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AUDIO - HSP #227 - Manraj Bath
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Manraj Bath, DMD discusses lip augmentation, dental implants, and why his office hardly ever gets dry sockets.
VIDEO - HSP #227 - Manraj Bath
Dr. Bath spent his childhood years in Warren, Pennsylvania before completing his studies in chemistry and biology at Erie's Gannon University. Dr. Bath earned his DMD degree from Case Western Reserve University in Cleveland where he received the AAOMS excellence award in oral surgery. He then completed his Oral & Maxillofacial Surgery (OMS) residency at University Hospitals of Cleveland and Mt. Sinai Medical Center where he received extensive training in facial cosmetic and reconstructive surgery and laser-assisted procedures and was Chief Resident. He is certified by the Ohio State Dental Board to provide training to other doctors and surgeons in the field of OMS and lectures frequently on both the local and national levels.
Dr. Bath maintains three OMS offices in the Columbus, Ohio area where he practices a full range of OMS procedures with emphasis in oral reconstruction through bone grafting and dental implants. Worth noting, Dr. Bath has accumulated experience with more than twenty distinct dental implant systems. In addition, Dr. Bath maintains a cosmetic practice, Bella Cosmedica, in Pickerington. A published author in the fields of OMS and aesthetics, Dr. Bath travels extensively to further his training. He's an active member of numerous professional organizations including:
•American Association of Oral and Maxillofacial Surgeons (AAOMS)
•Ohio Society of Oral and Maxillofacial Surgeons (OSOMS)
•American Society for Laser Medicine and Surgery (ASLMS
•American Academy of Cosmetic Surgery (AACS)
•International Congress of Oral Implantologists (ICOI)
•American Academy of Cosmetic Physicians (AAOCP)
•American Academy of Aesthetic Medicine (AAAM)
Dr. Bath is an avid movie fan and enjoys photography along with playing the electric guitar. He lives in the Pickerington area with his wife, daughters and African grey parrot Pojo.
2015 Columbus CEO magazine
Healthcare Awards Finalist for Volunteerism
Dr. Bath was the 2013 recipient of the Doug Barr Award that is presented by the Pickerington Area Chamber of Commerce. The award is given to an organization within the Pickerington area who has demonstrated continued commitment to the Pickerington/Violet Township area in terms of time, financial and personal or corporate support to community projects that enrich the community by going above and beyond the call of service.
In April of 2012 Dr. Bath was nominated for an Agent of Change Award presented by HandsOn Central Ohio. The award is designed to celebrate outstanding volunteers. Dr. Bath was nominated for his participation with the Dental OPTIONS program, who's mission is to assist Ohioans with special health care needs and/or financial barriers to obtain dental care.
Howard: It is a huge honor for me to be interviewing my buddy that I met at the MegaGen Symposium in New York City. I can still remember sitting there at the bar with you, half the night. We had a blast. Dr. Raj Bath. My gosh, you are an accomplished oral surgeon. From A to Z, you really are an amazing man.
Manraj: I got to hang out with you more often, Howard. You're good for my ego, but I don't know about that [crosstalk 00:00:38].
Howard: I'm going to read your bio. Dr. Bath spent his childhood years in Warren, Pennsylvania before completing his studies in chemistry and biology at Erie's Gannon University. Dr. Bath earned his DMD from Case Western University in Cleveland, where he received the AAOMS excellence award in oral surgery. Did you know Seetha Sriharan when he was at Case Western? You were about the same year as him.
Manraj: No. You know who I did know is Rick DePaul. I hung out with him a little bit. He and I were buddies.
Howard: Don't mention Rick DePaul or I'll start getting hungry.
Manraj: No kidding.
Howard: He then completed his oral maxillofacial surgery residency at University Hospital of Cleveland and Mt. Sinai Medical Center. Now, Mt. Sinai, that's in New York City, right?
Manraj: No. No. There was a Cleveland branch there that it was a Mt. Sinai Medical Center as well.
Howard: Where you were the chief resident. You were certified by the Ohio State Dental Board to provide training to other doctors and surgeons in the field oral and maxillofacial surgery, and lectures frequently, both at the local and national levels. Yet has never built an online CE course in oral surgery for Dentaltown.
Manraj: I told you I'd get to you that.
Howard: Oh my God.
Manraj: I've got my little note sitting around ready to do that. I apologize.
Howard: No. I can't wait to see it. You know why I can't wait to see it? Bath, I've lectured all around the world and in the United States they want to hear about CBCT's and lasers and CAD/CAM's and all this stuff, but when I'm in Africa, Asia, and South America, they mostly need oral surgery skills. That course, that'll probably teach more people that extract teeth in Africa, than it will in the United States.
Manraj: Wherever it works, here, there, or anywhere, it's little principles that I cannot put together. I call it my Bath 90 degree technique. That's the first one I'm planning on doing for you.
Howard: I really appreciate it. You know what? It's also cosmetic dentistry. For two million dentist around world cosmetic dentistry is how do you make a flipper, or a partial, or a denture. I've seen girls look in the mirror and start crying when some dentist in Tanzania made her a flipper for a missing tooth. Americans think a cosmetic course is veneers, veneers, veneers. It's like they forget that America's 5 percent of the planet.
Manraj: Yeah, no kidding. Sometimes we take the little things like that for granted don't we?
Howard: I know but you know how hard it is for me to get a doctor to make an online CE course on how to make a flipper? Then they do little things like take an impression and make it outside of the mouth. You just tripled the cost for this thing. I want to find some unicorn that can make a flipper in the mouth. How do you use the mouth as the model, create the flipper, all this? You can change a little girl's life in Ethiopia and Somalia and Kathmandu. I always look at the rich countries to find the smart people and then try to use the internet and the ismartphone app and all that to transfer this wealth for free to the less advantaged. It's like when you get off the elevator on the top floor any decent human should send the elevator back down to the bottom floor to pick up the 3,000,000,000 earthlings who live off 3 dollars a day.
Manraj: You mean you don't hit all the other buttons as you go?
Howard: There's so many things you can talk about. What do you want to start with? You want to talk about that Lip 6 Augmentation and zone classification system for fillers that help teach patients and communicate a team. What's all that about?
Manraj: It's something in the cosmetics aspect of my practice.
Howard: When my patients want fuller lips I just punch them right in the mouth.
Manraj: I don't know how you get away with that, but somehow looking like me, I'd probably get in double trouble.
Howard: Explain that. Looking at you. Why do you ... ?
Manraj: One, practicing right now, with a turban and a beard, that's obviously a little bit more challenging and [crosstalk 00:04:50] stuff.
Howard: That's the religion Siek, S-I-E-K?
Manraj: No. S-I-K-H.
Howard: S-I-K-H, I'm sorry I didn't spell that right.
Manraj: That's okay.
Howard: That's a huge religion in Asia. In India alone is it, like, 100,000,000? How many Sikhs are there?
Manraj: We're the fifth largest organized religion in the world. Ahead of Judaism but a lot of people don't know about it. We don't really actually have a organized conversion process for an act or need to get out there. One of the principles is is that if you're a good, whatever you are, Christian, Muslim, or Jew, be a good one at it and that's basically it.
Howard: What are the top 5? If Sikh is 5, what's one, 2, 3, 4?
Manraj: It's like Christianity, Islam, Hinduism, and Buddhism.
Howard: That is true that you make the top 5. Sikh you said there's a 100,000,000?
Manraj: Something like that.
Howard: Do you know what 6, 7, 8, 9, 10, is or?
Manraj: No. I thought we were going to talk about ... I would've studied a little bit more and boned up on that.
Howard: I always study religion and politics in the sense that at the end of the day we're all just trying to manage people. My book is Uncomplicated Businesses Manage People, Time and Money. Religion tries to do it, and get everybody to get along, and government tries to do it. Your family tries to do it and in my MBA it's trying to get the dental office to do it. Just managing your relations with other people is 90 percent of the game of your whole existence on earth.
Manraj: That's what I try and do when and if I run into something. I diffuse it from the standpoint of using humor or just education, field all questions, that kind of thing.
Howard: Yeah. I'm the one that should be wearing the turban. Cover up my bald head.
Manraj: Hey, I could be too.
Howard: Let's talk about lip augmentation.
Howard: What are your thoughts on that?
Manraj: I think we've let ourselves go to the point where we're okay with almost being a human comic. We've gotten to the point where we've got 2 lips that look like big giant fingers. I was trying to figure out ways to educate patients. They come in and I don't know that they really know what they want. They just saw, insert favorite actress here, Angelina Jolie is one that comes up frequently. Give me lips like hers. Much like, I know you and I talk, you're a TV and movie buff too, but if you remember back when Gilligan wanted to fix his broken nose. He probably could pick whoever's nose he wanted and that's not really the case. You've got to use what you have there to build from that standpoint. When you're talking to patients about anatomy and anything from dentistry, you have to try and describe it in layman's terms to be able to be effective at it.
I wanted to be quick as well as effective. I've broke everything down into about 6 zones and I use the oral quadrant system. Basically it comes up to 1, 2, 3, 4, and then the pre-maxillary lip tubercle in the upper, use that as 5 and then the upper zone above the upper lip. I think that's one thing that people won't pay enough attention to, so that segment right there, that 5 and 6 segment, made I think the best results out of everything. Now, I can actually tell patients, you're actually asymmetrical, and I can point to and say zone one right here, I don't have to say your upper right lateral lip is a little bit eschewed to the right. It just makes it a little bit simpler, just go, 1, 2, 3, 4, 5, 6. Most patients can count to 6 as they walk in the door. It makes it a little easier for us to just progress on and then also discuss it with assistants as well as note taking.
Howard: What percent of oral surgeons are doing, this is lip dermal fillers, is that what it's called? Dermal fillers?
Manraj: Yeah. Dermal fillers. HA fillers. Hyaluronic acid fillers basically what, everybody's doing it. We've got nurse executors, we've got dentists that are doing it, generalists, cosmetic surgeons.
Howard: Do you think this is something that general dentists could be doing in their office or do you think this is a oral surgery procedure?
Manraj: I'll be honest with you. You gotta be willing to get trained in whatever you're doing. Who can do it? Pretty much anybody that feels comfortable and feels like they have taken the time to learn what to do. Not only do you do it but then to do it well. Manage your own complications. Move forward. Everybody wants to try and expand their horizons I think. People want to try and give everybody their best foot forward. If we're just looking at the mouth itself and everything past the lips ... As you know, it starts from the outside and then you go in.
Howard: I was reading an article this morning about a dentist in England and he wrote a textbook on how to notice this child has suffered child abuse. That's what he's talking about. We start looking at the teeth and look what you missed and you could've helped this kid realize that he's getting beat up at home.
Manraj: Right. Absolutely.
Howard: Is this always done with Botox? Is Botox and dermal fillers go hand in hand or are these just 2 separate things?
Manraj: They're 2 separate things along the lines of one's, they're both in the category of injectables but at the same time Botox is more of a neuromodulator. It's something that will help be able to control muscle function, so that we can decrease that function from creating the wrinkles that we don't want. Both together obviously compound the result and get a much more aesthetic outcome as opposed to just one. You can't just keep blowing people up and make their lips so big that, great there's no wrinkles but at the same time they've got 2 big fingers for lips.
Howard: I'm trying to think of that cartoon show. Homer Simpson? The Simpsons? I swear I'm not making this up. I was flying home and the lady next to me, when she looked straight ahead, she looked like a duck.
Manraj: That is actually something that I have in my lectures is the fact that everybody's willing to be a caricature nowadays. In their Facebook pictures they're all peace signing, giving them the little duck lips, and that's actually one of the pictures at my lectures. No ducks.
Howard: Is this something that you can be trained and get up to speed online or is this something you need to go to a hands on course?
Manraj: I think really to be honest with you you can start learning about it online. I think nothing is as good as getting hands on experience. Again it comes down to doing the due diligence and get yourself to that level before you start to experiment on your own patients.
Howard: You should create a online CE course test so they can do all the didactics and then they could go to your office in Cleveland and do the hands on, or you could have a hands on town meeting or something like for people.
Manraj: That'd be great. I'd be glad to.
Howard: What I meant, one of the same fillers in Botox, do most cases require both? Botox, neuro? So that their muscles aren't contracting, and a filler, and then the way I understand it the Botox wears off in 6 months. The dermal fillers actually stays because it initiates some type of histological response and just starts laying down collagen and it's a more permanent long term procedure. If you keep doing it it stays, whereas Botox you need to freshen it up every 6 months.
Manraj: Right. Remember, Botox, because we're effective in muscle function it's also going to like once that muscle atrophies or the habit of puckering or those kind of motions that create those lines become less common, then the Botox will potentially be spaced out farther and farther. Usually the average is about 3 months to begin but if you stay regular over treatment you can get longer and longer uses out of it. With filler it depends on what kind of filler you're using as well as where you use it and how you use it. As to, there's a company now that has a filler for outside the lips, we're talking about lips but in cheekbone areas that it supposedly lasts for 2 years. Again those are the kind of things that you can get the didactics down but then there's certain ones that you don't want to use in certain places because you can develop irreparable damage
Howard: What brand name fillers and Botox are you using? Is there one company you like the most as a generic?
Manraj: Not really. I'm here to tell you, I'm a fan of all. I like to get the feel for what different things, how their function and use is, it is in a sense that it's like implants. Again, I've got experience with about 33 different types. I've actually used all kinds of fillers. In the lips at one point Restylane was the only one that had the lip approval for FDA and then I think Allergan just came up with Juvéderm as being allowed to be used in the lips now. There's a whole host of products and again you gotta know where to use them, how to use them, and when to use them.
Howard: My experience with dentists is, you call it a mentally, emotionally, anchoring. They'll go to the Pankey Institute for 6 weeks to learn TMD and TMJ or treating worn dentition and all this stuff. Then I look at their production and it's not even one percent. Is this a fun and games rounding error to your business game? Is this one percent of revenue or is this a real deal? Is this 5 or 10 percent of your ... ?
Manraj: You mean, personally, for me?
Howard: Yeah. For your business.
Manraj: Absolutely. What we actually did is I didn't want to be a salesmen. I took that aspect of my practice and moved it out of it. I didn't want Timmy's mom to come in while we're talking about Timmy and making it about mom. Hey, did you know we also do this? We actually broke it out and it's a separate entity all together. It's actually a separate entrance in the office, a building. Separate office space. The whole 9 yards. Yeah, it is.
Howard: You have 3 oral surgery clinics, right?
Howard: Does each of the 3 oral surgery clinics have a separate entrance for this deal or this just a new location?
Manraj: This right now is just in one location. We've got 3 different offices. I'm a glutton for punishment. I'm running around between all 4. We're in dire need of an associate. If you know of anybody let me know.
Howard: You're looking for an oral surgeon.
Manraj: Yeah. Somebody that has got their niche down and wants to do certain stuff. We don't all have to be ...
Howard: That's in the city of?
Manraj: Columbus, Columbus, Ohio.
Howard: Columbus. You went to dental school in Cleveland but you went to Columbus.
Manraj: I actually while young and stupid I thought, "Hey, I wasn't married. I don't have any real ties. I might as well see where I want to go." I actually interviewed all around the United States and ended up in Kentucky of all places for a year. Then slowly moved my way back to roots in Ohio. My sister is in Cleveland. Her and her husband are both general dentists up there. I've got a whole bunch of family that's all in the dental field.
Howard: Your wife's a dentist?
Manraj: No not my wife, my sister.
Howard: Oh, your sister's a dentist.
Manraj: My wife actually runs the cosmetic practice.
Howard: I think most people don't understand that last names used to mean occupation like Smith was a blacksmith and my last name Farran in Arabic means baker. When you go around the world and you study business. Most people live in a nuclear family and it doesn't matter if they're goat herders or dentists, they go back generations. I have been in houses in India and Brazil where there were 25 living dentists in the current family. Sometimes all of them in one house.
Manraj: You've got to look at how the family units have changed as we've evolved into different cultures.
Howard: I think they've just mostly changed in about 20 countries. I think out of the 200 countries, I think about 180 are still big into nuclear families and occupations run deep into families and pedigrees that date back.
Manraj: I hear you, totally. Again there's that love of the familiar.
Howard: Look at Kevin Coachman one of the most famous cosmetic dentists on earth in Brazil. Almost everybody in his family, every uncle, cousin, nephew, niece, they're all dentists or lab techs. He actually started out as a lab tech. Then he got talked into dental school. What's also interesting is the nuclear family in the arranged marriage has only a 9 percent divorce rate and in the western 20 countries with love marriages it's a half divorce rate. In those 20 countries if a post graduate dentist or lawyer, if 2 dentists marry each other. They only have a 9 percent divorce rate. It shows you the nuclear family is a lot smarter at fixing you up with a woman that you going out at the club and finding some girl that looks hot in a pair of Levi's.
Manraj: That's because next time you go to the club there might be another hot pair of Levi's running around. You never know when you're going to run into that.
Howard: Is the average oral surgeon today revenue about 70 percent exodontia, 30 percent implantology? Would you say that's still the norm or do you think it's shifted to 60 percent?
Manraj: I would say you're pretty close to there just simply from the standpoint that the general oral maxiollofacial surgeon pretty much exodontia and implants or the teeth and titanium thing is predominately what lays heavy with what we do. There's a big shift with the dual degree. Even the single degrees are doing much more on the large case basis. I met a little while ago, I was lecturing at ACOM's American College of oral-max doctor who's a single degree that just does vascularized flaps for cancer surgery. The neat thing is, is what we do whether it's general dentistry or oral-maxillofacial. We actually have a very broad area of what we can do, what we're trained at. Those are the bread and butters so to speak.
Howard: I look at the 9 specialties and I think pediatric dentistry would be the worst. I'd quit if I had to work on 3 year olds. My favorite is still exodontia, I have more fun pulling out 4 wisdom teeth than anything I do.
Manraj: I know it's fun.
Howard: I think part of it is just the instant satisfaction it's done.
Manraj: I look at it as a puzzle too. Sometimes you run into certain things, how would I do this. Probably the simplest and best way you could teach somebody about taking out teeth, is an old attending of mine threw out a box of doughnuts on the table when he was lecturing to us and said, "I'm going to make a hole in the top of this box now. You're going to tell me how to get the donuts out." The hole was just big enough to get adequately access to the doughnut inside. We all looked at him, weren't really sure what he was getting at. He goes, "It's real simple, you either make the hole bigger or the doughnut smaller. Class dismissed, let's go hit the bar." That was the easiest way to try and remove teeth.
Howard: In 28 years of having associates, every single time they couldn't get it out and I'd go in there. I'd just look at it and go, "You know what? I couldn't get it out either, I have no idea what you're doing." Then just spend 2 minutes making the flap bigger and pop it out. The old axiom, an inch long flap heals the same speed as a half inch flap. You know what I've noticed, just throwing some MDA analysis out there on you is, when I find oral surgeons that are 80 percent exodontia and 20 percent implants, there overhead is about 40 percent. When I go to an oral surgeon's office and they're 30-40 percent implants, their overhead is maybe 50-54, 55. I think that's a very interesting analysis for all dentists and oral surgeons to think about that. Implantology is a higher overhead operation than exodontia.
Manraj: That's true.
Howard: Pulling teeth, I almost do 90 percent of all my extractions are just a periosteal and a small elevator.
Manraj: I will tell you when I analyzed it. Geez, these numbers are from back in 2004. It cost me 700 dollars effectively to put in an implant by the time we get started, all the hardware, the staff time. Then it takes probably somewhere in the neighborhood depending upon what medications you use to put a person to sleep between 50 to 100 dollars to take out a set of wisdom teeth.
Howard: Yeah. A lot of people say, "Well, I'm charging a lot for these implants." It's like, "Dude, you have a lot of training and hardware and kits and surgery kits." People talk about money, they never watch the money. Make something, sell something, watch the numbers. They never watch the numbers. Rule of thumb is when you do a crown for 1,000 that's just half gravy. When you do a root canal for 1,000 that's just easy half gravy. Those are probably 40 percent overhead procedures, pulling wisdom teeth, probably 40 percent. You start getting into implantology and it's a lot higher overhead than anybody realizes.
Manraj: Absolutely. Not only that but there's more room for error, patients expectation management. There's a lot of stuff from a psychological aspect goes into it too not just a monetary investment.
Howard: You know what I saw when I was interviewing you today, I was so excited. The question that I can't wrap my mind around maybe you're probably the only one smart enough to know who's not on the inside. Look at Danaher, the largest dental company in the world. They're not all dental. Why would they buy the top line Mercedes 500 dollar Noble Bio care and the Southwest Dental implants drug. What is the thinking of having ... Are they just looking at it like General Motors? We want to have a Chevy, Pontiac, Olds, Buick, Cadillac.
Manraj: I like talking about stuff like this but as far as what would they think and I don't know. As far as what can I extrapolate, I would probably say that you're looking at exactly what you're talking about. Southwest dental they had the wide body implants that go to 8 millimeters. They have the Nobels which fit the rest of the general population of what implants do. I think what we've seen if you remember back from the beginning, implants have bottle-necked. Everybody had their little niche thing and then everything came down, there's only a few things that are left basically between what we have.
There's Midi implants and the regular size from 3.5 to 6 millimeter implants. You've got to have a wide body just in case. That's the only thing I can think of, I don't know if it's necessarily a Cadillac, GM and Chevy kind of thing. Maybe a SUV, sports car and run of the mill station wagon or soccer mom van. It's one of the reasons that I met at the MegaGen conference. One of the reasons I like MegaGen I have have elected for them in the past. They fit the whole gamut, they've got a little bit of something for everything.
I really just appreciate that part of their line of implants. Although I use anything that the specific referring doctor requests. Those are my go to's just simply for stability. Sampling, I could probably do some chin ups on those guys when you put them in. Take a tooth out put an implant in. There's always that possibility, gee there's a little bit of motion, hopefully we'll pack bone around it and keep it stable. With them I've rarely ever not been able to put in an implant and really feel secure with it.
Howard: Here I go again asking rich country questions. When I look at the download on iTunes there's like 206 countries checked off, I want to think of the whole world right now. My next question to say what low hanging fruit tips can you give on routine exodontia? Where do you think general dentists are getting in trouble around the world? We just talked about a lot of things flap, they can't see what they're doing. Talk to a 25 year old dentist in Tanzania who sometimes has trouble extracting number 29.
Manraj: This is a great way to go with the conversation because you definitely did hit the nail on the head. When I was a resident one of the things that the students would come in and say "Hey Dr. Bath can you help me with this, the tooth just broke off." My first question to them is "What'd you do?" I want to know when I get there did you really reflect a flap. When you would get there you'd see the papilla pushed out of the way. Development of a flap or reflection of a proper flap you have to see what you're doing just like you said.
I think some degree there's some level of discomfort and worrying "Gee, am I doing this right? Am I reflecting this properly? Is it really necessary for me to do?" In that aspect yes it is. The next thing is, is then once you got the visibility then you got to go for ... Just like you said, you got to reassess, what I call purposeful motion. You have to basically make sure everything you're doing should be moving you forward. If you just are wiggling and trying to see if anything helps that's not really doing you anything good.
If there's bone that's around it you need to have a plan. Am I going to put the root to the distal, if that's the case what kind of bone is there that's on the distal? If it's not moving then you need to try something and that's where my 90 degree technique comes in that I hope to explain in a townie CE. Is the fact that if you start looking at and "Gee I've always been working in this plane." My goal has always been if you literally shift your viewpoint and work in a 90 degree plane and do something different in that plane usually you'll have some sort of success.
From the standpoint of if you have a root that's this way and you've been trying to push it distal, sometimes you just have to gut it from a buckle [dilingual 00:29:16] section, split the 2, and then take it out in 2 pieces. If it's something like ankylosed then you have to be comfortable with a periotome and being able to get between the bone and the root. There's a lot of things, it's kind of like that challenge that I was telling you before. It's like taking on a puzzle, you have to almost know what you're doing when you're looking at the X-ray. When I see this X-ray this is what I'm going to do.
With the advent of cone beams sometimes you're fighting a root that you didn't realize but it's curved this way. We've got up down, we've got left and right, but we don't have front to back. You take a look at it in the 3 dimensional and all of a sudden you see this big giant hook looking at you. Gee, pushing it one way or the other's never going to work. You have to actually think about rotating it out. Again those 3 dimensional viewpoints use our tools. We don't necessarily always utilize that. Sometimes we have to actually stop and take an X-ray and say, "Where do I have bone that still my obstructing what I'm doing." Sometimes you got to take a step back before you move forward.
Howard: You probably have to have the most profound anesthesia for oral surgery as opposed to a filling.
Manraj: That would help.
Howard: Are you a Lidocaine man or a you a Septocaine man?
Manraj: I will tell you right now I am a Lidocaine and Marcaine man first. One of my old attending's Dr. Houser used to say "Listen, when you've got your arsenal all used up up front then you don't have anything to go to." I used to start looking at that in pretty much a lot of what I do. When you create a local anesthetic block and you do get profound anesthesia and you're not quite getting what you need, then you've got something to go to. Let's go ahead and use the Septocaine.
My theory on Septocaine is again if you're using it right off the bat and you're using it for a block. You know that just as well as I do there's a risk for permanent lingual nerve injuries. My theory on that is, and so far knock on wood haven't had that happen permanently from that perspective. I think it is anytime I've ever started to inject and if I was using Septocaine, I would use if the patient ever complained of any kind of discomfort on injection. Especially when they'd feel the little electricity in the lip or the tongue.
I think the injury of the myelin sheath is where the caustic nature of Septocaine comes into play. I don't have any research based evidence to back that up. However I do have multiple times wherever that's happened I just use the Lidocaine and Marcaine combo. Again I'm not just using bunches of the same thing. Lidocaine has one effect, Marcaine has a longer effect. Compounding the 2 make sense. I usually start with that and if I have to go to the Septocaine, that's what I use. Now in infections, I will usually jump to a Septocaine right away just simply because the architecture of the infections change the environment and the PH.
Howard: A lot of the dentists are stressed about pain meds because some of our peers put downward pressures on any form of Hydrocodone. Then some patients are like, "The Motrin didn't work." What's your go to post op? What's your thoughts on Hydrocodone versus Ibuprofen? Talk about that.
Manraj: Actually we have a whole sheet that we give patients and we do patient education on that. If you can use it in an alternating fashion that's even better. In reality the Hydrocodone just basically drugs you up so you don't care. It's really the Tylenol and Ibuprofen that's really doing the pain management. The rest of it's to take off the edge and maybe the anxiety and does it work as far as pain control, sure. At the same time I think when you're just jumping to MS Contin. I look at it as we have to find the cause and if the cause is a traumatic extraction very rarely do I go to a Percocet type thing. I've never written for MS Contin, but at the same time if we alternate and maximize the effect you've got 3 hours of this. Then you take a dosage of the alternate medication, you've 3 hours of another. Again compounding the effects of 2 actually in my eyes is what I'd like to do.
Howard: That's interesting because you like to compound Lidocaine and Marcaine. Lidocaine is short acting local anesthetic and Marcaine is long acting. Is that [crosstalk 00:34:13].
Manraj: Correct. Yeah.
Howard: I agree with you on the Oxycodone or the Hydrocodone making you not care. I've only had severe pain in my life 3 times and they were all 3 a kidney stone. It was the funniest story because the first time it ever happened to me I forgot how old I was.
Manraj: You should drink more water.
Howard: I was about 30 years old or whatever. I showed up at the emergency room and the emergency room doctor looked like she could have been my own daughter. She couldn't have been 25. She goes, "Oh, you poor thing, you have a kidney stone." I just look at her, I'm holding my left flank. I'm like "How do you know it's a kidney stone?" She goes, "It's the only thing that makes a grown man cry." I'll never forget she gave me Morphine and I could still feel the knife in there twisting but you just didn't care. Along with the deals especially for countries that don't have Hydrocodone available go through Tylenol, Ibuprofen or Aspirin which one do you think they should be using? If they're in a town and they don't have a pharmacy of Hydrocodone?
Manraj: You still reveal the effects of Ibuprofen and we found to some degree it does inhibit some healing. Long term use of that to some degree for what we're using, not necessarily going to cause a long term problem but when you're talking about overshooting the pain threshold. I usually shoot for 600 milligrams of Ibuprofen to 800 milligrams every 6 to 8 hours. Compounding that with if you're using it with Hydrocodone and Acetaminophen mix about 3 hours later re-dosing with about 500 milligrams of Hydrocodone or 650 now because they're 325's and 5 milligrams of Hydrocodone.
When you're trying to alternate it's at least if nothing else compounding the 2 effects, the different pain receptors and ultimately you have to also make sure the patient knows where the pain is coming from. Just like your kidney stone, the pain doesn't pass until you pass the kidney stone. If I'm that person there poking them in the shoulder with a sharp stick, they're just not going to care because they're high on Percocet and Morphine or MS Contin.
Howard: You keep saying MS Contin, is that Oxycontin?
Howard: What's MS Contin? Is that the brand name?
Manraj: I think it is the brand name that was being really abused a lot in emergency rooms.
Howard: MS Contin?
Manraj: Yeah. The times when I was a resident the only times I saw that used were cancer patients and ER patients.
Howard: I want to ask another stressful question. I feel so honored to have an accomplished board certified oral surgeon with 3 offices and all that. I'm just trying to rattle through so many questions. I know some of these kids are thinking. Podcasts are devoured mostly by young people, it's not an old man's sport. Although I have gotten, I have to admit. I did get 3 emails yesterday by guys saying, "Hey, you always say it's young kids on the phone, I'm 61." Another who said, I'm 69." Anyway I had 3 60 year old people yesterday tell me they were big fans of the show. A lot of times Raj, they're looking at a tooth and it's a lower molar it's got a pericoronitis.
Some of their brain is saying the best thing to so is get this thing out of their mouth and put them on antibiotics. Then part of training is, what if the infection spreads Ludwig's angina. I should put them on antibiotics first. Be specific, talk to a 25, 30 year old dentist. They're looking, there's a flap of tissue over the back, there's a lot of pain. When do you say, "Let's just finish this off, get them numb. Take that out. Put them on antibiotic." Which antibiotic do you put them on? When do you say, "No. No. No. Let's manage the infection first. Let's get them on some antibiotics. Then when would you have them back, 24 hours, 48? Can you talk about that? This is a very stressful question for a lot of individuals.
Manraj: Absolutely. Perfectly understandable it's part of what I do every single day. In the sense that people are always worried about managing the infection. We have to go back again to, what's the cause? The cause is the tooth and the flap of tissue the pericorocitis is resulting in a worse possibilitya full blown abcess that could become a Ludwig's like you mentioned. When you've got a tooth that needs to come out, if you're not going to do it then refer to somebody that will take care of it relatively quickly. If it is abscessed, then if it's extremely large you don't wait for it to control the infection.
The infection at that point is out of control. You have to get it to somebody that can manage it either in the hospital or otherwise and get them the proper IV antibiotics. Now if [inaudible 00:39:32] in the office, a little bit of swelling, a little bit of this, a little bit of that. Something I can handle right now, take the tooth out. Put them on some Peridex, put a drain in, whatever it's going to require. However use have to move forward purposefully. Again purposeful motion, what's going to get rid of the problem. The problem is the tooth and the offending tooth has to be gone. The infection then later on can be treated by antibiotics and that.
The first line of defense with oral infections is the Penicillin family, Amoxycillin, whatever. If they're allergic I'll go to Clindamycin or Cipro if other issues come up from there. It comes down to what are you comfortable with? If you're not comfortable, you need to move it down the street potentially. Managing it is knowing it needs to come out. Trying to do the old, "Hey let's give you some Amoxycillin 500 milligrams TID. Either treat the infection or don't. If you're going to give them Amoxycillin, great give it to them 4 times a day sometimes even 5. You've got to get them to the level where the infection is going to be treated. However you never know what's going to happen. What if it's a resistant infection. You've got to get the source taken care of first.
Howard: Why do you like Amoxycillin more than Penicillin?
Manraj: Just a little bit more broader spectrum. I don't necessarily like it more. Penicillin, depending on the degree of infection, I just don't want to sit around and wait in case it is Penicillin type resistant a little Beta-lactamase in there or something.
Howard: What's your response to this post I've seen on Dentaltown several times. I like to give them a gram of Penicillin and maybe 800 milligrams of Ibuprofen before I even numb them up. The antibiotics is already in their bloodstream, anti-inflammatory is already in their bloodstream. When you go in there and do your job. They think when the infection spills in the blood stream the antibiotics are already there. What do you think of that whole theory?
Manraj: Perfectly good thought process on your part. When you've got that available. What happens if they don't. Is it wrong to go forward without doing it. You still get get a little bit of septicemia from getting the infection into the bloodstream. You're not necessarily wrong either direction, if you don't carry the antibiotic, there's no point in writing up a prescription, running down to the pharmacy, having them take the antibiotic and pain medication and then come back in. Moving forward again, you can always get them started on that but they have to know, "You've got to start this antibiotic as soon as you leave." If there's something that is worse off, hey even if you get that tooth out and you're still a little bit worried.
You send them fro management to whoever you use for that purpose or to the emergency room. You have to make sure you cover all your bases, not just from a legal standpoint but from an ethical standpoint. You want to make sure that patient is educated. Half the time, they go I'm going to send this prescription off to my mail order prescription place. You never know, they're not going to get it for a week. I've literally had that happen before. An older lady sent something off in the mail. That was [inaudible 00:43:09] in my career, that's where the emphasis comes from. You've got to educate them now before you send them home.
Howard: Then let's talk about the post operative complications. Dry sockets, do you agree or disagree that they're mostly found in women, women on birth control and smokers. Is that would you say true or false to that?
Manraj: Smokers I would agree with. Women to some degree. I don't know if I've necessarily personally experienced that. That's also some degree when you see people and say no smokers don't have nay issues, it's usually a smoker that feels that way. I think smoking is a big deal.
Howard: You think it's because of the carbon dioxide and the nicotine or do you think it's because they're sucking on the cigarette is sucking out the blood clot? It'd be no difference if they were sucking on a straw or on a malt from Dairy Queen.
Manraj: Here's the thing, the straw thing will get to in a second because I think that's a little bit of a misconception. The sucking aspect of smoking I don't think causes the dry socket. Traumatic extractions, the vasal constriction from the nicotine, the first order of any kind of surgery is that nicotine effects your healing ability. As far as the straw here's the thing. I think the reason that the whole don't use a straw after an extraction came about.
It becomes worthy to note was it water that they were drinking out of a straw or was it a McDonald's triple thick milkshake. I sat down and analyzed it and said, "You know what? Don't eat anything solid, you're on a liquid diet for a while." Guess what? What was the easiest way to get some nourishment? Milkshake, it's cold, it's refreshing. Pulling that through a straw does create the possibility of a dry socket. We actually have a fairly low level of dry sockets in our office. Probably somewhere like 2 percent or less on a national average probably more around 7. I think the main reason is strict post operative instructions, not smoking.
Howard: How long do they not have to smoke?
Manraj: I tell them a week. The thing is most people go, "Don't smoke for a couple days, great. I joke with patients. One of the hardest things I can ask a smoker to do is, is to not smoke for a week. The even harder one is to hold there breath for that week because that's just difficult to do. It's an addiction, they need that. They need that rush when you have that anxiety and that helps them calm down so they want it right away. If you tell them don't smoke for a couple of days, you're lucky if you get a couple of hours. I've had parents smoke through their nose, through their fist, any number of different methods.
Even patient with smoking history through their trach. That's a difficult thing to overcome. I'm usually pretty strict about it. "Hey listen, between 3 and 5 days you're going to get a good chance of a dry socket, don't smoke for a week. That's not something that I even want you inhaling second hand smoke as a joke." In some degrees I just feel like in my personal experience that's been helpful. What else do we do, we're just gentle with the tissues and definitely irrigate when you are using a hand piece on the bone. Trying to do more work I talked about making the hole in the box bigger or the doughnut smaller. I definitely always try to make the doughnut smaller. I also feel that the parts a patient has to heal later equates less work for that body to do or less pain.
Howard: When they do have a dry socket, how are you treating that?
Manraj: A lot of times it's also a misconception is misdiagnosis. I've had a lot of luck with doing some physical therapy with them right afterwards. It's more a trismus thing. We have to find the cause. If we're just dumping a bunch of dry socket paste, Balsam of Peru, Eugenol, whatever your favorite thing is. One you've got to remember that if the nerve has been exposed that's caustic to the nerve. Second is if you've packed it and they're still not having a problem. What else could it be. It also could be that they're gritting their teeth so tight the muscles are spasms and the trismus is so bad they can't even move their mouth. We've had some good luck about getting the difference between what kind of pain is it?
When does it come about? it wakes me up in the morning. Great that's clenching your teeth at night. Wakes me up at night, same kind of thing. First thing I usually do is say, "Hey, open your mouth." If they can't open yon wide, that's one avenue to start working on is the physical therapy. Just packing everything isn't really going to do anything because again the packing itself then becomes as a deterrent to natural healing. I think our body actually knows what to do. I think the big guy upstairs made us in a pretty amazing way.
Sometimes I think we get involved in that healing process a little too much. Again I think finding the cause, educating the patient and then moving forward. If they need a dry socket pack, you're going to look in there. You've got to know what it is. If there's nothing there and you see exposed bones then it's a dry socket. If you look around in there and there's granulation tissue in there and there's a granulation tissue in there. There's a fibron coating that's fully covered all throughout the socket. Then you've got to look at another possibility.
Howard: What do you think of dentists who after their done with the extraction site will irrigate with a big syringe of Peridex? They think that ...
Manraj: I don't it and I don't have any more infections than anybody else.
Howard: It sounds like you have a lot less, 7 percent is average and you only have 2 percent.
Manraj: The other thing is that putting Clindamycin on a gel foam pack has also been proven to help. I'm not doing that and it doesn't necessarily work in my hands. If that works in your hands, great. I think sometimes we talk ourselves into things just because so and so does it. So and so's a big name in the industry. I'm going to do what so and so does. We forget sometimes. I get a cut, it doesn't heal as fast as my little girls cuts do. Why? You can't treat me like we would treat her. She's younger, her body's in a different state of healing ability and mine's in a different. You've got to try and treat the patient and not try and treat a cookbook.
I do this in every single one. I remember there was a person in my school. She used to tell me about how her husband used to take out teeth. First thing he did was break out all the periodontal fibers with a 15 blade. I'm like, "Why?" There's not necessarily a purpose. The first thing they taught us in oral surgery, you got to use an elevator. First you luxate with an elevator. I'll be honest with you. If I'm taking out teeth and there's plenty of tooth there, I'll just put forceps on it and take it out and use the forceps the way it's supposed to.
You don't necessarily have to do all these things and I don't have tears in the tissue and I don't have buckle plate fractures. Don't get me wrong, do we have complications and do we have things happen. The more you do something, you're bound to run into something. At the same time I think if you utilize the tools in your toolbox properly, you're going to end up having a method that works for you. If you've got to rinse everything else out to make you feel good at night then more power to you. That's fine.
Howard: You don't necessarily put an elevator around the tooth and push back the tissue and then elevate with a small elevator before. You go right to a forcep?
Manraj: Not always, again it's I like using the term it depends on how fast you drive. It depends on the situation. If I'm dealing with a 12 year old who's got 4 bicuspids coming out for orthodontia. Why am I flexing all those teeth. They're already a little bit mobile. You're taking other teeth and luxating them potentially. In reality, they come out fairly easily. Whether they've got the spindly double roots or they're conical. You have to be able to almost feel it when you're taking it out.
Do I reflect some flaps? Usually after that, even teeth that are broken off at the gum line. Sometimes those take a number 9 and literally go right around the root without reflecting a flap and using my number 9 just to core it out and push it out. Why am I reflecting flaps when you don't necessarily have to. Again that works well in my hands. If you're somebody who needs an inch long incision to do every single one. Great an inch long incision heals just as good as a half inch incision.
Howard: Have you videotaped many of your surgeries?
Manraj: I just started. I've been into photography ever since I was a kid so more photos. Actually I got a digital camera when I was a chief resident. The attending's always wanted us to get photographic capabilities on this big giant cameras and SLR type stuff. I was the first one on our community to get a digital one. I've started toying around with it. I'll be honest with you, I photograph everything just for the sake of, one being able to lecture about it and 2 also being able to look back at what I do.
Howard: How many lectures do you have?
Manraj: On tape? About half of them.
Howard: What about on PowerPoint?
Manraj: Probably somewhere in the neighborhood of about 20.
Howard: 20 different lectures?
Howard: How long are each one?
Manraj: Anywhere from a couple of them are different versions of the same. Anywhere from taking a 2 hour lecture down to 20 minutes. I have some that are 2 hours. Most of them are about an hour, hour and a half range.
Howard: Raj, I would do anything to get those online. I've just been to so many places. We don't care about [Sarak 00:54:28], we don't care about CBCT and we don't care about bleaching and bonding. I remember specifically Kathmandu and she's like, "Can you give us more courses in oral surgery?" I can't think of anyone better to do this than you.
Manraj: There's a whole host of people that probably could do it just as well if not better than me. I'm glad to help.
Howard: You're just humble [crosstalk 00:54:51].
Manraj: I appreciate their [crosstalk 00:54:51].
Howard: No. You're just humble.
Manraj: Maybe it's just the way my parents raised me, I don't know.
Howard: You're just a humble guy.
Manraj: I appreciate that.
Howard: What's this X-Nav thing you bought?
Manraj: This is actually the ... I think this is the Oreo cookie thing you were talking about. The implants and safety, you've got those being the cookies. The cream is going to be the thing that holds it together. The X-Nav is basically commitment Navigation and guided surgery put together. It's a really actually something that's going to be a game changer for a lot of things. Not so much robotic surgery but it is going to be commitment based where you can literally ... If you plan out your surgery and your implants.
Say, now we have to do the commitment scan, we have to do the model, we've got to send it off to the lab to be fabricated into a splint and then use that surgical stent. There's some degree of error, there's human error, there's the laboratory error. There's a possibility, you've got to remember the CT's are extrapolated. There's some extrapolation error. Any of those things can come into play. Now these guys have actually come about. Now there's 3 of them that are out on the market but X-Nav is the one that's gotten the FDA approval first.
Howard: Where are they out of?
Manraj: I believe Philadelphia, it's the gentleman, Ed I'm blanking on his name. Ed used to be the one that started out with I-CAT before he sold it off.
Howard: Is he a friend of yours?
Manraj: He's getting to be. I'd like to think that we're more than just acquaintances.
Howard: Can you email me Howard@Dentaltown.com and CC him and say you guys should talk about X-Nav?
Manraj: Absolutely. Actually that's one of the other topics I plan to do for you. I plan on jumping on board with these guys and developing a whole host of teaching opportunities with them because it's really going to be a game changer. In the sense that they're touting a 2 micron degree of error. If you're putting your implant into the bone, you're putting it right where you need it, and you're seeing real time. If you need to tip your implant drill a little bit mesial, a little bit distal, a little bit lingual. It tells you right there. It's almost like a video game, you're watching the screen while you're drilling.
Manraj: Yeah. I go to their website, it's X-Nav tech.com.
Howard: X-Nav tep.
Manraj: T-E-C-H I think.
Howard: You're going to make us a course on this?
Howard: Your going to be up til midnight tonight dude. You've got a lot of courses to put up.
Manraj: I didn't mean right now.
Howard: No. You're going to make it right now [crosstalk 00:57:44].
Manraj: I've got patients.
Howard: Put me on the phone with your office manager and I'll cancel all the rest of your day. I'll send all the patients home.
Manraj: I've still got to pay the bills Howard. MDA should have taught you that. You can't pay the bills without seeing patients.
Howard: Then will this replace a CBCT is this X-Nav tech in conjunction with your current CBCT? How does that work?
Manraj: It's not going to replace a CBCT it's based off of a CBCT. In other words we've got a 3dimensional patient, using 2 dimensional pictures to be able to represent what the skeletal anatomy is. However we've always lost out on that third dimension. The CBCT's allow for us to utilize it and we should be utilizing it more. It's been touted as the gold standard for a long time. You should definitely be investing in a cone view because ...
Howard: Do you have one in each of your 3 offices?
Manraj: Yeah I do.
Howard: Are they all the same kind?
Manraj: No. Actually I've played around with them, it's just like implant systems, you've got to find the one that you like. I bought the I-CAT first. My other office is a satellite office that I rent so they have one. that's a [Serona 00:59:06], I think. Then the one that I just got it's a Samsung Guts, remember that with Sony Guts thing? It's Samsung and it's LED.
Howard: It's called a Samsung LED? [crosstalk 00:59:22].
Manraj: Samsung is the ...
Howard: It's the Korean that makes the guts.
Manraj: Yeah but LED is the one that distributes it. They also distribute the Velscope. That company is, I think Canadian based but at the same time the picture is amazing. The neat part is the [Anato-launch 00:59:41] thing, I just like taking those pictures and putting them in the Anato-launch. The X-Nav has their own computer software that will be able to help you plan out your surgery. Technically you import anything as far as DI-COMMS from other places. They have the ability to place the implant where you want it. Then the angulation that you wanted to make sure you got the size you want. They're touting a .25 millimeter.
Howard: It's the first one FDA approved for what specifically?
Manraj: For guided navigation surgery. They're basically making the whole environment better. You've got to believe in what it's doing and believe in the better. Here's what I've heard, I just came back from a national meeting. The big thing is oh man another thing to make it easier for everybody else to do implants. That's not really necessarily true because I think that when we try to embrace the technology and embrace what we're trying to do. Ultimately we're trying to do the best for our patients.
It helps us all sleep better at night when somebody can do something that they didn't necessarily have the surgical skills to. This doesn't necessarily take that and make it that much easier. It actually makes them have to again, learn how to treatment plan. Learn how to deal with the complications. What do I do when this doesn't go right. There's still going to be some degree of human error. You can't just imagine the computer is going to do it all for you. We're still the driving force of the treatment plan, where the implant goes. There's still some knowledge and didactics that come into play.
Howard: We have run out of time but I have to ask you one overtime bonus question simply because I know they're thinking it. Of all the implant companies, this dentist is all alone. My whole mission with Dentaltown, is that no dentist should ever have to practice solo again with the internet, smartphones. If you had to pick one implant system, which one would it be?
Manraj: That's tough because again they've all come to the point of being Niche, but they've all started to grab from each other. They're looking more and more to be very, very similar.
Howard: Then give a few names then.
Manraj: I like MegeGen like I said, they've actually got a couple host of implants. I think what I like the best is that they're concept, they're trying to get rid of that [inaudible 01:02:22] on the cervical aspect of the implant is that they want to preserve crust of the bone. You have to again be knowledgeable about what the shapes of your implants are and why they're that shape. The other line I like, I like Implant Direct, they've got a whole host of internal connections, a whole host of shapes. It seems they've taken into consideration the cost of it. We've got to champion implant dentistry if we really believe and we've made the commitment. We've got to try and keep the costs down so it's affordable for our patients.
Howard: You never want to make predictions, especially in print or in podcasts or whatever. I'll make a prediction that I feel comfortable about. Jerry Niznick will never go away, he'll be back. He started one implant company. What did he start? Corvent?
Manraj: Corvent, a long time ago and then Paragon and then.
Howard: Did he start Paragon?
Manraj: I think so yeah.
Howard: Then he started implants Direct and he sold that to Kerr, Sybron, Deneher and I swear to God that guy probably sleeps about 8 minutes a night.
Manraj: I'll tell you what, love him or hate him, he's done a lot for dentistry and he's been very shrewd at what he's done. Success ...
Howard: Lots of overtime, overtime, overtime. If someone was going to buy a CBCT. You've worked with ICAT, Serona, I assume Galileos, Korean Samsung Guts distributed by LED, you said it's a Canadian company.
Manraj: I believe so yeah.
Howard: If you were going to buy a CBCT, would you buy one or do you think a dentist should just refer to a radiological center?
Manraj: Again it comes back to how committed are you to what you're doing. If you're really going to start doing implants and trying to get more involved, then yeah you're probably going to think about buying one. Does it have to be brand new? No, but you have to think about reading them. You need to take the courses. You can't just go buy technology and think that you're going to make use out of it or it's just going to sit there. I ran into a doctor at a aesthetics show one time. She just kept buying technology, I asked her I felt like I was you for a minute. I started asking her questions about her business, what's her overhead? What's this? What's that?
She's like, "If I have the technology people will come in." I said, "Not necessarily." She had just bought a laser that ... She already had one laser now she's got another one. I'm like, "What's the purpose? There's an overlap." You've got to be able to utilize your technology. You've got to be able to know how it does things, why it does things and how you're going to implement it into your practice. You can't just go buy something. If you do use a center to scan your patient you've got to still be able to utilize that information. How are you going to utilize it? Are you going to maybe use it for X-Nav or still continue making the surgical stents. It's just a matter of putting in the due diligence outside of patient time. You've got to sit down and actually plan out what you do.
Howard: In 1987 I answered if a patient asked for something, we said, "No." They had to try it. That was when we had prescription pads. I had a getting to yes prescription pad. One of the first questions I had to say no to. Someone called and said, "Do you have a laser." We said, "No." At lunch time I bought a laser pointer for each operatory . I said now you tell them, "Oh my God, Dr. Farran has a laser in every operatory.
Manraj: In every room. At least you didn't lie.
Howard: Hey Raj, thank you so much. I just adore you. I think you're the nicest, most adorable oral surgeon I've ever met in my life. You're just a hell of a guy. I'm sorry we had to meet and it wasn't at a fun bar in New York City. That was a fun hotel [crosstalk 01:06:17].
Manraj: I had a good time, that was a really nice place. We'll do it again sometime.
Howard: Yeah. I hope so. Until I see you again, thanks for all you do, buddy.
Manraj: Try and make it short this time. Take care. Thanks a lot. I appreciate the opportunity to talk to you.
Howard: Okay. We look forward to your courses online.
Manraj: All right. Take care.
Howard: All right. Bye-bye.