you can get veneers now it's gonna look like Halloween but you can still get veneers. My point is we can't let patient sentiment dictate where this profession is going.

Howard: Alright so we call this podcast peri-implantitis treatment with Dr. Samuel B Low, Dr. Gordan J Christensen and Dr. Alse Klemma does that sound like a good title?

Asle: That sounds great

Howard: Alright it was a huge huge honor to have you three legends on the show today, thank you so much for coming on and talking to my homies it was just an honor to have you guys on and thank you for your candid honest trustworthy thoughts and opinions on all things peri-implantitis.

Gordon: Thank you Howard

Asle: Thank you Howard

Sam: Thank you and thanks Gordon for being on this I really appreciate it, it's definitely an honor to be with all of you. 


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