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VIDEO - DUwHF #880 - John Minichetti
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AUDIO - DUwHF #880 - John Minichetti
Dr. John Minichetti is a general dentist who has been placing and restoring implants for over 25 years. He is a fellow of the Academy of General Dentistry (AGD) and the American Academy of Implant Dentistry (AAID). He is also an honored fellow of the AAID and a Diplomate of the American Board of Oral Implantology/ Implant Dentistry.
Dr. Minichetti is a former faculty member of Fairleigh Dickenson University and Mt Sinai Medical School, and an attending at Englewood Hospital and Jersey City Medical Center. He is past president of the Northeast district of the AAID and President of the Bergen County Dental Implant Study Group, Past Co-Director of the NY AAID Study Club at NYU, and past Chairman of the AAID Research Foundation. Dr. Minichetti is a Past- President of the American Academy of Implant Dentistry.
Dr. Minichetti is the Director of the Dental Implant Learning Center, where he instructs a year long “mini-residency” for dentists teaching both implant surgery and restoration. He is also the Director of the Las Vegas AAID Maxicourse ® at UNLV, School of Dental Medicine and the New York AAID Maxicourse ® at St Barnabas Hospital. He has published numerous scientific articles and lectures worldwide.
Dr. Minichetti is affiliated with these associations:
Howard: It is just a huge honor for me today to be podcast interviewing Dr. John Minichetti, all the way from Englewood, New Jersey, which is pretty much what, across the river from New York City?
John: Absolutely, we're by the George Washington Bridge, yeah.
Howard: And what river is that?.
John: That's the Hudson River.
Howard: The Hudson River. John Minichetti is a general dentist who has been placing and restoring implants for over twenty five years. He is a Fellow of the Academy of General Dentistry and American Academy of Implant Dentistry. He is also an Honored Fellow of the AAID and a Diplomate at the American Board of Oral Implantology. Dr Minichetti is a former faculty member of Fairleigh Dickinson University and Mt. Sinai Medical School and an attending at Englewood Hospital and Jersey Central Medical Center. He is past president of the northeast district of the AAID and president of the Bergen County Dental Implant Study Group, past co-director of the NYAAID study club at NYU, and past chairman of AAID Research Foundation. Dr Minichetti is a past president of The American Academy of implant dentistry. He is the director of the Dental Implant Learning Center, where he instructs a yearlong mini-residency for dentists teaching both implant surgery and restoration. He is also the director of the Las Vegas AAID MaxiCourse and UNLV School of Dental Medicine and The New York AAID MaxiCourse at St. Barnabas Hospital. He has published numerous scientific articles and lectured worldwide, and I can't believe I got the man himself to come on my show today, Dentistry Uncensored has gone to a new level. Thank you so much for coming on the show.
John: My pleasure.
Howard: But basically, podcasters are millennials, they're all born after 1980, and I know how they think. And they're all coming out of school saying, Doc, we didn't place one implant in dental school, how do I go from never placing a single implant to placing my first implant? And it's scary.
John: Absolutely, it's a dilemma for a lot of the young guys out there because they want to get involved and some of them are nervous and rightfully so, they don't have the training and they've almost been downplayed, like, you can't do these type of procedures. So, that's our business, our business is to try to get these guys involved and get them involved properly, so they have the confidence, the knowledge and they can even get credentials to prove that they're adequately trained in these procedures.
Howard: Why do you think it is, when you lecture around the world, that like, in South Korea three out of four general dentists placed an implant last month, same goes for Germany and Brazil, whereas the United States the number of implants per ten thousand total placed is lower than all those countries? And then you micro-drill down those numbers it's almost all periodontist and oral surgeons, why do you think that there's such a cultural difference in the United States?
John: I think because, well, number one is legality, I mean, the legality issue in the United States of course prohibits a lot of doctors from reaching outside their round, we have our specialists who have been placing a lot of implants, although those statistics are changing, more GPs as a percentage wise are increasing, it's slow but it is increasing. That's because implant dentistry just really rocketed after the Branemark studies came out in the mid '80s, and specialists were the ones who were entitled at that time to learn it and entitled at that time to teach it and promote it, and the companies were behind that. But I think you're seeing a paradigm shift now in this country getting more equivalent with some of the other processes that have been going on in Europe for years, and Asia for years, that people have specialties but are practicing a full spectrum of dentistry for their patients. You see that in dentistry today, if it's not done by one practitioner, the so-called super dentist, well at least it's in a group practice where patients are going from service to service to service, or practice to practice to get different portions of a service.
Howard: I think what you're doing is amazing. Where are all... how many different places are you doing this year long MaxiCourse?
John: Well, right now the MaxiCourse is a trademark that the American Academy of Implant Dentistry put out, who I've been a big advocate for. Because being a general dentist... my background was that I got trained, God, thirty years ago and things were different back then, it was the older techniques before the Branemark came out, and the only academy around was the American Academy of Implant Dentistry. AO didn't come in until the late '80s, early' 90s, and ICOI was kind of, an off branch of the American Academy of Implant Dentistry. So, being one of the past presidents I'm kind of, proud of our MaxiCourse program, which is as close to a didactic and/or hands-on residency program as you can get. They trademarked that name for a three hundred hour program, which has a minimum requirement of the basic sciences including anatomy and physiology and basic sciences of bio-mechanics etc, to instruct doctors over a three hundred hour, year long program. So, currently we have about, I think close to fifteen or eighteen programs, if you go to aaid.com you can check that out, worldwide, with about eight or nine of them being in the United States. I myself was asked to start the first one in Las Vegas, which is, kind of, a great venue, but we're doing it now in conjunction with the Continuing Education Department at UNLV Dental School for its intake. That's a newer school which, their only specialty is really the orthodontics and pediatrics, so they have a little bit more of this broad spectrum where they actually have their GPs doing much more surgery in their office or their dental clinic. And we're running a program there and currently we have eighty dentists signed up in that program. Now, it's got so popular that we're mimicking it on the East Coast, this is our first year of launch and I've been on staff at St. Barnabus Hospital, so we're launching it out of St. Barnabus Hospital and we already have about forty signed up for this year.
Howard: Now, your last name has got to be Italian.
John: How did you...? Yeah, definitely, both my parents were immigrants to this country. My father came over when he was eight.
Howard: I'm embarrassed that as a... going to a Catholic grammar school, high school and college and I'm not sure who St. Barnabas is.
John: I would have to say I'm not sure myself but I know the hospital. We have two St. Barnabus' here, we have the St. Barnabus here in... my Catholic school [00:06:44] [inaudible] too... we have the St.Barnabus here in New Jersey and one in New York, which is the Hospital Medical Center there. It's in the Bronx area, which is the upper part, just the upper part of Manhattan, right over the waterway there. And they have a large dental department there, they have twenty general practice residents in their department, fourteen orthodontists, sixteen pediatric dentists, and they have six in the anaesthesia, dental anaesthesia, which is one of the other upcoming, kind of, specialty programs that we're seeing in dentistry where the dentist are two year training, two to three year training in anaesthesia.
Howard: Okay, pop quiz, do you know who the patron saint of dentistry is?
Howard: It's St. Apollonia.
John: There you go, so, you know more saints than I do.
Howard: Did you miss that lecture at grammar school? One of the problems that young doctors say is, they say that when they try to learn implant training they feel like they have to pick the system first because so much of the training is based by the companies making the implants. So, do you agree with that assessment or not agree? Is the MaxiCourse associated with an implant brand?
John: Yeah. So, that's a very good point because a lot of the education over the past really decade or two, couple of decades has been corporate driven, in fact the original Branemark was corporate driven, they were the ones that came out with this brand throughout Europe, the Branemark design, Nobel. And that philosophy or that way of training, I think, is really not the philosophy that we want, or we definitely do not promote that for the MaxiCourse, we want doctors to have a generic background in implant dentistry. We actually introduce them to some of the older techniques of course, as a historical background, with subperiosteals and blade type implants. But you can't just pick an implant based upon one company because some of the companies are a little bit different in their philosophies, nowadays you have some bone level implant companies, you have platform switch type of companies, different types of prosthetic options, so we just try to give a generic course. Of course, we have corporate sponsors that sponsor us just like any other annual meeting does or annual conference does, or societal meetings do. But we try to teach basic science and basic generic implant dentistry so that doctors can choose on their own really which manufacturer they want to use, or use multiple manufacturers if that works out for them.
Howard: There's a big debate between, do you buy premium implants or do you buy the more value price, I mean, do you fly first class in United or do you fly Southwest Airlines, how would you answer that?
John: It's a good question because a lot of my students are just starting out and they don't know which system to get. And I kind of, tell them, don't get the cheapest, you don't have to get the expensive but do get something that's going to be around for a while, that you can have people that you can physically talk to or maybe even come to your office to help you out with, because, particularly when you're starting these cases, that's a source for you, that's one of your mentor sources. They know the sizes of the screws, the bolts, the nuts, they've been there, they're in the trenches every day. So, I tell doctors not to go ridiculous with a foreign company that's just over the internet, that's not the way to start. And certainly once you get more involved and you want to start fiddling with that type of stuff you can, but pick a company that's been around for a while, that's reputable and that's going to be... can provide service and questions and you know they'll be around for [00:10:40] [inaudible.
Howard: Well, you know they all want to know which one you use.
John: They sure do, I don't have my sponsorship logo on, do I? Well, I'm actually a pretty big Zimmer user, I have been with Zimmer, and now it's Zimmer Biomet, for many years. I particularly like that system because it's easy, it's very simple, it's very accessible, now it's I think the number one, two or three in the world with their merger. And they've always had the reps there to help me, although there's other companies out there that we use, I mean, several... because we use companies for support, Neo Biotech, Neodent, Implant Direct, there's a lot of companies that sponsor us and help us out at our programs and also too that we want to support, because all these companies have good products. Some, I think, the concepts are a little bit different than others, and some of that's based upon clinician preference for sure. And what we're seeing over the long term, I'm not the first guy on the block to start the newest technique, but certainly I try to keep as up-to-date as possible.
Howard: Now, Zimmer Biomet, that was from the 3i acquisition, right?
John: Correct. Yeah, that's right. Zimmer Dental and 3i Biomet dental department came together when the orthopedics at Zimmer merged with 3i orthopedics, or Biomet orthopedics, so that was a huge...
Howard: That was one of the originals, I remember seeing those courses when I graduated thirty years ago in '87.
John: Absolutely, a lot of that has some of the early background was Gerald Niznick was the huge competitor with Nobel Biocare, and in fact he did a great service for a lot of the general dentists, including myself, who needed to get implant education at root forms not being a specialist at the time we weren't allowed to take those programs. So, that's some of that specialty mentality that we touched on earlier on. Not to say... I mean, I work with specialists, trust me, we need specialists, but we're of the opinion that there are some specialists who know implant dentistry well and some that are in other areas of their oral surgery or periodontal specialty, or prosthodontic specialty, just as there's general dentists who know certain procedures very well or have certain limits of those procedures.
Howard: What was Gerry's first implant company, was it Core-Vent?
Howard: And then he sold it to Dentsply?
John: Yeah. It was Core-Vent, and then he was with Dentsply, he had the Paragon system on his own for a while, he came back to Zimmer and then eventually sold out to Zimmer, yeah. And then he ended up launching an Implant Direct company, which was something that he kind of, got off of the internet, that's why he called it Implant Direct, and yeah, so he was a real historian and a super good developer with his engineering background for sure.
Howard: So, he started three implant companies then, Core-Vent, Paragon and Implant Direct?
John: Yeah, he did.
Howard: Wow. Well, you make a very good point, when he started Implant Direct, buying online over the internet versus having a physical person in the field, it seems like every... I always believe that you don't reach critical mass until you do a procedure once a week, and I wouldn't want to have an operation by someone who does the surgery once a month or every other month. But it seems like whether you look at quality or profitability, the break-even point is you've got to do it one time a week. But it seems like when I find all those dentists doing it one time per week they pick their implant system mostly because they have a really strong relationship with a rep in their city or their town, do you see that also?
John: Oh, absolutely. I think that's a very important point. There are some reps that are so knowledgeable about the parts and pieces, and not only that, the procedures. I mean, you just see it working on some of these models, they're hands-on some of these reps, they're very good and they can actually see this stuff and they can really guide that doctor. Not to say that doctor shouldn't have the education to do this stuff to begin with, but it's like, that way in orthopaedics too, in the OR, the whole controversy of some of the orthopaedic reps getting a little bit too involved with some of these orthopaedic procedures in some of the hospitals but, because they have the knowledge, they know the products and you need that.
Howard: So, what would you say to... some of these kids come out of school and I mean, a lot of them, right out of the gate say, oh, I don't like blood and guts I like the pretty stuff, I like bleaching, bonding veneers, Invisalign, sleep apnea, they did a couple of molar root canals and they got stung, they try to pull out a wisdom tooth and end up having to refer, they pulled out the crown and had to refer the roots to the local oral surgeon. What would you say to someone who is just twenty five and she's just scared, she's like, the first two times I did blood and guts I didn't really think it was for me?
John: Right. Well, I mean, if they really do want to pursue it they just need more exposure to it. It's like anything else, the first time you walk into a cadaver lab, I mean God, I had one of my assistants, I remember her frozen against the wall as I'm giving the course like, what's going on? And this girl has become a super assistant, unbelievable. And so, it's exposure to any procedure, of course the unknown is frightening. And once you understand, once you're more comfortable, once you're more experienced with those procedures it becomes second nature and you can start expanding on that knowledge. So I mean, unless they just don't want to get involved in it, fine, at least... I mean, we have certain people take our MaxiCourse and probably never do an implant surgery, but they become so much better diagnosticians, so much better treatment planners, they're not blindly sending a case to some specialist or another specialty and then allowing an oral surgeon to prosthetically treat an implant case, where maybe that's not his forte either. So, you do need an understanding, it's a comprehensive field with both surgery and prosthetics so intertwined.
Howard: So, your course on the East Coast is at St. Barnabus Hospital what city...? You said it's in the Bronx?
John: Yeah, it's in New York City, yeah.
Howard: So, they can either go to the Bronx on the East Coast or they can either go to Las Vegas, Sin City, for the West Coast, what does this course cost? And is it once a month, is it two days, three days? How much does it cost and what is the time?
John: Yeah. This is a three hundred hour program, so the three hundred hours are, some of it is with online and self-study learning. But about two hundred hours of it are weekends. So, we do about eight modules, some of them are three days so that it increases that time. And all of the... of those eight weekends, about six of them are in Vegas and the other two, one happens to be at the Zimmer Biomet simulation lab out in California, they have a state of the art multi-million dollar facility that they've built out there, it's actually brand new, they just re-did it, what am I talking about? They just re-did it a year ago, started about ten, twelve years ago, where they have simulation areas, we have up to about thirty docs that we get in there, we rotate then in and they work on mannequins that are, have the x-rays of what they're working on coordinated in more simple implant cases to more advanced over a three, four day period. And then we also have the same facility that we use out here on the East Coast at the [00:18:27] [inaudible], it happens to be located in New Jersey, which is about forty minutes outside Manhattan. And then we also take them to Colorado, we've been down to Colorado this past year and we'll probably be going there for cadaveric hands-on. So yeah, it's going to take them about, at least eight weekends of their time, and they're going to get three hundred hours out of this program, and the costs on that are variable because it depends upon where they graduated. We are one of the programs around that actually offer them student rates because we have about twenty students this past year because we're out of the University of Las Vegas, Nevada that actually participate, so they get a student rate. We have first, second, third year graduates and then we have our tuition rates.
Howard: And what city's that in California?
John: It's in Carlsbad, which is about forty five minutes north of San Diego. In between [00:19:22] [inaudible] and San Diego.
Howard: Yeah, do you know when you're in grammar school they tell you California has three cities, San Diego, L.A. and San Fran and then you go the rest of your life and you never meet anyone from those three cities, you always have to ask, okay, is that city near San Diego, Los Angeles or San Fran?
John: Yes, it's near San Diego, most will go with San Diego for that one.
Howard: This is Dentistry Uncensored, so I don't want to talk about anything everyone agrees with. So, let's get right to the most controversial parts. Seems like everybody that's placed five thousand implants or more doesn't ever use a surgical guide. And then it seems like everybody thirty and under believes that it has to have a surgical guide, do you see that too? I mean, so many old timers... and some of the old timers even say the same thing about a CBCT, they go, dude, I placed ten thousand implants with a two dimensional pano, and I never used a surgical guide. So, how do you address, when she bought this practice and upgraded from a 2D pano to a 3D CBCT is going to cost her a hundred grand, and then they're talking about does she get a 3D printer for her surgical guides when the old guy across the street is sixty years old and said I've never used one in my life and I'm still using a pano? Address those two controversies.
John: Okay. And they're good ones because we have freehand ones versus CT guided surgery and then we have the diagnostic. Now, and myself, because I've been around, even though I don't look it I have been around before we were doing all these CTs for our implant cases. Thirty years ago I started with... 1982 was my first implant placement. So, the first CT I used was a medical CT to take a CT for a CT fabricated subperiosteal, talk about going back in history.
Howard: Wow, do they even do subs anymore? When's the last time you've seen someone do a sub?
John: Actually one of my colleagues sent something out on social media, he did a sub, maybe about two years ago, so I was... I'm sure there are guys still doing those procedures out there. So, not to say that it's not indicated at all I mean, certainly the age of the patient and how you really start, I mean, if you're doing a false mandibular subperiosteal [00:21:43] [inaudible] full upper I guess that's still appropriate, I mean, I usually don't do those type of procedures anymore but it's still out there. But getting back to the technology part, and the other aspect, yes you can do it without the technology, you can place implants and you can do with all of technology, so, everything in life is a balance. You don't want to scare away these students saying they have to buy all this technology, but then again they should have access to those cases and know which cases are indicated for that technology. So, for instance, if... I tell my students when they're starting out, the easy versus complicated case, I mean, if a simple over denture, lower over denture with two implants in a patient with lots of bone that you just did tooth removal, I mean, you can get by without guided surgery on those type of cases, it's just not necessary. I mean, then again, if you want to be a big shot and tackle a full arch case where you've got to reduce bone etc. you'd better have some CT behind you and know exactly where you're going and how far you are. So, each case is different and each doctor's experience is different, you're talking about experienced guys who don't need that technology and some of the experienced guys who are now embracing that technology. There are some conversations now whether the technology provides the same tactile sense that we used to have etc. but that all being aside, certainly having access to the guides or CT technology is important, and certainly it's important for those cases that indicate it. Then again it's not necessarily absolute contraindication to doing implants on a simple case, so I would say to the guys, particularly the young guys, and probably a lot of young guys listening to this, you don't need all that technology to enable you to do this dentistry, that's what we teach at the program, is that there are simpler cases where you don't, and those cases where you do you have access to it without even owning it. There are plenty of CBCT machines out there, either from a specialist who can take it for you, or a radiology center that can provide this information, so, you can do the case if it's complicated and it warrants it. And guided surgery we expound by that, my partner, my co-director of the Las Vegas course happens to be the current president of the American Academy of Implant Dentistry, Dr Shankar Iyer, and he's one of the first ones... he owns navigation, he owns CT navigated guides, but he's the first one to say to students, look, you guys need to understand how to make a basic little flap, a simple flap, evaluate bone because you never know when you're getting in trouble with the guides, so don't listen to the manufacturers or the companies that say you need all this and this is the way to do it, or it's simpler because of this, because it may not be and you need to be able to do some basic implant surgery the good old fashioned way. So, you need to learn that first, you need to walk before you can run.
Howard: So, what is CT...? you said CT navigation guides, is that...?
John: Yeah, so you're talking about a guide where you're looking at like, a 3D navigator while you're working.
Howard: Is that CT www.x-navtech.com?
John: Yeah, Navtech is probably one of the companies, yeah.
Howard: Is that his?
John: Yep, yeah so you'll have...
Howard: So, www.x-navtech.com, what is all that about?
John: Well, that's some of the really latest stuff we're using, it's kind of like a [00:25:23] [inaudible], where you have a CT and while you're doing surgery you're viewing, you're actually viewing the positioning of your drill as you are working on the patient, so you can see the relationship of your positioning of the drill and the implant placement on the screen as you're physically working. So, that's some of the newer technology for diagnostics and guided type of surgery.
Howard: And that's X-Nav Technologies LLC, out of Lansdale, Pennsylvania?
Howard: Is that a suburb of Philly?
John: I think so, I don't really know, but I think so.
Howard: So, let's go to more controversies. It seems like some people are really falling in love with the shorter, fatter implants, and being a short, fat, bald guy I promote anything that's short and fat. Some of these are amazing where, to avoid a sinus lift, they put a really fat eight millimeter or ten, avoiding [00:26:21] [inaudible], what do you think of some of these people using shorter fatter implants?
John: These are great concepts because these are some of the...
Howard: And how fat do I have to get before they name an implant after me?
John: It's funny you should talk about the controversy because that's some of the stuff we did when I was the scientific chairman of that meeting in Washington, where I saw you. We had the controversies, and one of the topics was to discuss short versus long, wide versus narrow. So, certainly it depends again, on each and every case, if the bone, because you've got not only bone volume you have bone density and how much surface area you're going to need based upon that, you've got occlusal load against it, every case is different. We find that we're definitely using less implants and shorter implants, in general, than we did years ago. Years ago everything was so biomechanically oriented that we wanted to maximize everything. And now we're, kind of, finding that you may not need to maximize the length, particularly if all the stress of the bone, all the stress on the implant is at the crest of the bone anyway. That's where some of the concepts come in with lowering the platform a little bit more, using some type of platform switch to help support that. And some of these wider implants are out there today where we wouldn't have considered using wider implants, as we have narrow implants, we have two piece [00:27:50] [inaudible] now where, when I first started I mean, you had a four piece implant and that was it. And if you had a lower central incisor you only had a four diameter implant, that was not an easy task. So, as the needs are developing and as our knowledge is developing on what's best suited for particular patients in particular bone areas the technology is coming out to provide for that.
Howard: On Dentaltown we have to make everybody play nice and it's hard, because on Facebook if anybody disagrees with you you just un-follow them, so you just gather a bunch of friends who agree with everything you say, but Dentaltown you don't have that luxury. We do have a report abuse button, and if you don't like the tone of a post and you hit the report abuse button a bunch of volunteer dentists look at it immediately. But we had to separate a couple of groups, one on CAD/CAM, we had to separate the Cerec users from the E4D, because...
John: Oh my gosh.
Howard: But on implantology we had to separate implantology and mini implant, some of these guys, every time they place a mini implant case would say, oh, you shouldn't have done it, blah, blah. And we had to sit there and say look, just stop. But why is mini implant so controversial? And what happened to 3M's ESPE mini implant?
John: I'm not sure what happened to 3M ESPE mini implant, maybe the sales weren't there, maybe they had problems with it because they had people switch to another company, so I'm not sure particularly with that company. But as far as minis in general, I think they get a good and a bad rep. Unfortunately they were touted as a simpler technique, so it's for doctors to, kind of, just try to avoid learning some basic implant surgery, avoid anatomy and just use a very narrow implant that would fit anywhere. Well, in some cases it's not the best implant to use, I mean, to place, in my opinion to place six or seven implants, mini implants in between their frame, and when you have plenty of bone just to place a couple of standard implants for all your dentures it doesn't make sense because you may have to maintain these, particularly if the bone is cancelous and it's a wide bridge, which it would be cancelous, why don't we use an [00:30:07] [inaudible]? Just because you don't want to lay a flap? So, I think it best... and that's something that we talk about, I actually have someone come lecture, Dr. Brian Jackson, who is one of our Diplomates at the Academy, comes to lecture on small diameter implants. When you say small diameter implants it's less controversial than the minis, but it's the same thing, small diameter implants, when to use them, when not to use them, when you're pushing the envelope a little bit, but with the intent that you should know basic implant surgery. If you're only limited to mini implants then that's all you do. So, can you use them and should you use them as part of your armament [00:30:46] [inaudible] as an implantologist? Certainly they have a purpose in implant dentistry, yeah.
Howard: A lot of people... when I podcast interviewed Carl Misch, he wasn't a very big fan of drawing blood and spinning it and all that, what. are your thoughts on that? That's another controversy.
John: That's another controversial thing, and you know what? I used to spin blood, so I guess for some of us that used to spin and we didn't get the big benefits out of it, I'm of the opinion too, I'm not a big spinner of blood. I used to do PRF and never got into the PFG really because it's a little later technique, but for me I don't really see an effect. I just read a study that was showing PRF in a case where to keep space [00:31:37] [inaudible] and it wasn't as good as an [00:31:39] [inaudible] graft in maintaining space, or a particular graft. So, I think that you're going to see that sometimes these can come and go as fads, I can't see it hurting, I just don't see such strong benefits in it. I think there's a lot of other stuff in your implant surgery that's more important, such as your implant placement, such as the bone quality, such as your preparation of your sites, such as flap closure. There's a lot of techniques I think that are probably more important than adding this to that technique. It can not hurt if you're doing good implant surgery though. So, my personal thing, I don't do a lot of it because I didn't see the benefits of it there, but for those doctors who are using it as part of their good surgical technique I think it can only enhance their surgery.
Howard: So, my job is to estimate the questions out there. you used some terminology to clarify, what's the difference between PRF and PFG?
John: Okay so, you have a fibrin glue where you're going to be using it sort of, as a memory or space maintaining or a membrane, and then you have your PRF, where it's, sorry, PRP, where you're going to introduce much more platelet concentration, with the intent that they're going to put more stem cells in the area for either bone growth usually or initiation of osteogenesis around your implants.
Howard: And you dropped two other terms I wish you'd clarify, you said there were a lot of new implants that were quote, either bone level or platform switch, will you explain the difference?
John: So, for so many years we've had bone level implants, where they were not necessarily meant to place the head bone, we all know that the bone will not grow, or we should know, that the bone doesn't grow above the implant itself, the implant fixture itself most of these two stage implants have your implant and your abutment. So, bone usually grows up to that connection point, this allows the clinician to attach bridges to it or attach attachments to it for dentures etc. or snap-ons rather than a one piece type of implant that's designed to have an abutment on it already with a [00:34:02] [inaudible] clamp. So, these two piece implants for the most part, have been what we call bone level implants, where they're placed down to the bone level and then from there we can get maybe some slight remodeling that was shown in these studies from Zarb and Albertson years ago, that you might get point one, sorry, one millimeter bone loss initially, then you should get remodeling around it and then it stabilizes over time. As of late, at the past probably decade or so, we've had the introduction of a platform switch, the platform switch is using implants with a wider diameter than the abutment connection to it. And what that does is it potentially allows for bone to come up and over the implant body itself to hopefully form a more stable interface or biological interface. And those implants are actually designed to put below the bone because they're usually rough into the top of the implant to allow for bone growth as high as we can get over the implant body, so it's a little bit of difference in philosophy.
Howard: Well, if you go to Dentaltown and you do a search for Minichetti, M-I-N-I-C-H-E-T-T-I, the first thread that comes up was just posted yesterday, the AAID MaxiCourse is a very organized program that well trains a clinician for placing and restoring implants, it also sets up the dentist for... it goes on and on, this guy is singing your praise, I assume this is your brother, or is this your [00:35:34] [inaudible], or is it your cousin?
John: I don't know but I would like to know him better.
Howard: Well, he adores you, and he's touting, saying it was a very good thing. And you can't really learn how to place an implant on a one day course, I mean, this is really going to be a year long commitment, isn't it?
John: It is, yeah. I've been teaching it for years and that's part of the... I have a dental implant learning center, it's thedentalimplantlearningcentre.com, and under that auspices are these MaxiCourses I'm running. And I started a mini residency which is, kind of like, a... that was about seventeen years ago, I have my office here with a group of small doctors, ten doctors, and we went for six, seven months, once a week, it was for local guys in the New York area, many of them have become Diplomats now at the academy, and yeah, it's that repetitive learning that helps. And I had courses for the weekend and we do a mannequin course, but that basically just became mechanical training for doctors. You've got to digest it, you've got to take it back to your practice, particularly if you're not in a formal residency in some type of hospital or school. You've got to take it back to your practice so you can incorporate what you're learning, either on a monthly basis, which is the MaxiCourse, or on a weekly basis if it's some other type of program.
Howard: You have a lot of friends on here, very many friends. If you have that course, three hundred hours of it, and you have a hundred hours of it online, you've already got the content you should put one of them online on Dentaltown. Because we've put up four hundred courses and they've been viewed almost one million times, I think it would be great advertising for you. They'd get to meet you and hear you and if they feel a connection with you they'll want to do more but. Because...
John: We've got to do it. I know we talked about this a few years back so we've got to do it, it's a matter of getting some people to help me get it done, yeah.
Howard: So, we just lost Carl Misch and Pierre Branemark last year that was kind of, that was two legends of implant dentistry. How did those two men affect your life and career?
John: Absolutely. And I want to mention Dr. Leonard Linkow too, the father of implant dentistry, we've lost three, incredible. These are icons in implant dentistry, they set the bar to push clinicians to research, to push the... to make this real, think about it, to make this discipline acceptable. Because when I was in dental school, I mean, I can only go back that far, but when I was in dental school, and I graduated in 1982, there was no mention of implants in dental school, I didn't know what it was until I got out and met someone who was involved with implant dentistry. Lenny Linkow was one of the leaders back then in this country, one of the past presidents of the American Academy of Implant Dentistry. And people don't realize, Carl Misch actually spent about three, four months in Lenny Linkow's office years back to learn all these techniques that he was doing, he didn't have the science maybe behind some of it, but he understood it nuts and bolts, particularly from a restorative aspect. And then there was the science that came out through Branemark that made this more validated and made the specialists in this country actually accept that discipline of osseointegration and that's what really helped propel this discipline over the past few decades. And it was a big loss, these people will be missed, I personally knew both Lenny and Carl, they were great clinicians and they were great people, they were just good people.
Howard: It was the most viewed podcast I'd ever done, it past a hundred and ninety two thousand views and, all my podcasts are an hour, but he was very sick and I wasn't going to stop him at an hour, he went for two and a half hours, it was so amazing. I just posted on that thread that I am podcasting the man himself right now do you have any questions for him? And this gentleman just said, if I take these three hundred hours will I earn my AAID fellowship and ICOI fellowship hours? Is it enough hours to finish any of these fellowships?
John: Okay. So, that's a very good point, let's talk a little about credentialing or certification as we call it, but it's credentialing. So, in implant dentistry everybody, not everybody's doing implants, but everybody who's doing implants is putting a sign on the corner or a post out there that they're the implant expert. So, how can we, kind of, define or, kind of, push doctors to really study this discipline a little bit better, and that's where the AAID, kind of, comes in with their credentialing. What they have essentially now are three credentials and one recognition, one recognition is called the Affiliate Associate Fellow, that's a... when you complete three hundred hours of CE, either in a MaxiCourse or on your own, but at least seventy five hours of a continuum course, which our academy, American Academy of Implant Dentistry, recognizes, continuum of implant dentistry through one program with some kind of purpose to it as part of the necessary education. So, you get those three hundred hours you're entitled to take what we call a fellowship examination, it's a three, well it's over four hours, but it's a four hour examination and if you pass that written examination you're then recognized as an Affiliate Associate Fellow. It's one of the things that I worked on getting approved as President of the American Academy of Implant Dentistry. Once you have passed that written exam then it's time for our academy to look at your clinical ability. Now, since we don't have any formal residencies per se, although there are are two implant residency programs, one in Brookdale and one in Loma Linda, but other than that we don't have a lot of residency programs to view doctors clinical training. We have them present cases to us like a board as they do in other boards. So, we have our credentialing board through the American Academy of Implant Dentistry, your next level would be the Associate Fellowship. So, once you pass the requirements, you submit your cases, I believe it's ten types of cases, I'm not sure off the top of my head, it changes on a yearly basis, and present those cases and take an oral examination then you could become an Associate Fellow. Our highest credentialing level is our Diplomate status, and that's what we won in the courts to allow us to call ourselves a specialist, we won in both Texas, Florida, California, and some of the states now are changing some of their state by-laws to recognize the American Board of Dental Specialties, which we can talk about later, as another recognizing board outside of the American Dental Association as a specialty for implantation. But, getting back to this kid's question, yes, if you take a three hundred hour MaxiCourse that gives you the necessary hours to take the written exam, then if you pass the written exam you will become an Affiliate Associate Fellow. Now, our pass rate is pretty good from our students, we prepare them well, it's like, 90% plus will pass that written. And then from there you have to put together your cases, if you don't have them already you have a three or four year period I believe, to put those together and present it to the oral board, and then you can become an Associate Fellow. So, that's the purpose of it, not only to train you but to push you to study, to take the exam so you can understand the didactic information and then also to help you get the cases.
Howard: If someone said, why do implants fail? Would you first categorize that, split that herd up into those that fail out of the gate versus those that fail years down the road? Do you think that's a fair way to break up implant failures, immediate failure and long-term failure?
Howard: So, if someone said, why do implants fail out of the gate, versus why do implants fail long-term, how would you answer that?
John: Well, you have to see. So, you're talking about failure from stage one to stage two [00:43:46] [inaudible], if we're using a two stage system, which most of the time we are, or from placement to load, that would be the first initial early failure. Those failure rates are actually higher, and a lot of that has to do with, can have to do with surgical placement, the receptive area of the patient, if you placed it in enough bone to begin with what's the quality of that bone. So yeah, that's the initial failure rate and that's usually the highest, then you get into failure after load, and that's a late term failure, and they'll occur, most of the failures will then occur after load, maybe one or two years. Once you get to that one or two year success rate and the implant's still there, most of the time it will stay there, although then you get that smaller rate of those late term failures that we're really classifying as peri-implantitis cases. And that's become a little bit of a problem for us in the implant industry, we don't really know how to handle this situation with peri-implantitis. Most of the presentations you see, we're talking about maybe using some of the re-attachment procedures that your Millennium or your DEKA laser units to try to treat some of these pockets with peri-implantitis, you've got some advocates of utilizing antibiotic coverage, oral systemic antibiotic coverage or localized antibiotic coverage of these sites, or even opening it and flapping it. But that late term failure is the toughest one to treat, that peri-implantitis, why are we getting an inflammatory response in some patients and not in others?
Howard: A lot of advertisements... some of the kids ask, well, I've looked at the ads, in my own magazine Dentaltown, and they're quoting different, various success rates, and they seem to be always extremely high. What should a young graduate think of when they see these companies advertising these success rates? And they're always, always in the upper nineties.
John: Yeah, they're always high, I know, and you've got to be realistic about this, you've got to say there's going to be a 10%, there's a 10%... anybody sitting in my office it's 10%. I mean, I just did a consult this morning for a young fellow, he's got some severe periodontitis, and it's almost classical of the juvenile periodontitis that we've seen in the literature, and severe bone loss, just lost his lower anteriors, he's in his mid thirties. And I told him, yes we could go to full arch reconstructive on you but there's never any guarantee that you may not have peri-implantitis around your final case, so before you make this huge decision on whether you want to start to treat this perio or retain some of your teeth area you've got to know that. And I don't think we should be touting percentages, the 99% that you'll see in the literature from some implant company that may be very selective, and they're only doing it from stage one to stage two anyway with these statistics.
Howard: Yeah. Would you agree that in our lifetime, in our thirty years, of the nine specialties recognized by the ADA, the periodontist specialty changed more than I think endo or pediatric dentistry or orthodontics? And it seems like thirty years ago it was all perio surgery and then there was this big shift to treat all this molar perio with forceps and titanium. But now it seems like that pendulum is starting to swing back, do you agree with that assessment?
John: I absolutely do think we need to re-read this, because there was one study that came out I think recently doing a comparison from saving teeth to placing implants, and we're finding that some of these statistics may be the same. So, before we condemn patients entire dentition to this we need to take a real hard and look at whether we should be doing that. I'm one of the people who I think, we may be extracting too many teeth out there, condemning too many arches when it may not be necessary. So, we have to be conservative in our implant treatment for sure, it's not the cure all, it's definitely not the cure all.
Howard: Not to say this in a bad way but, we all know that at least a quarter of all people are crazy. How do you put on your doctor hat when a lady comes in and says, I don't want metal, I don't want metal in my body, I have allergies to metal and I want a porcelain, ceramic implant, what would you say to her, how would you say that?
John: Personally I'm not placing ceramics, I would definitely say that to them, and there's a reason for it. Because I'm not... again, I say that I'm the one person, I want to be on board with all the newest technology but with something like that you've got to make sure that this is something that's been proven and that it's something that's going to last so, because implant failure, there's nothing worse than implant failure. So, from my personal experience with learning about the ceramics, there's been a lot of studies that come out, but again it could be some of these studies that we talked about before, so you have to look at these studies with a kid glove from Europe. But they have some promising statistics, but if this is such a great technique, if it's such a great material to utilize for implants, then why aren't the big companies on the band wagon to mill these left or right? I wonder about that. And I've heard of some clinics getting involved with it and the failure rate is a little bit higher than titanium, so based on that knowledge I'm not dabbling in zirconium yet, and so we'll see. I mean, certainly the coefficient of thermal expansion on that is nowhere near as tight for titanium, so I can't see it being as compatible with the bone as the other metals. We have tantalum that's being fiddled with, you can't mill it you actually have to make it through induction, they're using those sleeves on some implants, but that's a better flexible metal than zirconium. So, I would say to that person who's asking for that I would say, be very careful in researching this based upon that you think you're going to have a metal object, because zirconium is a metal too, so I don't see the difference at all.
Howard: Good point that zirconium is a metal too. Do you see any evidence that there are metal allergies to the current titanium that's being used?
John: I believe there are some. There's very little in the literature but I've had a couple of patients where there's no explanation on why they're getting reactions to these implants, certainly can even have something to do with the alloys versus commercially pure titanium, might be some differences in that. And in fact, it's funny you should say that, I'm actually the Scientific Chairman of our present meeting coming up, so, you should come out, we could do dinner again, last time I was Scientific Chairman, there you go.
Howard: Where is the meeting, where's it at?
John: It's at... American Academy of Implant Dentistry is having our next annual conference in San Diego, we've just spoke about San Diego, it's going to be October 12th, I'm sorry October 11th it starts through October 14th 2017. And one of the programs, and I'm putting this together, I try to get people to discuss different things, we're having someone come speak about allergies to titanium versus allergies to zirconium metals, that's going to be one of the main... she's coming in from Germany I believe.
Howard: Well, I may hit you up on that because I've got a little five year old granddaughter and when you say San Diego she translates it to SeaWorld, Lego Land and the San Diego Zoo. And that is grandpa heaven, in fact that's why I've moved the Townie meeting, we had it every year for fifteen years in Vegas and we're moving it out to Orlando because there's this little girl named Taylor who wants grandpa to take her to Disney World.
John: That's what it's about.
Howard: And you know what? Everybody's heard of SeaWorld and they've all heard of the San Diego Zoo, but I think the most overlooked theme park out there is Lego Land. I mean, even if your granddaughter doesn't even play with Lego they just love that place.
Howard: So, what did you think of the Texas ruling?
John: I thought it was a fair ruling. I think that what you're seeing now is that implant dentistry is coming to age. Our academy has been working very hard to get our credentials recognized. Now, we have doctors who are boarded in oral surgery who take our credentialing, and we feel that they have separated themselves as better implant dentists than other oral surgeons, by proving to themselves that they have a thorough knowledge of implant dentistry, which is very prosthetic oriented, it's not just surgery. We also have periodontists who've taken this exam, and they're dual boarded perio and implant dentistry. We have a lot of prosthodontists who also place implants, and these guys are probably the best restorative doctors out there, great understanding, certainly for these full arch cases. And they understand the planning, where implants should be placed for a load, the prosthetics set up, the implant positioning in terms of restorative aspects, and that's what our academy has stood for. It's not to say that there are not other specialists out there, but we were actually endorsed by the American Dental Association as the implant organization, the American Academy of Implant Dentistry, never though getting a specialty recognition, even though we applied twice to their board, and some of that might be political. So, when you have a... and let's put it this way, medicine, the American Medical Association does not set their specialties, they have a separate board called the American Board of Physician's Specialties, or the American Board of Medical Specialties, there's a couple of boards, and those are the ones that really recognize the boarding process, it's not the organization that votes for laws or a membership organization. And so, in dentistry you're going to see a change, the American Dental Association, even though it's been referred to by so many states over the past whatever, hundred years of our existence, or sixty years, seventy years of our existence, you see now that we formed another American Board of Dental Specialties, and in that is anaesthesia, which has formal hospital residency training, we have oral medicine, we have oral facial pain and we have our implant society, and it's a valid board and I think the courts rightfully can see that it should not be a membership organization being in charge of recognizing specialties or deferred to in the recognition of dental specialties.
Howard: I posted under implantology that I'm talking to the man himself right now, do you have any questions for him? And one of the questions is, what is your standard routine antibiotic protocol for dental implant surgery?
John: My preference is very similar to what the American Heart Association recommends for prophylaxis for cardiac, it's a loading dose of two grams of Amoxicillin or Clindamycin, six hundred milligrams, if they're allergic to Amox. And ideally you should only follow it up for the first twenty four to forty eight hour period, but conventionally it's not too easy to do, so we keep them on for at least four or five days [00:55:06] [inaudible] with either one.
Howard: Another question concerning controversy is, when you and I were in school, doctors were getting bad press because we had all these patients in pain and we were too conservative to prescribe pain medication and a lot of people were dying of cancer anyway so what difference does it make? Now the pendulum's swung all the other way that now doctors are causing all these drug addicts and we [00:55:31] [inaudible]. So, what is your standard protocol after implant surgery? Do you still do opioids, narcotics, Vicodin or do you believe that that's not a good protocol?
John: Well, this is a... it's a real drug epidemic out there, there's certainly concern, and I think there's probably so many factors contributing to it. And one of them may be the over-prescription of opioid narcotics, for sure. So, I can tell you that in my practice we don't write them as freely as we did years ago, you're absolutely right about that because we have to be very, very careful, don't write more than you need, [00:56:10] [inaudible] not left around the shelf as much, and evaluate each procedure and just see, really ask the patients, [00:56:17] [inaudible] routinely have to write for forty Percocet after a single tooth implant procedure, particularly if you just did a root canal on that patient four months ago and that patient basically took [00:56:28] [inaudible]. So, that's, kind of, how we do it. One of my first questions to the patient, do you think you'd be okay with [00:56:35] [inaudible] or Tylenol? How were you last time when we did the extraction etc? Did you have to take anything? And if they don't then, you're right, they're not going to get that opioid. But for some procedures, obviously if we're doing a whole mouth extraction case and placement of implants, I think it's only appropriate to control pain over a short period of time. So, if it's over, if they're going to get whatever, twelve pills for three or four days that should do it, if it's extending over two or three weeks there's something going wrong anyway. So, usually those patients are only in pain for two or three days, I'm finding that actually the implant procedures are probably less traumatic than some of our extraction procedures, so we're not writing opioids as much for those patients. And that's kind of the generality of it.
Howard: Another question people are wrestling with is, some people bone graft after every extraction, they want to fill the socket with something, other people don't, what is your thoughts on that?
John: So, it depends, if we're going to be placing an implant into this extraction site of course, so if we're doing delayed placement, extracting a socket and we're going to be placing our implant as quickly as possible, I'm an advocate of grafting and I'm an advocate of grafting with an allograft that's going to remodel within a three or four month period. It gives you more stability and more control when you're drilling later on, you don't have to engage the bone past the socket site as much. So, I tell my students, it's a very good practice if you're going to be placing implants. If you're not going to be placing implants, you're going to be placing a prosthesis or a [00:58:10] [inaudible], you may even, a [00:58:12] [inaudible] you might want to use a less resorbing graft material. So, I'm an advocate of socket grafting, I'm actually a bigger advocate of delayed placement, if I could delay placement of something versus immediate placement I actually prefer delayed placement, it gives me another surgical shot at the case and I have a better blood supply at each step.
Howard: What allograft do you like.
John: Well, I love mineralized allograft, my favorite actually is Puros, I've been using it for a number of years, but I've used some of the allograft from both, OraGraft also, I use that also, but probably Puros is my number one go to allograft.
Howard: And it seems like there's a lot of different types of sinus lifts, what are your... which sinus lifts do you teach? Which ones do you like?
John: So, that's a very good point because you have approach to the sinus, and that's something that we go over in our program, whether you need to even elevate the sinus, or get it involved, are you going to put a shorter implant, what's the load against it, what's the diameter, what's the density of it? If you're going to be elevating it minimally you might want to consider doing it from the crest of course. And then what techniques do you have available, there's a number of crestal techniques from simple osteotomy with a mallet and Summer's Technique, to using some of these kits such as the Sinus All, you've got your Megagen kit, you've got your [00:59:42] [inaudible] kit, and we have certain clinicians come and introduce different stuff, I want our students to get different approaches to get all the knowledge they can on these. Some of the techniques, as you get to certain skill levels you tend to lean towards simpler techniques. Some of the doctors like using these old reamer type of drills or diamond type of drills so they don't tear. And then last of course lateral window access to the sinuses is sometimes necessary in those cases, particularly where we have minimal bone to support implant, where we're going to try to lift the membrane over five, six millimeters, I mean, it's just not conducive to doing it from the crest. And then those are the types of cases where lateral approach with different, again different armamentary, you could use [01:00:27] [inaudible] surgery, you could use a reamer drill, diamond drill, you could use your high-Speeds. So, we cover all those techniques, we try to give the students the best education they can get, and what is their preference.
Howard: I can't believe we just passed one hour, I can't believe you gave me an hour of your time. Can I just ask one overtime question on one more controversy?
John: Go ahead.
Howard: The big one, screw or cement?
John: Ah, screw or cement retained prosthesis? Well, I still... my preference is cementable, it's actually easier for me, I don't have to deal with the holes, the patients like the look of it. I don't care what type of filler I use over screw, it'll never be perfect. But then again you've got to be careful, pericementitis, it's a problem, I understand that. So, the doctors have to design their abutments so they are cleansable and you can avoid those things, and always take x-rays after you're cementing stuff.
Howard: Is there any cement that you think cause less peri-implantitis than others?
John: Yeah, my preference is, if I can have an abutment in a cementable sleeve [01:01:31] [inaudible] so much retention I can use a temporary cement, that's my preference, I'll use a temp one.
Howard: Temp one, very interesting. Well, I think you're an amazing man you've done so much for dentistry you've done so much for implant dentistry, I really think these kids if you're getting out of school at twenty five, I mean, the implants are only going to get bigger and bigger and bigger.
John: Oh, for sure. You definitely have to be part of it, you have to understand it first, absolutely.
Howard: Last weird question and I'll stop. Do you think it's, kind of, a religious mentality that we don't want to file down two virgin opposing teeth and do a three unit bridge but have no problem blowing up the sinus with all this titanium and cow bone and paper clips and hormones? Do you think that's kind of, illogical? Because when I go... I've got local ENTs and local rhinologists who think that we're nuts and they're like, dude, you had a tooth in front of that and behind it, file down two teeth and stay out of my sinus. So, it's, kind of like, if you're in ear, nose and throat your God is the sinus, and if you're a dentist your God is Mr. odontology and you worship enamel... even the terminology, virgin teeth, how could a tooth be virgin? I mean. So, do you ever think about that? Do you think we're just weirdly biased towards enamel and dentin as opposed to the sinus?
John: Maybe, I think what we're opposed to is post-operative complications, whether they be, now you've got to do a root canal or now you have a tooth loss down the road in that three unit bridge or if their sinuses... you run into a complication with a sinus, you're not lifting them or playing with them too much anymore because that's not easy to deal with. So, whatever is going to produce the least complications, that's the procedure you should choose. And of course you want to take into each case the individuality of the patient of course. If it's just the simpler thing... there's nothing wrong with general dentistry, that's why I love to have my general dentistry background, it really enabled me to expound on this technique and not push the envelope to ridiculous limits.
Howard: Well, I mean, there is... I read an interesting study the other day where, when they study primates, there's always one at the bottom that they're all beating up and picking on, they're all shaming him, and if they take that monkey or ape out they pick someone else. And they're realizing that the hard-wiring of man is that you had the four hundred pound gorilla all the way down to let's beat up the small guy. And so that's shaming or bullying, but you do see dentists shaming and bullying people who do three unit bridges versus an implant and a crown, I mean, do you agree? Have you ever witnessed that?
John: Yeah, I mean, for sure you can hear that. I mean, certainly you compare [01:04:42] [inaudible], certainly if we had a [01:04:42] [inaudible] space that was perfect for an implant without any augmentation of the sinus, I mean, I might say then, why did we grind down these teeth? Because that's a situation where you're more likely to have a complication. So, each case is individual. And I think what the danger is sometimes, then the question of, oh no, wait a minute, because I couldn't do the procedure is the wrong way to do that, you should know both procedures, or certainly plan both procedures, or if the insurance company only paid for that procedure, that's a trap, that's terrible.
Howard: Okay, last... I swear this is the last, what would you do though, back to that three unit bridge, what would you do if you got a patient came in and she was gorgeous, it was her front tooth missing, she had a high lip-line and she wanted it to just look gorgeous and she had this beautiful smile, would you go after an implant and a crown on a central incisor on a pretty girl? Or would you think that would be easier to nail with a three unit bridge?
John: Each case is different but no, yeah, I'm doing single cosmetics on these high lip-line young kids, yeah, absolutely we're doing them. You've got to know what you're doing, those are the most complicated cases I tell my students, the most complicated.
Howard: Well, thank you so much for coming on my show, dentalimplantlearningcenter.com, it's Dr. John Minichetti, and my gosh, if you want to start placing implants it's going to be a year long commitment and I couldn't think of a finer man to study. Thank you so much for all that you've done for implant dentistry.
John: Howard, thanks for you.
Howard: All right, I hope you have a rocking good day.