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AUDIO - Sheldon Lerner - HSP #89
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VIDEO - Sheldon Lerner - HSP #89
Howard and Sheldon talk about the problems surrounding implantology today, and why Blue Sky Bio might be your new best friend.
Currently Chief Technology Officer and co - founder of Blue Sky Bio implants
Previously in private practice from 1982-2010. Practice limited to periodontics and implants. Practiced implant placement exclusively from 1996-2010.
Howard: It is an extreme honor today that Dr. Sheldon Lerner who's the co-founder of Blue Sky Bio Implants accepted my request to do a podcast. I was begging him to do this because somebody started a thread about Blue Sky bio implants surgical guides and I mean the thread in all reality it went viral. I mean there's like 10,000 views on this thing, so basically in the ... [inaudible 00:00:36] school in '87 first the big hotspot was the interal camera and then it was two twightening and then we have the cosmetic revolution. You are sitting right in the middle of the Tsunami hotspot of dentistry where there's a lot of convergence of things going on.
We were gone from a 2D X-ray machines to 3D, so now implants surgery that it's been really a game changer for implant surgery. Basically oral surgery in general because you are thinking about pulling a wisdom tooth and you see that lingual nerve but you don't really know where it is but with 3D you know exactly where it is. It's usually a lot more lingual than you think. So first of all have you seen that thread and what do you think about that thread?
Sheldon Lerner: Of course I've seen the thread I'm on it, first of all Howard thank you for inviting me it's an honor. A lot of what we do is all your fault, screams at me "what are you looking at?" I say "I'm on Dentaltown, here see, there's no pictures of anything bad here, look at those bloody things." Anyway so like a lot of people Dentaltown has replaced television viewing for me. A lot of what we do is essentially your fault and I've given her your home address. So call your house and complain to you.
The traditional convergence is happening on Dentaltown, there's something called crowdsourcing, you've probably heard the term I don't know if everybody on Dentaltown has heard the term. I live in two or three worlds, one of the worlds is in dentistry and the other world's on the digital side. Somewhere in the middle are these young guys that I got to talk to and talk to them in their lingo, it's a whole different life. The guys who are supposedly working but they are using guide wires to like fly themselves from the course [inaudible 00:02:26].
It's like a nursery school, its basically our digital group which is only on guys they speak a different language. Crowdsourcing means in essence that instead of trying to guess what your consumer or customer or in this case clinician wants, make them part of the research team and have them decide what would be better, what could we do, and so on and so forth. So essentially that 10,000 thread, 10,000 view more, it's close to 11 or 12 I don't know how many by now on Dentaltown is the world's first crowdsource digital resource for us to develop a very responsive program or implant guide planning.
Essentially what we do is we listen to everything that's said on that wire to your guys who are on there and say I'd like to have this. Well we tell our development team we've never unravelled that. The same development team that was there in the beginning is there now, we say okay this is the latest out of Dentaltown, they want this, 2 weeks later its in a build. Sometimes if it's really advanced it takes 2 months, so we've gone from I wish there was something like this to it's here. Anybody that asks us anything we generally put a team apart, our team they decide to put it in their roadmap to completion.
The other thing is that we ... I'm a surgeon, I'm a periodontist, the other people who step by or the other founders Dr. Albert Zickmann he's a neural surgeon. Essentially the people who are on our team they have in the interviewers and they use our artificial intelligence hopefully we have a proper intelligence to build the intelligence of a surgeon in to the program. So a) it's being worked on by everybody at Dentaltown and across the world and as well as by ourselves, because we've essentially said okay deprogram us and our team said okay how do you figure out where the mandibular canal is?
Well this is how we did it, so now the program recognizes the mandibular canal all by itself. The next version which I think is coming soon all you'll need to do is take a virtual tooth which is built in to a library, put it where you want it and the program will pick the diameter of the implant, the position of the implant, knowing that it needs a certain amount of space between the buckle wall so there's a blood supply, angulation, everything is built in, length, it's all there, all part of that artificial intelligence.
Howard: Okay let me back you up a little bit because these podcasts have excluded items, we've got about 2500 listeners per episode of every single congener, so let's back up all the way to the beginning. What are you even talking about, what is Blue Sky Bio?
Sheldon Lerner: Blue Sky Bio is [inaudible 00:05:24] company that was founded in 1998 and we did our research and development and we actually first went public in terms of ... Not public in terms of stock market but in selling implants about 2004. We started as a consulting group for other implant companies and eventually decided to come out on our own. So we started doing compatible implants but relatively about halfway through we realized the world is going to go digital and we started developing a digital team as part of what we are.
So Blue Sky Bio is essentially two companies, it's a digital company and it is also a dental implant company. The additional company and the implant company grow in lock step with one another. For example Blue Sky Bio already is the number one treatment planning software for dental implants, I'll talk about that in a minute. There's a new user Blue Sky Plan which is our digital version of our software every 15 minutes. We have users in every continent on earth with the exception of Antarctica. I didn't know there was a cone-beam in Kenya did you?
Howard: Yes I was in Tanzania and Ethiopia last Summer.
Sheldon Lerner: Well have users in almost every country in Africa and every country in Asia. The software is in I think 8 languages.
Howard: Explain this software, how does this ... How much does it cost, do they download it?
Sheldon Lerner: That's one of the reasons for its growth and despite the fact that it's free it's as good or better than any paid program out there. See programs that are $7000 that are plan catch-up to Blue Sky Plan essentially because there's a new build every couple of weeks. What it does is a patient goes for a cone-beam X-ray which is pretty common place right now, they get a stone model of their jaw made even before the cone-beam or after. The patient is scanned in the cone-beam which is a small dental CAT Scan.
The stone model is also scanned in the same cone-beam and the software kind of almost automatically merges the 2 images together. The stone model which is like a 3D model of the jaw as well as the cone-beam which is a 3D X-ray merge them together and then it allows you to put an implant then exactly where you need it to be for the crown because there are virtual teeth in the program. Virtual tooth means a 3D image of a tooth that you can bring down from the library and position it is positioning tools. Then you can loan your implant so that the implant really is restoration driven.
Once that's done you can take the same stone model and everything is all right and the same stone model is then scanned by what's called an optical scanner. You don't have to have the optical scanner, there are partner groups and labs that work with us that are also blogging on the Dentaltown thread. That for $30/35 we'll scan your stone model in an optical scanner that will then help you merge it to the images you've gotten already. There is simply one button that you press that has an artificial intelligence agent in it and it will create a guide.
All the CAD/CAM is essentially artificially intelligently built in there so that anybody, a 12 year old for example can plan ... Probably can't plan the guide because you don't want to trust a 12 year old with that. If you oversee what they do the CAD/CAM part is essentially pressing a couple of buttons and the software does everything else. That's what people wanted, they didn't want to have to spend weeks and weeks and weeks learning how to use a CAD/CAM program it's all built in with artificial intelligence, that's a revolution.
What's that's doing is its taking ultimate plan, ultimate accuracy and bringing it to the masses. The example I like to use is when I was, I was an engineering person before I was a dentist, so I remember learning at how to do computers on an IBM360 and IBM360 was the size of I don't know a large 14/18 foot truck. I had to wear a winter coat in this summer to work in the room and you had the punch cards that you would write only 80 characters. So the world really was like that only people with really big computers and only people with really expensive equipment could do guided surgery. You had to pay a lot of money because there wasn't a lot of places to get it.
Even the laboratories had to work with only a few companies. Now every single laboratory ... We are in our own laboratory either the planning is done by a general dentist or a specialist or a lab person they are all the same to us. We have a tremendous network of partner laboratories that will produce a guide for very low dollars in sense. If you wanted to go ahead and plan it on your own, there are people who print the guide fee for $35. If you want some help then they charge you for that help but nobody's holding a gun to your head anymore. It's the same revolution as when PCs happened.
Now everybody has a PC, that PC revolution and the creation of the internet is what helped Blue Sky Bio become a force in implant dentistry. Essentially everybody is the same, everybody has the same competing power. Once you have the same competing it's a level field so we can compete. Now everybody else can compete, there's always somebody in Kansas can't do the same work as somebody who's near some kind of large CAD/CAM Center, it's all the same now.
Howard: Yeah so basically to our viewers you have a digital implant software to help that merges with the 3 dimensional X-ray machine to help make guided surgeries?
Sheldon Lerner: Right and that software is free.
Howard: That software is free and then you actually sell implants?
Sheldon Lerner: We actually sell implants and that's what we did, instead of doing the coffee cup ... Listen you are a doctor, you are a dentist also and so was I. The last thing we needed was a knock on that door saying and your secretary coming in, you've got 12 patients in the ... not 12 patients but always feels to the dentist like they have 12 patients. In over your head you've got callback people and let's say is an implant at the front door why do I need that for? Like instead of that, instead of the coffee cup, instead of taking somebody to dinner, we figured why not just give some people what they really need which is this powerful tool.
Why not give the people support just like the way you and I are communicating right now over a podcast I can see you, you can see me, instead of using a person who may not have ever done surgery as your rep, as your helper, why not have a team of surgeons who can connect to you video wise, live, look at the cases, look at the X-rays and help. We have enough people we could outperform in terms of support almost anyway. This is all the digital revolution which could not have happened and you're part of it.
Howard: So to my viewer there how does he get a copy of this free software, would he go to Blue Sky Bios. Blue Sky's Bio ...?
Sheldon Lerner: Blueskybio.com which is our corporate site.
Sheldon Lerner: Right and he clicks he/she will click on the topic says software and right there's a whole page and there's a little icon you clicked on it. It's SU Mac and/or Mac or Windows and you download whichever version you have, the software works the same whether it's Mac, its different versions of the software but there's one version of software for Mac and another version for Windows, they look and operate exactly the same. Obviously the coding behind it is different because one they are working on different operating systems.
They are both available, you download it and you are off to the races. There are video tutorials, we have a dedicated teaching staff online for people who are running in to problems if they watch the video they want a little explanation here and there. We have people that talk to them it's all free that's our rep, that's our knocking on the door ...
Howard: So then on the software app, so now this person has a CBCT they are going to need either ...
Sheldon Lerner: They have pCT, they have those little fans that drive to them with a cone-beam sitting inside. Well they'll refer to usually ... usually people get friendly with their orthodontist, a lot of orthodontists have cone-beams now. [Inaudible 00:14:11] for the cone to the orthodontist or might be an endodontist who doesn't place implants, can you do me a favor and image the case me. There's also people who are friends, who have 4/5 docs will get together and they'll do a cone-beam and they'll share it.
Howard: You know what oral surgeons in periodontial the smart ones tell me they said that this person always did bridges and partials and dentures and bridges and partials and dentures and they never refer to him as [inaudible 00:14:37] or anything. Then the referring doctor got in to start in a place a single implant here and there and now they just see implants and now there are referrals for four on the floor, full mouth stuff that they don't want to get in to has sky rocketed. So you got to think and hope, growth and abundancy not fearing, scares. I think a periodontist and oral surgeons are afraid of a general dentist placing some implants I think it's the wrong thinking.
Sheldon Lerner: The software is designed for everybody, I mean a lot of our users although it sounds like we are a general practitioner implant company, the opposite is essentially true. Most of our implants are actually sold to specialists because we started that way both I'm a specialist and Dr. Zickmann who's the other founder, he's an oral surgeon, that's who currently most of our customers in terms of the implants purchased, they recognize a very good well designed implant at a reasonable cost. We also want to give the tools to everybody. The specialists, generalists issues are an issue only in the United Sates so to speak. In Asia, in Europe there aren't that many specialists and people who decide themselves to try to work harder on it.
Here in the United States I do see that the people who help their refers do something, they get a lot of referrals, I saw it at my own practice. I had one of the large, I'm told I had one of the largest implant practice in the United States, we did well over 1000 implants a year. We did that because we dedicated our staff to assisting the restorative docs. I stopped using implant reps to walk to the doctor's office, I had a dedicated staff and team member that would help with the impressions that would go there with the instruments.
I would stop by, I would have them at my office, I would teach them how to do grafts, I would teach them how to do simple implants and my practice just zoomed and I got all the more difficult.
Howard: It is selling when you go to a country like Korea, 15,000 out of 20,000 dentists placed an implant last year. You come to America and 9 out of 10 general dentists have never placed an implant in their life ever.
Sheldon Lerner: Korea has 3 to 4 times utilization than United States, when people ask me what do I think the expansion capabilities of the United States are, we are doing only one third of the implants, we could be compared to Korea. Israel has 700% more utilization per capita than the United States.
Howard: Explain the math on that, can you do the math?
Sheldon Lerner: Yeah there are 7 per capita, there are 7 times more implants placed in Israel than in the United States. I believe Israel's ... That's the highest utilization in the world I believe. So there's about 8 million people in Israel and so Israel is placing same number of implants as 54 million several states but together equal 54 million in the United States. Korea which I think is about 90 million something like that is placing almost as many implants as the United States in total.
Howard: Yeah and it's hard because when someone comes in and they only brush maybe once a day, they never floss and this tooth is bombed out and they just ... You're not going to change the behavior of this person and they do a heroic root canal build up crown lengthening, the behavior doesn't change and if they just sort of place an implant in the crown the bugs couldn't have eaten it.
Sheldon Lerner: That is a view but then there's also a lot of people who loose tooth because of trauma or genetics and periodontal diseases so on and so forth. The numbers of people, a question of training that's why there's much demand for training. That's why Dentaltowns implants ... I don't know what the number one group is viewed on Dentaltown but its a great experiment, I believe its the endofills is that correct? That's the number 1 and I think maybe cosmetics is number 2` is that correct? Number 3 is the implant.
Howard: Implants yes.
Sheldon Lerner: So right now the number 3 area in terms of interest on Dentaltown is our implants. Yet the number of people trained in the United States have placed an implant probably approach is around 10-15% of the population. I'm not talking about restoring, I'm talking about placing, so we have a long way to go in terms of people being trained. Now just because you are trained doesn't mean you want to do it, it doesn't mean you are going to do it. At least a person's eyes will be open towards or maybe they'll do 3 or 4 or 5 a year. The desire and that thirst for education is there which is why Dentaltown is so important.
Howard: Let me ask you a question Sheldon because you're a periodontist, periodontics evolved in 90s especially that probably has changed more in our lifetime than any other specialty would you agree with that?
Sheldon Lerner: I stopped doing perio in 1996, I referred out my perio.
Howard: So explain why that ... Would you agree that that profession has changed the most?
Sheldon Lerner: One day I was doing the sinus lift and the hygienist asked me to check a patient in the middle of a sinus and I said that's crazy. I said to myself why am I torturing myself, that day I said to the hygienist that was in my office because you've got a month off of pay that's the good news. The bad news is I'll write you a very good letter of recommendation. I walked over to the front on a spur of the moment, I walked over to the receptionist and I said, you are going to send out a letter now to all of our maintenance patients, they are going back to their GP or to another periodontist and I'm done I'm not doing perio anymore.
No that doesn't mean that that's what other people should do but that's what I did because I think it's possible and I was not practicing in Manhattan, I practicing in Brooklyn, New York, it's part of New York City. Nonetheless it's a neighborhood driven city I was practicing at a particular neighborhood and people tended either to get on the local train and go to Manhattan where they stayed in their neighborhood. People did usually go to a different [inaudible 00:20:43] but to a different dentist.
So it's a lot like small town structure even though its in the city. I said I'm going to do just implant placement and that's it and I'll help my restore guys restore sort of guys and girls restore and that's what I did.
Howard: Well you are a periodontist, what do you think is going to last longer, crown lengthening and heroic perio, surgeries or loose a tooth and replace it with titanium?
Sheldon Lerner: I think that the numbers of crown lengthenings that are being done in the United States probably speak for that by themselves. I myself almost stopped doing crown lengthenings by the mid 90s. Certainly root splits or facetious, can they last a long time? Sure I was trained at Penn, I was 25 years of retrospect from Dr. Morton Amsterdam passed away recently all those things. I lived in 2 different worlds. I think the world's changing, I think that people not everybody but I think that people do want something that is reliable which is why the patients themselves are driving the desire for implants.
That's what's going on and the need by everybody to suddenly get really versed in implants and the digital side of implants is so great right now. People want and realize that they've got to satisfy the patient demands, the patients want to have something reliable, a lot like lasik. The demand for lasik in terms of having your vision corrected is not coming from the lasik company, it's patients themselves or people themselves who look at their friends and say hi, I had this done and I can see well, that's great I don't need my glasses anymore.
That's what driving lasik revolution, in implantology that's being driven by the patients, the patients want this.
Howard: The lasik surgery was I still think the greatest gift I ever gave to myself is $4000 ... What people don't realize it's not that you're into your glasses, they told me I had 20/20 with glasses, after lasik they told me I had 20/20 but I can see twice as good. I mean my boys so many times I'd be somewhere and my boys I say like in our backyard I go, "wow look at that ledge there, what is that, an indentation?" "Like dad are you kidding me, we've lived here 20 years there's a road there." I mean you just see so much better.
Implants is just huge, so I want to go back to specifics, so this person is driving to work, most of my viewers are going to be on iTunes, on our commute to work, or maybe they are coming off of work. So they are going to go to blueskybio.com do you have one like overall video that they can watch to sum this all up or what would they do first? They are probably thinking I download this on my computer, I got a CDCT how do I get that CDCT read in to that software and second of all you're talking about a lab doing optical scan, how do I find a lab, I'm in Phoenix Arizona.
Sheldon Lerner: Its all on there, if you spend a little bit ... There's 3 ways this happens, one way this happens is somebody could be slightly more engulfed technically and they go on the website and they see okay step by step videos for the whole process as well as all the partner labs, that's one way they could just find a way around on it. Which is how a lot of people throughout the world do it because they don't have necessarily the time zone or the language skills necessarily in English to call up.
The second or whatever send an email, the second is send an email look I'm a newbie with this, I'd like a little bit of help, can you help me? We have a dedicated digital staff that will email back and forth and guide them that's step number two. Step number 3 ...
Howard: What is that email address?
Sheldon Lerner: It's plan.
Howard: @blueskybio.com? Plan@blueskybio.com?
Sheldon Lerner: If they download the software and there's automatically, it automatically wants to generate a license and it tells you how to do it when you download it. When you do that and send for the request for the license within 30 seconds the computer, our servers send back license code and then within a day or two you get a personal email from the Digital Director says, "hi there, my name is Michael, can I help you?" So that's also there and it's all free. Or they'll send me an email and say Sheldon, or they'll send Albert an email, we are very visible, I'll give you my personal email address it's not a big deal.
It's email@example.com. They'll send me an email, will say, "Sheldon I feel a little bit lost what do I do next?" No problem we'll take care of it.
Howard: You are amazing like that, you've very you know yourself and when you said that plans the implant you're talking about the length, the diameter and the length of the implant?
Sheldon Lerner: That will be the next version ... Right now you still have to pick your length and your width and kind of orient the implant and tweak it a little bit. The next version which is coming out in about a month will actually do a lot of the artificial ... Has a lot more artificial intelligence built in and it will make a lot of the decisions I can't say make the decisions for you because that would be scary to me. I still want the pilot landing the plane even though he has little pilot or she has little pilot. It does it in a way that you should only need to tweak it that will be the next version.
In addition the guide itself will ... This is again for people who've done it a while, staffs will be built it, heights will be built in, a lot of things that you normally have to think about or tweak it's all done for you. A lot of the artificial intelligence will be built in.
Howard: Sheldon a lot of my questions I ask you are just because I try to ... I'm trying to think what questions are ... With Dentaltown no one [inaudible 00:26:26] again so does this only work with your implants? Does your software only work with your implants?
Sheldon Lerner: No it works with everybody's implants. Like two versions from now you'll be able to ... Most of the libraries of implants will be on there already so if somebody has an unfortunate misconception to use somebody else's implants other than Blue Sky Bios they will be able to choose from a library of their own implants until they learn better that there are better places to get them. Obviously I'm speaking common chic here.
Howard: Right but ...
Sheldon Lerner: So they can just pick their own brand because their own brand will be up there. Right now let's say if they don't find their brand since ours are compatible, they match different implants you can pick ours and it will match in terms of the length with and the taper. If they have an unusual implant or something that is not in our library, we are not compatible with the software allows you to create what's called a custom implant. That custom implant has a height with an [inaudible 00:27:19] diameter, they plug that in and it sends, it will give you a form of an implant that needs your custom criteria. So any implant can be manufactured.
Howard: Well you and I have a similar story, I started a Dentaltown selfishly for myself, when I put my kids to bed I was all worried about the next day's cases and I just wanted a place to go talk to the dentist. So I started Dentaltown only for me, Bob Gibson started [Rembrandt 00:27:45] toothpaste just because he couldn't stand how the toothpaste took the lustre off his composite fillings and that was the birth of [Rembrandt 00:27:54] so why did a periodontist, an oral surgeon why did you guys start your own implant company.
Sheldon I think IDS in Cologne, there were 275 implant companies that just had a boothe. I mean how many implant companies are there and what would make a periodontist and an oral surgeon start their own company? What did the others not do for you that periodontists, or oral surgeons that we are just going to do this ourselves.
Sheldon Lerner: We are ancient history so we've been around for a while. I started practicing in 1980 and because I was an engineer implant companies would come to me. It's really nice to say that oh I was so smart and I did this, I'm so smart I did that and this is what I did it, I did it, I didn't do it. What essentially happened was a series of events that maybe one day over a beer you and I will sit and talk. There can only be ... I'm a faithful person only could say that there is a God somewhere who basically created a situation where I had to do this.
I made a lot of mistakes thinking that I could do this easily well Albert and I think that we could this easily. Essentially what happened is we had a patent, we approached the company, the company said great we love what you want to do, we are going to pay you x number of money, we are going to give you a percentage and it sounded great to us. We signed off on the paper work we sent it in, by the time it got there everybody in the company had been fired including the CEO. I don't know why he was very upset.
A year later the new CEO calls us and says, "I just finished going through all the paperwork, we really like your idea come down." We went down and they had a team of like 15 engineers and a super computer downstairs that they were going to test our design on. When we finished our presentation they turned to each other and said we don't need to test it, it's fine. He said this is the paperwork, we signed it, we sent it in and can you guess what happened?
Howard: He got fired.
Sheldon Lerner: Everybody got fired. Nothing to do with us, so we said you know what if what we did the two of us and our engineers they didn't even have to test it, maybe we know just as much as they do, let's start our own implant company. This goes back in the year 2000. So silly we thought it as going to take a quarter of a million dollars of our own funds, had a year or two to do. A couple of houses later it's hence another $15,000, hence another 50,000, hence another 100. Another couple of houses later we had an implant company and our first implant.
So if I had known what it was going to cost, how much time it was going to take and so on and so forth I never would have done it, never.
Howard: So what did you think of so unique that actually got you a patent, I mean a patent is an incredibly hard thing to get, how did you get a patent on the implants?
Sheldon Lerner: The crazy things that the patent ... It is a very good implant and it's a really good patent we never commercially made it.
Howard: Okay so I'm going to ask you a question that everyone's thinking out there, when you go to the IDS meeting which is Europe's biggest meeting and there's like 100,000 dentists there for a week and you see 275 different implant companies, what would you say to general dentist driving this car saying, "come on Sheldon, isn't titanium, titanium, titanium," how does the body know the difference in Adidas and Nikey?
Sheldon Lerner: It is titanium is titanium, titanium, the major difference is going to be the following, how easy is to use and is the implant designed from the surgical perspective of somebody who's placed it. Some of the biggest implant companies have the most clunky placement systems. I remember I won't mention the name of the company but he used two hands to remove them out with a rusher going one way and the stabilizer going the other. One of our first patents that we did use was a way of placing an implant without needing to have them out, without the need of them out.
So that perspective of surgery and engineering together works in very few companies where the designers are actually surgeons. So there are only a few implant designers in the world, there's probably a half a dozen of us. That's it, the rest of the companies just straight out tried to copy. So we make compatible implants, we also clone or whatever but its done in a way that surgically it's a better implant to place and it is more reasonable in terms of how it handles and so on and so forth. That's one, the second thing is that out of the 200 and something implant companies there are only less than a half a dozen have a digital force.
There is nobody currently that combines the ease of use and the ability to ... There is not a single implant company out there that has the ability for a periodontist sitting in a room somewhere they spend 5 minutes planning a case and press 1 with 2 buttons and make a guide. That combination of the digital viewpoint as well as the surgical viewpoint as well as reasonable costs made in America so on and so forth, that is a pretty tough combination to go after.
Howard: So Sheldon when Harvard [vis-à-vis 00:33:11] studies the most successful CEOs versus the least successful as far as profitability and they are looking for character traits of the leaders. Just by publicly available information they always come to a conclusion that humility is the top trait. That the most successful CEOs are humble and they listen to their customers, they listen to other dentists.
As the owner of Dentaltown I'm always dealing with all these upside companies because someone made a complaint about their product. How do you describe ... Why do you think you were so counter-intuitive that you saw that as just awesome information, that you didn't sit there and say you can't say that and you can't say that. We are listening, we're going to make those changes, we'll have a new update in 30 days. How come you are a owner and listening to the customers on Dentaltown when everyone else just wants no one to say anything about their product or their company?
Sheldon Lerner: It has to probably do by the way I was raised and the way that Dr. Zickmann was raised. We were raised in a particular way and in a particular fashion. Let's put it this way the most uncomfortable, I am at by most uncomfortable sitting after a classical music concert. I like classical music and the conductor comes out for curtain bows. My skin's crawling, one curtain bow, another curtain bow, its all orchestrated and that is so against how I was raised and how the world that I grew up in that there's nothing to ... I mean that's how I was brought up.
How do you do that and say it's me, it's me, it's me, it's not, it isn't. It's all those guys over there who are playing, they work hard too they should be the ones getting up and bowing.
Howard: I just think that it's amazing, I mean if every CEO of every dental company should see those 4 million posts on Dentaltown as their free market research. I mean if all the dentists are saying God I wish it wasn't blue, I wish it was red. Wouldn't a smart guy just say okay, let's make it red?
Sheldon Lerner: I'll say it right now the worldly implant reps and all the CEOs that having and maybe Albert will me for saying this but kudos out to you and to the people in Dentaltown. We have the largest research organization in the world and that's called Dentaltown. We ... It's not like [inaudible 00:35:37] people email us and call us all the time. We really listen because actually the reason why Blue Sky Bio started is because people wouldn't listen to us.
We were lecturing for another implant company, we kept telling them that there is a problem here. They wouldn't listen. I kept saying well I'm having this problem now but next sentence is something you might recognize and every single person who's ever placed an implant will have heard this sentence. I hate this sentence, "well doctor we are not hearing it from anybody else but you."
Sheldon Lerner: So baloney.
Howard: I know.
Sheldon Lerner: When I went through that I have a drawer, there's a certain implant from Germany that doesn't exist anymore, that had some kind of a plastic insert. I'm not mentioning the name, don't you mention the name either. I put 400 of them in and you know where the 400 were? The 400 at the end you can't see it right now, this is not the drawer, but 400 of them after 5 years ended up in my drawer not all 400 probably 395. When I said like why are all these things failing, they would say well [inaudible 00:36:41] is on you, it turned out to be that the HA coding was melting. You remember ...
Sheldon Lerner: You probably know what I'm talking about the main cheek [inaudible 00:36:49] was melting on it and the implants ended up going bye and bye and the plastic insert was fracturing. It was like what do you mean I'm the only one, I'm not crazy. After that happens to you as a clinician and it happened to happen to me I never think as a business CEO personality. I always think about my patients who were my patients, although I'm not practicing anymore but they are still there.
Howard: Now I want you to take off your doctor learner periodontist hat and I want you to put on your Dr. Phil hat, because you and I have lectured all around the world. We've graduated in the 80s and we know that 3 out of 4 dentist in Korea and Israel placed an implant probably last month. We are talking 80% of our audience right now is America and 95 of the 100 have never placed implants in their life. They are driving to work right now and they are just saying, and they are thinking, Sheldon I'm kind of scared I'm not really a blood and guts person, I don't know this just seems so overwhelming.
Put on your dad hat what if your daughter just walked out of dental school and she never did a surgical training implant, why should she learn how to place an implant and why should she commit to this? She has to decide she wants this, why should she drive in to work right now and decide okay Sheldon, okay Howard I'm going to commit to placing an implant someday. Talk to that person.
Sheldon Lerner: So there was a time where people didn't want to do bonding I know its hard to believe but you went to Dental school you learned how to do bonding. When I went to dental school I had to get special permission and a signature in order to do a bonded restoration. The patient had to sign off that that was something that was going to fail and so on and so forth. The light activation for us I go back a long time light activation was just invented that year that's how 4 got to 1.
I think of the revolution that has occurred in cosmetic dentistry, imagine that you at that time were not going to do cosmetic dentistry, you were going to say I'm not doing any bonding, I'm just doing a mouth restoration gold and porcelain fused metal. Could you imagine doing that right now after what you've done at dental school and the answer would be no, no I don't. I said this is the revolution that we are actually in the midst right now of it. That sounds strange to people already placing implants but the revolution is already there, you will either be part of it or you will be the same dentist who doesn't do bonding.
When my last day in practice was I think 2010 or 2011 I remember looking at the patient I'd just finished an [inaudible 00:39:38] for and I looked at the patient and I came back especially because I promised her a year before that I would take care of her. I said to her, "when I graduated Dentist School in 1980 my first thing I did was I put in an amalgam restoration and right now I have never, today is the last day. There's not one single thing that I've learned or used in dentistry that I'm using now 30 years later." In other words I injected with a 30 gauge needle, what 30 gauge needle in 1980?
Right I was using marking what's that in 1980, I was using implants what's that in 1980? The people who were going to be ... There'll be two kinds of dentists well, there'll be three kinds of dentists, there'll be dentists who don't do digital, that's something that's going to happen now. If you are not in the digital world that's going to hit you, if you are not in the implant world that's the same as not doing cosmetic bonding or cosmetic dentistry right now. You are going to have to change, you don't have a choice.
Howard: Sheldon how come I see people, dentists all the time they say no I don't think I can do that but they pull teeth. They'll pull molars, it's like well how can you pull a molar and not put in an implant?
Sheldon Lerner: Well right that's one of the things you actually asked me how does that go? If somebody right now is not extracting teeth, if your periodontist is not extracting teeth it's unlikely that they will be able to develop an implant practice. First they are not really ... people aren't really being taught generally how to place implants, first step in placing an implant is to learn how to extract atraumatically. On Dentaltown and it's in other places some of the hardest courses on right now are not placing implants, it's step one.
How do I extract a tooth atraumatically and that those courses are being attended by periodontists, those courses are being attended by oral surgeons who trained in a different era and those courses are being attended to by general practitioners. You need to learn how to take out a tooth, if you are not taking out a tooth, you are not going to place an implant.
Howard: You said they got to do it atraumatically?
Sheldon Lerner: Atraumatically.
Howard: Any of these course you recommend or any of these techniques to atraumatically remove a tooth?
Sheldon Lerner: There's plenty out there, I think that there's actually a Dentaltown thing called Murph or something ...
Howard: Tommy Murphy?
Sheldon Lerner: Yeah and I haven't been and for example you've heard of Garg he's also on [inaudible 00:42:10] so Arun Garg runs what people think as an implant training program and that's true. The level one, Arun will tell you himself level one is going to the Dominican republic under supervision, learning how to remove a tooth atraumatically, it's a full course by him. Very well attended, he said he instituted that because people were coming in and having a teeth extracted in an atraumatic fashion. Many of the patients that were coming back then to get implants in the Dominican Republic and training, they weren't candidates.
I've seen it myself we added the Dominican Training Center, the patients mostly weren't candidates, they didn't have enough bone. So most of the work was being done at an advanced treatment placing, try to replace bone. He says now that I've made a course on how to atraumatically place implants and grafts everybody coming back is an A easy case. That's number one, so the first step is I'm not going to ... People say I'm going to go to a class and learn how to place implants in the weekend, I think they are fooling themselves.
Dentists, I'm not going to scream about Dental Schools, but Dental Schools aren't teaching what they need to teach right now which is how to atraumatically extract teeth when a patient really needs to atraumatically extract teeth. Once they learn that that's their certain tools they can use, they can use, there's 3 or 4 companies that have special tools that extract teeth, there are periotomes, mechanical periotomes is a piece of surgery which is an expensive toy. I had one the biggest use I had was to extract teeth by cutting it out without turning the PDL.
There are all kinds of tools and toys to learn how to extract teeth. There are full courses on it, you either grab a little plier, rocking buccal and lingually to try to break the buccal plate to get the tooth out. That's done I know it's old school but it's crazy it's not how it should be done.
Howard: Just give me one little experience of what he's talking about is just exactly these when we were in oral surgery they laid all these forceps and pliers and it was a muscle job. Now by just pushing like a periosteal all the way around the tooth.
Sheldon Lerner: That is a long tiny skinny thicker knife that goes and sneaks in between the periodontal ligament of the bone, it severes the periodontal ligament and then you rock the tooth easily and distilly not buccal lingually with small little elevators to get it loose. You grab the tooth and you pull it occlusally. That was actually the course I tour, I met Dr. Zickmann because I tour the course in extractions for an implant company and Albert Zickmann who was an oral surgeon was teaching how to do plastic surgery in the oral cavity for implants which is supposed to be a periodontist job.
We feel like that was funny and we got together that way but that's true, the truth is that you need to be able to learn that skill. Which is let's [inaudible 00:45:02] distilly, cut the teeth out with what's called the periotome which is an elevator which has ... Which looks like a perio probe but the elevator is flexible and thin that goes inside and cast the PDL in. That's looks like [inaudible 00:45:16] they get the tooth out. There are other devices that help you as well, there is two or three different devices.
Titen has one that uses like little endo post that screw inside and has something else from the ... it's either you screw it down and it pops the tooth out. Dentex has one also they are not cheap but this is the world we live, this is ...
Howard: I want to add one more instrument that they don't sell on this technique, that is hydraulics, have you ever seen a dump load truck by pushing fluid in there you can lift infinite amount of weight. That's what happens when the body is swelling and a lot of times these kids they are just trying to rush and force it out there, if they would slow down and keep elevating and this older guy knows that sometimes when it's just not giving that's a good time to go do a hygiene check, go to the bathroom, go check your email and then you come back.
Sheldon Lerner: Swell and push it up.
Howard: That tooth is just waiving in the winds so just slow down let mother nature do it. Now I'm all by myself I'm in Dentaltown solving the no dentist practice all again. I'm now at a convention, I see 275 different implant companies but right now I get to talk to the owner, the founder of Blue Sky Bio. Why should I buy your implant?
Sheldon Lerner: I'm going to be sitting in your earphones.
Howard: For the relationship so you are saying, you need this relation.
Sheldon Lerner: I walk through the same ideas [Cologne 00:46:41] meeting and I walked together with Albert Zickmann and Albert was ... He's probably going to listen to this, he was a little depressed, he said "how are we going to survive?" I said "Albert there's a big difference here, we are not in any of those boots, when people work with us they are working with the surgical teams, they are not working with somebody who's got to sell you something in order to make a bonus for the Christmas holiday. That's not who we are, so they are working with a team, that's one of the reasons why we have ... We partner with education, some of the parts is greater than the individuals.
Yes I can sit there and tell them why our implants are great and wonderful and they are.
Howard: So what I just heard you say is you can buy an implant from a faceless institution or you can buy an implant from a real person you who they are starting out right now in Dentaltown and YouTube.
Sheldon Lerner: We have all the engineers we need and probably there's more. We have all the machining stuff that's all done in California and Pennsylvania and Minnesota it's all done in the US. We have the lawyers, we have the accountants, we have the business people, we have what we call the suits. There's one thing that ... We don't do that anymore. What we do is we are available we decided we are going to be the people that do the support. When somebody calls up and says I've got this case I'm not sure how to restore it, you speak to us.
I know that this doesn't sound very, what's the world I'm looking for, that's so low and it's beneath me and so on. No that's my only job, my job is only be on the phone that's what I do because that's what Albert and I do. We can't hire that, I've placed over 10,000 implants in my career, Albert almost the same. Where am I going to get somebody who could sit there on the telephone and have that amount of experience to be able to speak to somebody. I'd do it, are we adding people that do it, yes we are currently adding surgeons who are a little bit older, they are cutting back on their time.
They have one thing that nobody else, no rep can do and place 1000s of implants and those are the people that are taking the phone calls.
Howard: You are completely transparent with me I'm most amazed on Dentaltown how available you are, you are ... I'm going to go back to the kids though because again we are in a country where 9 out of 10 people have never done this. We've been around the block for 3 decades, what lasts longer a 65 year old man comes in, broken down, failed root canal it's to the bone, what lasts longer? Heroic post buildup and a full cast gold crown or pulling that and do an implant?
Sheldon Lerner: The world is already ... For those people who place implants they have already decided that the better restoration is an implant and the patients themselves have decided as well. I practiced doing implants from ... My first implant was in '81 okay and so I've placed them for a long time. So after a while the patients themselves would come to me and say I broke this tooth, I don't want a tooth, I want an implant. So they are self referring after a while so even though my practice was a referral practice I never restored, I only placed.
30-50% of my patients were self referred just like the lasik, you know you want. Your friend just had the lasik surgery, they can see, you want to see the same way you're self referred. Those patients will hear from you that's part of the reason why my daughters would hear from me that listen it's going to pass you by because if we don't do this, patients are going to walk some place else. It doesn't mean you have to do that, you could establish a relationship with a specialist, a very close relationship where they can do it for you as well.
You can also do the easy ones, it's not so difficult if you choose to. If you don't feel comfortable extracting a tooth because the blood bothers you and there's a number of dentists are that way not a lot but there are a number of them, they are not going to get involved in the placement that's okay but they are in a large number that would. The person who took over my practice is teaching every single person they can in their area to do implants and has a course for it. Jerome Smith does some stuff on Dentaltown but he used to do a lot, he's a little bit older a lot this year, he made sure that I think the cleaning ladies in his county know how to put implants in.
He trained everybody and that's why he's very busy so I think 3 dedicated surgeons. What I did in my practice is I said okay I'm going to teach people how to do extractions and grafts, they want to do an implant that's great and they are referring more patients. I'm going to as a periodontist I'm going to make sure that they get them a custom abutment if they wanted or stock abutment if they wanted. I'm going to make sure the patient comes with a temporary if they wanted. Certain periodontist listening to this, again I can say to you most of the people who purchase our implants are specialists because they want a better implant if I may throw in a little word like that.
How do they deal with it, I speak and they've even put in 1000 plus implants here, how did they do that in an environment if there are so many general practitioners who are starting to get involved and it's very simple. They make sure they ask the GP what does he or she want. Well many of them want that abutment in place, many of them want the temporary, many of them want assistant placing the custom abutment and/or the restoration and they sell to them.
Some that you have on Dentaltown are genius he's not from the United States, his name is Bill Schaeffer, I don't know if you've ever seen his name.
Sheldon Lerner: Bill I don't know how he did but Bill has permission to walk on water. He is the most super trained probably one of the more super trained people you have in Dentaltown. The guy is a head/neck surgeon excuse me, and he said that and he decided to do dentistry right?
Howard: Where is he from?
Sheldon Lerner: England he's from Brighton some ...
Howard: That's right.
Sheldon Lerner: He's from Brighton.
Howard: That's right.
Sheldon Lerner: He has a full digital lab in his facility and he's a referral practice because he's supporting, his refers by generating all the custom abutments, all the restorations, with your help digitally. He's doing 1700 implants a year excuse me. Why? How? He's a specialist because the man decided that he know the way around this is to support my refers to the [inaudible 00:53:09]. If you are a specialist and all you are doing is sending ... There are certain people who want you only to send it back with the cover screw and the [inaudible 00:53:17] above it. I understand that, there's a lot of people who don't.
There's a lot of people who even are wanting that healing abutment back but want the digital help. The world will be 5 years from now, the world will be that the specialists will be the helper in the digital support world, that's where it's going.
Howard: Will you send your buddy Bill email tell him to do a podcast with me?
Sheldon Lerner: I've offered to fly him to America I will let him know.
Howard: I think I ...
Sheldon Lerner: Very early though because he's not English time.
Howard: Yes but go back a little bit, we always talk about dentistry as if we are engineers. It's always building a bridge, or a canal or a jaw but at the end of the day isn't dentistry really about biology, because at the end of the day it's the termite in the house. It's the bacteria in the barn and I'm a huge implant fan just because streptococcus mutants doesn't eat titanium and I want you to weigh in on this. There's a lot of people who think that well if you pull a tooth in a patient with periodontal disease they are still going to have ...
It's like if you test positive to Herpes and [pull it too 00:54:27] you still test positive for Herpes, so if you have periodontal disease in your mouth and you pull a teeth you still test positive to P. Gingivalis. A lot of people are concerned that you are going to get periodontal disease around the implant. You are a periodontist, speak on that?
Sheldon Lerner: I think the studies that show that peri-implantology does not have the same bacteria or does not have the same causes as periodontal disease, those studies occurred in the 80s. The only reason why people don't know them because people don't go back and read literature it's 30 years old. That's an old question that's been handled already, there is no relationship between periodontal disease and implantology. There is some relationship to people who have some people call them NY dentition where they are not brushing their teeth and they allow plaque and bacteria to sit there next to an implant because [inaudible 00:55:15] on a tooth.
So there is ... If you leave a bad tooth next to an implant the periodontal progression is going to go ahead and eat up the attachment on the adjacent tooth, that's going to happen as well. Eye people are doing what they call clearances they are not talking about en masse clearance, they are talking about somebody who just can't take care of their mouth and they are taking out all the teeth and placing 4 or 5 implants and placing a restoration on there. Those are ... You have to think well in their heart, you're redentulating a person but the reason they are doing that is because there is some [corrosive 00:55:49] activity only if you put an implant directly next to a periodontally involved tooth.
Howard: You are saying an implant next to a tooth that has tartar and buildup and periodic control that that's not a good idea?
Sheldon Lerner: Periodontal disease with a supulation.
Howard: Tell me if this bothers you because it bothers me. I see a lot of patients come in that have 4, 5 or 6 implants and they've been connected with a bar and the bar is just buried in the gum. There's just really ... I mean they can take out their denture but they can only brush a bar, they can't get under the bar. Is that an issue to you a periodontist, cleansability of these bars?
Sheldon Lerner: I wouldn't think that it would be, well part of the reason why it's not so cleansable is because there is ... Again this is somewhat controversial so I'm going to catch some stuff, but there is the need for attached gingiva around an implant also. The need he has to do with preventing ... In the old days there are people who would, still are, people never to get a denture out and they would get [inaudible 00:56:51] out of there, we get this overgrowth tissue around the denture, it would almost be like there's a separate gum that was growing over the denture holding it in place.
People who have an Asian population know what I'm talking about right away, there's no difference between that and what's going on around the bar. The bar if there's no attached gingi around the bar and there is some food impaction or hygiene issues, the tissue is going to respond because it's microza plain non epithelialized, no not keratinized, it is epithelialized but not keratinized tissue, it's going to just overgrow the same way it does in a denture. So that's why there's a real need for attached gingiva around implants. When you see that bar it's for two wings a) in a bar like you said it's not cleansible and b) there's no attached gingiva around those implants to allow for the tissue to remain tied down.
You get what amounts to be ... Listen if I was an academician my whole life would be around getting something named after me, but I'm not an academician. If I was to coin a phrase I would call it [inaudible 00:57:53] as opposed to whatever, fish your arm around a denture. So there's a bar fish around because there's not enough attached gingiva around many bars and it doesn't create cleansability. That's a hard one.
Howard: I'll source your way on something else a lot of times people talk about all on 4 and I know that's a brand name but it's really just a concept but it's for implants and everything. Then a lot of people come back and say yeah but it's none on 3. Meaning you loose one implant, you lost the case. What I don't understand I see a lot of cases where someone's paid 15, 20,000 bucks for an arch and it's like on 4, it's like do they not understand spare tyres or would you want some leeway. I mean with the price of implants plummeting from where they started out when I got out of school [inaudible 00:58:39] shouldn't like ... A lot of these people that lost their teeth they were smokers or they did have Diabetes or they were obese so they didn't have the best homecare.
Now you got a whole case, so you have all this background behavior why they lost all their teeth and how they gave you a lot of money. It all comes down to one little implant fails and we've lost the whole darn case, this doesn't seem rational to me. Further now I want to make one more statement before I forget because we are done in a minute but you know why I believe a lot of these [inaudible 00:59:12] implants, doctors are surrounded by a lot of people that just say yes doctor, yes doctor. They are hygienists, assistant Ops Manager, patients, spouse, almost no one stands up to the doctor.
I want to tell the doctor that I'll stand up to you, I'm not here to be your friend, you can't hurt me and I'm just going to say this, start warranting all your root canals and crowns 5 years. You tell your patients oh this tooth will come off, front tooth snapped off the gum I'm going to do a root canal, a post buildup on the crown, oh yeah you are a hero doc, warranty it for 5 years. Usually walk back in in 3 years and you got to redo it for free you start changing your whole diagnosing and treatment planning. Then you start thinking yeah maybe I should have pulled that tooth out and done an implant. Warranty every root canal 5 years and you'll start placing implants.
Sheldon Lerner: The patients themselves are demanding it, they themselves said that they spent money on it. The demand is there, the demand is maybe not all the financial [inaudible 01:00:09] but that's changing. The cost of doing this is dropping as you see, there are companies like ourselves who don't need to maintain a sales force are able to provide US made implants of the highest level of quality and with digital help. All of a sudden the cost of doing care drops and more patients are able to afford it like lasik.
Howard: Weighing on all on 4, none on 3, I mean do you think you should have an entire treatment plan based where if one implant fails, you are going to need to take it out.
Sheldon Lerner: I'm going to weigh in on both sides okay because I used to ... I would tell my patients I had a case fee, I didn't have a fee per implant, I had a case fee. Just like a person's going to build your kitchen they are not going to count how many nails are going in. I've got to build you a mouse and I'm not going to count how many implants I'm putting in, I don't care. Patients go wow how is that? Request for an extra $100, 200 for an implant, what do I care. Where it becomes a problem is in that the more implants you place in an arch the more difficult it is to parallel those implants and get them that restoration parallel.
It's part of the reason behind the all on 4, if you have enough bone, you can do it all on 4 and they'll work quite well [inaudible 01:01:26] so on and so forth. It will be a much easier restoration because you are only trying to parallel 4. You grew up in restored dentistry, I practiced restore dentistry for a while. If you had to tell me that I have to do a full arch restoration crown and bridge and there are no path x, I could prep 15, 14 teeth to get that restoration in there. How long it's going to take you to prep such a case, well the answer is a couple of days or a whole day. I got rusted in one day, I sweated like crazy to get the [temps in 01:01:58], I broke a case up even though I didn't want to. That's what periodontal prosthesis was, I was trained in Penn.
That's a periodontal prosthesis, these guys were geniuses they could prepare periodontally fault teeth and get them all parallel and get them splinted that's hard. The more implants you have the harder it is. I think that's one pressure, the other pressure is well I don't have to do all-on-4, I can do all on five, I could put in a couple of extra in the back. So yes it doesn't have to be all-on-4 but there is a lot of all-on-4. I don't think it necessarily is because of ... Well maybe it is, they are using maybe more expensive implants. I really don't know. I think part of it is because they have got to get the case in.
Howard: We are in overtime I'm 2 minutes over so I got to wrap this up but just a lot of these guys are asking do you always have to connect it with the bar, what about locators and balls and locators, are you a fan of balls and locators or do you always prefer bars?
Sheldon Lerner: I'm a fan of bio snap and the reason why I'm a fan of bio snap is because we do a lot of R&D that's what we do, we just don't clone. So I don't know if you know this yet but you had a blog on Dentaltown I know you don't read the [Dentaltown 01:03:12] as much as you should and one of them is ...
Howard: I'm on there all day everyday.
Sheldon Lerner: You didn't see the thing about the vodka? I got you.
Howard: The Vodka?
Sheldon Lerner: I said I was giving a free bottle of vodka if somebody could figure out how many cycles the new polymer we have that works on our bio snap would last? Again we are an R&D company so we use the same plastics that are used in heart valves and in heart rebuilds which can't fail and also in military applications and also biocompatible. We try to wear them out, so we got to I think a million cycles and we couldn't wear it out.
Sheldon Lerner: The same resistance so I'm not going to use the word locator because I think we have just ... I think that polymer is a game changer.
Howard: What's this called?
Sheldon Lerner: Bio snap.
Howard: You don't have to have a bar so you are saying $1000 on the lab build but I mean what are pros and cons of a bar versus balls and locators?
Sheldon Lerner: The different between a bar and individual implants is that a snap retained implant case or a denture case. When the patient bites down, the implants cannot be what is supporting the load. It has to be the tissue underneath it. What will happen is that the pressure of the denture lingual will create a force on each of the implants and eventually push them. That's much more of a problem in the maxilla, in the mandible you don't need a bar at all, in the maxilla because the bone is more flexible and it will tend to bend down towards the buccal the implants tend to loose bone on the lingual interestingly enough.
The pressure on the denture case that's why probably more people do a bar on the upper. On the lower that's not the case because the vertical axis, the load is generally directly over the implants so they can do it. The reason why people do a bar and a low is because sometimes the tissue is so thin and it's painful, they've lost a lot of the bone almost up to the nerve, they need to have something to take off the load. Individual implants cannot take off the load in an unsplintered fashion on a denture long term on the upper I believe.
I know a lot of people who do it and a lot of people do it successfully, for example that's why there's 2 of us. 2 of us we don't necessarily think things because Albert [inaudible 01:05:27] myself. Albert has had 100s and 100s of implants on the upper supporting a upper denture, no problem, me it drove me crazy.
Howard: You are an amazing person I can't believe it's an hour and five minutes, I could talk to you all day every night, you are a great guy. You are so amazing on the boards, your sharing never stops. I have a lot of friends who know you from Dentaltown, everyone thinks you are just one hell of a guy, I think you are hell of a guy. Thank you for all that you do for dentistry, thank you so much for all you do for Dentaltown and thank you so much for giving an hour of good time today.
Sheldon Lerner: No problem anytime Howard, thank you for what you do for dentistry it's really amazing.
Howard: All right I'll see you on the Boards.
Sheldon Lerner: Thank you bye bye now.