Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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884 Lessons In Implantology with Dr. Steve Hurst : Dentistry Uncensored with Howard Farran

884 Lessons In Implantology with Dr. Steve Hurst : Dentistry Uncensored with Howard Farran

11/16/2017 9:02:47 AM   |   Comments: 0   |   Views: 291

884 Lessons In Implantology with Dr. Steve Hurst : Dentistry Uncensored with Howard Farran

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884 Lessons In Implantology with Dr. Steve Hurst : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #884 - Steve Hurst



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AUDIO - DUwHF #884 - Steve Hurst



Dr. Steve Hurst was born and raised in San Diego. He graduated from UCLA School of dentistry in 1993 and married his classmate Dr. Bridget Hurst in 1995. He spent  two years with the Public Health Service and four years in a Loan Repayment Program in Central California.  

In 2000 Steve and Bridget returned home to San Diego with three kids in tow and currently practices general dentistry with a strong emphasis in Implant dentistry.

Dr. Hurst is a Fellow of the California Implant Institue (CII) and was instrumental in starting CII’s Live Surgical Implant Program in 2012.  The program provides 50 U.S. patients a month with no cost extractions, bone grafting and Nobel Biocare implants. Dr. Hurst is responsible for patient screening, initial CBCT diagnosis, surgical instruction, post-op follow up and final restorations, which include Crown and Bridge, locator over dentures and Full Mouth Fixed restorations.

When he is not working he enjoys surfing and spending time with his wife and 4 kids. Alexis their oldest just applied to dental school.

Howard: It is just a huge honor for me today to be podcast interviewing Steve Hurst all the way from San Diego. He was born and raised in San Diego. He graduated from UCLA School of Dentistry in 1993 and married his classmate, Dr. Bridget Hurst, in 1995. He spent two years with the Public Health Service and four years in a loan repayment program in central California. In 2000, Steve and Bridget returned home to San Diego with three kids and currently practices general dentistry with a strong emphasis in implant dentistry. Dr. Hurst is a Fellow of the California Implant Institute and was instrumental in starting CII's Live Surgical Implant Program in 2012. The program provides fifty U.S. patients a month with no cost extractions, bone grafting and Nobel Biocare implants. Dr. Hurst is responsible for patient screening, initial CBCT diagnosis, surgical instruction, post-op follow-up and final restorations which includes crown and bridge, locator over dentures and full mouth restorations. When he's not working, he enjoys surfing and spending time with his wife and four kids. Alex is the oldest and just applied to dental school. Congratulations, man!

Steve: Yeah. Alexis. Yeah, so.

Howard: Oh, Alexis, I'm sorry. Alexis.

Steve: Alexis, yeah. She's ...

Howard: So, she turned out just like her mama?

Steve: Well, yeah, you know, her mom's third generation, so that'll make Alexis fourth on her mom's side and third on mine, so, genetically she was done, she didn't really even have a choice.

Howard: That is so cool. You know, a lot of people, I don't think they realize that a lot of our last names came from our occupation, like Smith was a blacksmith, you know, putting horseshoes on a horse, and a lot of ... when you go around the world, family businesses are very common. I mean, you know, you go to these countries and if your father was a goat herder, I mean, that's just ... it's natural to follow the family business. I mean, you start with a huge advantage, you know. In Kansas ...

Steve: Yeah.

Howard: ... those wheat farms, I mean, some of those wheat farms have been in the family for hundreds of years.

Steve: Yeah, yeah. My family has land in Nebraska that we just got a plaque for, it's been in the family over a hundred years, so, yeah, good luck starting a farming career without, you know, inheriting some land.

Howard: Yeah, what do they farm? Corn?

Steve: Corn, soybeans, a little [00:02:28] [sounds like: Milo], [0.4] I guess, but mostly corn.

Howard: Yeah, mostly corn, amazing. So, you know, they say the fastest growing sector of the dental industry, number one fastest growing is clear aligner, Invisalign.

Steve: Okay.

Howard: And number two is implants and I think the reason is obvious as I've done these podcasts from, you know, twenty-some countries, is that a lot of people have insurance from the government or whatever that fixes ... or PPOs in America, that fixes the fees on cleanings, exams, fillings and x-rays, and most of these dentists have extremely high overhead, but they never set the fee for Invisalign or dental implants. So, you know, I've been in dental offices in Cambodia where they say, "You know, we basically run at a break-even but if we pull one implant out per week, at fee for service, and I do fifty implants a year, that's how I make my money." So ...

Steve: Yeah.

Howard: So, implants are really booming but a lot of people are scared. So, I want to tell you that most podcasters are listened ... are born after 1980, so, I know your audience is more closer to Alexa's age than our age and they're all saying the same thing. They're commuting to work right now, they're saying, "Steve, I just got out of dental school. We didn't place one implant. I don't even know where to start. How do I go from zero to one?"

Steve: Yeah, I would say there's never been a better time than now to start getting into it. So, you know, five, six years ago, I'd restored a few implants, but I wasn't doing any implants, but I, kind of, could see the writing on the wall and, my g*d, I loved it when somebody came in and all I had to do was tighten a screw, put in a little Teflon tape, a little composite, and that was my screw-retained crown. And the fees are great! So, I mean, implant dentistry, like you said, it gives you an opportunity to kind of beat the PPO monster and, g*d knows, people need this. So, anyways, I was looking for a live course. I didn't want to take another class and then come home and be too scared to place an implant. I had a buddy take a Misch class and when it was all done he said he was just too petrified to do anything, and I didn't want to do that. So, I'm lucky, I happened to live within a few miles of the California Implant Institute - they call it CII - and I happened to own a surf condo down in Mexico, and I was thinking wouldn't it be great if I could write off this surf condo by somehow getting it involved with dentistry. So, I knew there were live courses, but there wasn't anything on the West Coast, so I approached Louie Al-Faraje, the founder of the California Implant Institute. I said, "Let's do something." He kind of looked at me and said, "Okay, well, you know, let's go take a look at your condo. Let's see what it looks like." We ended up renting a condo next door to mine. We took out the furniture, we put in a couple of chairs, and in 2012 we did our first course. We had three chairs. In 2013, we had three courses. Our average course will last five days. We'll probably see fifty to sixty patients. We'll usually have sixteen or seventeen doctors. We'll place around a hundred and fifty implants, and do a lot of bone grafting too, sinus lifting, that kind of thing. And, you know, fast forward to 2017, next year we're going to be doing a program every month and it's, sort of, just taken on a new life of its own. What excites me is these people who need this full arch treatment can get into the implants now at no cost, right. We can do the surgery for them. We can do the bone grafting and we can place the Nobel Biocare implants for them, and then they can save that surgical fee and put it toward the restoration. And that's what I'm starting to see in my practice now. I'm, you know, for every implant I place, I'm probably restoring fifty, you know. And, Howard, you know, I mean, there's surgery guys and there's restorative guys. I've done a lot of implants, I've done over a couple of hundred implants. I ... when we do our programs, I'm a surgical instructor. I know what I'm doing. I like to help new doctors get started. But the bottom line is, in my practice, I'm mostly restorations. And, if you have homies out there who might be interested in getting into implants, you know, the surgery is one side of it, but the restorations are the other, and we should talk about maybe, you know, teaming up with some people, sending us patients, we can do the rest... we can do the implants, and then we can get these people into these full mouth reconstructions that they need but can't afford. I mean, g*d knows, the numbers are out there. I talk to ... hell, I'm talking to probably seventy-five people a month and a lot of them need these full mouth restorations, but they've been blown away by ClearChoice. They're out there. We just need to figure out a way to, you know, get the service to them.

Howard: Wow, that is an amazing program. So, are you mostly talking to dentists in ... was that a shout out to your local homies in San Diego?

Steve: No, no, no! Listen, here's what happens. Okay, sixty patients per program. One program per month. We get twenty from San Diego. We get twenty from California, you know, north of San Diego, and we get another twenty who fly in for it. And then of those patients who fly in, a lot of times, they go back to their hometowns and there's nobody who can restore them. And if we could have a network where, you know, I could talk with the doctors and they can understand what we do. They could feel comfortable with the surgery side of it, maybe handling suture removal here or there, and then if they could restore these patients, I mean, you could do one to two full mouth reconstructions in their practice per month pretty easily. We have the demand; the doctors are coming to us with the demand. We just need to provide, you know, ideal patients I say. I mean, I would like to provide these doctors with patients who are going to go home and get restored. Right now, probably a good third of our patients disappear, I never see them again. I don't think that's an ideal situation. So, I'm looking to, kind of, you know, trying to put out the word and see who's interested.

Howard: Well, you know, Dentaltown has fifty categories. And that's the difference between Dentaltown and all the social medias, Facebook, Twitter, LinkedIn, they all have the endless newsfeed, and whereas Dentaltown, you go to Dentaltown and it's organized in message boards. So, we have fifty categories. One is implants, and you should go under implantology and post a thread on that.

Steve: Okay.

Howard: I think that would be huge. I mean, I think a lot of people would really get excited about that.

Steve: I mean, I was surprised at how straightforward some of these restorations can be. And I'd be willing to work with people, kind of show them what we're doing. You know, a lot of this stuff can be ... it's very amenable to an auxiliary, especially an auxiliary with extended function. They can place impression copings, they can, you know, take impressions, they can see, you know, some of this crown and bridge, and they can help with the full arch stuff. So, yeah, I think there's a fantastic opportunity to help, you know, you probably know the numbers better than I do. I can just tell you, there's an entire population of people who need this service. ClearChoice blows them out of the water. They go home depressed. You know, they're too young to go into full dentures, they don't want to stick their dentures ... they don't stick their teeth in a cup at night, you know. Half the people who are edentulated get eduntulated before the age of forty-four. These are young beautiful women who just ... they're just too young for this. And, you know, we can't solve everybody's problem, but, man, we can solve a whole bunch of people's problems through this program that we have going, and I'd love to see where it would go. I mean, who knows?

Howard: That is amazing. So, what kind of lessons have you learned from helping over three hundred doctors place their first dental implants?

Steve: Well, you know, so, we've probably had four hundred go through our program and a fourth of them come with a lot of dental knowledge, but, you know, the majority don't. So, and you see a pattern. I know you mentioned, you talk a lot about patterns that you see. Well, it's predictable when you have a new doctor come in, we can almost sit back and just watch them go through the learning curve, and I will tell you this, if anybody out there is thinking, "Oh, I'm not surgically oriented. Oh, I can't place an implant." I would challenge you on that, because if you can do, you know, an MOD onlay, you're more than qualified to place an implant. So, there's a couple of things that I would encourage the new dentist to look at. Number one, you know, don't do this without a C.T. scan. It's crazy. You know, you wouldn't drive across town without being strapped in, without your seatbelt on. Get a C.T. scan. With a C.T. scan, you're going to see enough information and you'll get the confidence that you need to not worry about hitting anatomy or angulation. You'll know approximately how deep the implant needs to go. You'll know what size implant. You'll know the density of the bone. So, get a C.T. scan. Just get a C.T. scan. I'm just saying.

Howard: Which brand? Homies always ... they always want me to hold your feet to the fire and say, they want to know which one you bought.

Steve: Yeah, I mean, we like the i-CAT, but it's not ... it doesn't have to be an i-CAT. I mean, you can send your patient to an imaging center or, you know, I don't know, maybe ... I know they're expensive. I get that.

Howard: But, why did you buy the i-CAT and not the i-DOG?!

Steve: You know, 'cause my partner has an i-CAT, so, I got comfortable with that. But, once again, any machine out there will work, just get comfortable just knowing how to treatment plan on it. And then you're going to have so much confidence when you go to the next step. I would say, you know, you've got to embrace the flap guys. You know, this flapless stuff - that's an advanced technique. If you learn how to flap and where to cut and where not to cut, and you're looking at a piece of a beautiful bone and it's right in front of you and you know how deep you can go, you know, if you have a stopper on your drill, you know, anybody can place the correct angle of the osteotomy into a ridge that they can see. But you have to see it first. You know, it's not like doing an MB2, where you're in there and you're blind. I mean, that takes skill, but placing implants in adequate bone that you can see will lower your learning curve dramatically.

Howard: Okay, you just said 'beautiful bone'. That means you are third generation dentist and you might have ... not many people call it 'beautiful bone'.

Steve: Oh, man, yeah. My partner and I, sometimes when we look at a C.T. scan and it's, I mean, you know, I say, "This is C.T. porn right here. It's just beautiful bone. Nice, dense, hard bone. Lots of it." So, I get excited about that.

Howard: Well, you know what? That's neat, because in Dentaltown there's a couple of threads ... there's a thread called 'dental porn', and a lot of people don't [00:14:31] [unclear]. [0.4] They think porn is about nudity, but the definition of porn is - it's very interesting how people don't realize that ...

Steve: It's a beautiful sight. You know, what do they say about the ...

Howard: It's basically something that's beautiful.

Steve: Yeah.

Howard: Yeah, something that's aesthetic, that creates an emotional feeling. It's not just smut. It actually means that something is ... it comes from ... but anyway, it's something beautiful. But, anyway ...

Steve: Well, yeah.

Howard: But, I already know what she's thinking. She's driving to work right now. I know how she thinks. I've seen her ... I've been on Dentaltown four hours a day since 1998, she's thinking, "But I can just get a surgical guide and not lay a flap, and just punch that hole right through the tissue. I don't want to lay a flap. I don't want to be a surgeon. I don't like blood and guts."

Steve: Okay.

Howard: So ...

Steve: Good.

Howard: So, address that.

Steve: Okay, well, you know, you know as well as I do that surgery is not for everybody, and if I had to choose a camp, you know, I've placed a lot of implants, but I do like the restorative side of it too. And so maybe you're not a surgery guy, that's fine - or a surgery gal, that's fine. I would challenge you to at least come and, you know, maybe sit in on one of our programs, and you don't have to be a surgeon, you can come just to watch. We have ... some doctors will bring a patient with them. All right. The patient gets the implants. That patient goes back with these doctors. The doctor restores them. That pays for the course. All right. So, it really shouldn't be, you know, that hard to get compensated for your time while you're getting educated. Just learn the process. But, I mean, how many pilots fly on autopilot without knowing how to turn off the autopilot and land that plane safely if something goes wrong? What if you have a guide and it's off or, you know, what if, you know, there's an [00:16:30] [SOUNDS LIKE: intra-surgical [0.8] complication. You want to know how to get yourself out of it, you know. It's like Invisalign. You mentioned Invisalign, okay. Well, yeah, I do some Invisalign, but how often, when that damn case is done, are you looking at a posterior open bite or something, and then you have to go place some brackets and close the bite and salvage the case. I mean, so hard to be over-educated. So, before you make that decision or tell yourself, "I can't do that", you know, check into it first, and ... because I bet you would come to be able to place the simple implants, and you would enjoy it and certainly you should be able to restore your implants as well. I mean, that's lucrative and fun and, yeah, and there's ...

Howard: That was worth the whole podcast for me, just for that analogy about, you know, a surgical guide being like an autopilot, but a real pilot has got to be able to turn off the autopilot and land the plane manually or lay a flap. That is so cool, because I've had a big discussion. One of my best buddies is a pilot and my first cousin is a pilot and a lot ... you know, they've been doing cruise missiles for so many years with, you know, those airplane engines and the cruise missiles are perfect - they don't have any pilot error - but they'll never going to take the pilot out of the airplane because you've got a fifty million Dollar piece of equipment up there with a hundred and forty souls, and they're not going to have driverless airplanes ...

Steve: No.

Howard: ... when you got a fifty million Dollar aircraft and a hundred and forty live people up there.

Steve: Yeah.

Howard: They're always going to leave a live monkey. You might have ... Uber might have driverless taxis someday, but you're not going to see driverless 747s, but ...

Steve: Yeah.

Howard: But I want to go back to that point again and ask it in a different way. You know, her problem is she just ... you know, your self-limiting beliefs all live between your ears. So, to come out of dental school and say, "I hate surgery. I hate wisdom teeth. I hate molar endo." You need to solve that problem. That's an attitude problem. And just get over it. I mean, the best thing about endo is, they're coming in there begging you to do treatment because they're in pain ...

Steve: Yeah.

Howard: ... whereas veneers, you've got to be a salesman and try to sell them on bleaching, bonding, veneers, but they're begging you to fix a toothache and, but what ... but go back to that ... the surgical guide because that was one of the most controversial threads on the on the implant dentistry deal: to surgical guide or not. And I'm talking about ... yeah, just talk about surgical guides, because a lot of people do swear by them, and a lot of people who have placed a thousand to ten thousand implants have never used one.

Steve: Yeah.

Howard: So, how can you have this huge ... how do you have this very asymmetrical body of dentists where you've got all these studs that are placed - five thousand plus - never use them; then all these kids that are Millennials say you have to use them, I use them for every single case. Where's the fifty shades of grey, the middle?

Steve: Yeah, yeah. I mean, honestly, I think it just depends on how you learn, how you, you know, what your experience level is like. I've never used a guide. I mean, and, you know, Howard, some of your other guests have talked about the old guys don't use them and the new guys, kind of, are. So, I was taught by an old school guy and, you know, we do everything from single placement to full arch, and a guide never crosses our minds. I don't know. I guess you'd have to talk to someone who does both.

Howard: Well, I guess there's fifty ways to skin a cat, right?

Steve: Yeah, yeah.

Howard: And they can both do it correctly.

Steve: Yeah, it just seems like if you have a C.T. scan, you kind of know where you want to go, you know how deep you can go, you got a scalpel in your hand, you load the patient up with some dexamethasone, a nice steroid, so they're not going to feel anything for a few days, you give them a little Halcion, you know where to cut, you know to reflect, you see this bone in front of you, and you make your basic osteotomies based on measurements that you learned, and, you know, this is all part of the course. You can be super, super successful and never have to go to a guide. But I'm sure guides have their place. I know guides have their place. I don't say anything about guides because, man, the stuff that comes back from some of the surgeons that I refer to - beautiful, beautiful work with guides. But sometimes you just want to, you know, remove a tooth and place the implant in, you know, not order the guide.

Howard: I've seen a case where a single guide ruined a dentist's entire career. Remember that guy who hired a guide to go shoot a lion and he led him to Cecil, the lion?

Steve: Yeah, beware of guides.

Howard: That ended ... that guide ended his career.

Steve: Was that the guy who bought John Lennon's tooth?

Howard: No, no, that's [00:21:23] [unclear]. [0.1]

Steve: No, different guy.

Howard: That's a Canadian.

Steve: Okay, alright.

Howard: Who was the guy? Was it ... here, I'll type in 'Cecil the lion'. Walter Palmer.

Steve: No.

Howard: The dentist from Minneapolis who killed Cecil, the lion.

Steve: Man.

Howard: That's got to be the worst guide that you've ever had in all of dentistry.

Steve: Yeah.

Howard: But I will call that a 'lion guide'. You've written about the anesthesia eight ball and don't get behind it. What do you mean by the anesthesia eight ball?

Steve: Yes, yes, gosh, okay. In general dentistry, you know, most of our procedures we can get by with a couple of carpules, alright. With implant dentistry, as well as extractions, man, numb the hell out of your patient and get them numb as hell before you get started. Whenever they start to have a twitch, numb them some more. Plenty of Halcion, if that's what you want to use, but stay ahead of the anesthesia. What we see in our course is patients ... the doctors will come in, they'll numb, by the time they get the extractions done, they're starting to wear off, but by this time they've flapped a little bit too much, now it's too hard to go back and re-anesthetize before they have to shape the bone, place the implant. So, I would tell the new dentist, you know, "Give a little extra anesthetic, use Marcaine, use something that's going to last a while, but you need to numb the patient more so than you do with most of your general dentistry procedures, and that's something that we see time and time again. The new dentist gets behind the anesthesia curve and then they're fighting the case the whole rest of the time, so.

Howard: So, your go-to, standard anesthesia in dental implant surgery as Marcaine?

Steve: Usually, we ... I personally like Articaine or Septocaine in general dentistry, but we'll use it. We usually, like for a mandibular case, two carpules of Lido and one of Marcaine. Same thing for the other side. And then, you know, you can comfortably treat the patient and not have to fight the patient as they start to feel things, 'cause they're numb as hell.

Howard: Yeah.

Steve: Yeah.

Howard: Talk about ... you also talk about atraumatic extractions and that you've got to clean the hell out of the socket.

Steve: Yeah. So, you know, a lot of times, you know, can you place an implant in a site that has infection? Okay. Chronic infection we treat, we clean the hell out of the socket, we get in there, we scrape it out, we'll place implants though in any socket that has chronic infection. If there's acute infection, we don't. We don't even bone graft those sites. You make your money in implant dentistry with the extraction. I mean, that's what takes the time. The atraumatic extraction. Because you want to try and preserve as much of that bone as you can, and if you're a little too aggressive at that stage, it's going to complicate placing the implant. So, you've got to learn how to do extractions atraumatically. In 2017, we use the Piezo surgery units. You know, we like the physics forceps, we like periotomes, whatever it takes to atraumatically extract the tooth. You don't want to take a bunch of bone with your extractions. No [00:24:35] [SOUNDS LIKE: bueno]. [0.4]

Howard: Man, I wish you'd write it, build an online CE course on atraumatic extractions. We've put up four hundred online CE courses. The views are coming up on a million views. I mean, these Millennials love it. If they're on a smartphone, if they're on an iPhone, you can throw the iPhone ... from your Dentaltown app you can throw it right up onto your Apple TV. I mean, Apple TV is only, like, two hundred and twenty-five bucks, but you just said a lot of things that I wish you could go back - you said physics forceps, what else?

Steve: The Piezo surgery units, you know, those have special tips that can just work their way right down the PDL. Yeah, you know, sectioning teeth, whatever it takes to get the tooth out without bringing a lot of bone with it. So, once you have your extraction, you're about seventy five percent of the way home.

Howard: Yeah, and why do you like the physics forceps as opposed to your regular forceps?

Steve: Well, I mean, I don't think there's anything, you know, magical about the physics forceps, but we have those in the program. People like them. Yeah, so, I can't say a whole lot about the physics forceps, but, just, atraumatically get the tooth out. Take your time.

Howard: But you do like the Piezo unit?

Steve: Yes. Yeah.

Howard: Yeah.

Steve: Those are expensive. So, I mean, I'm not saying you run out and buy one of those right off the bat. But, you know, periotomes as opposed to, you know, elevators and that kind of thing.

Howard: What ... were physics forceps ... were those invented by Carl Misch?

Steve: You know, Golden ... Golden Forceps. I think Carl may have partnered with the guy who invented them.

Howard: Okay.

Steve: Yeah.

Howard: But a lot of it's just keep elevating and elevating and then ...

Steve: Yes!

Howard: ... and going down the PDL ...

Steve: Yes.

Howard: ... and going slow.

Steve: Yeah.

Howard: You know, another trick that a dentist taught me a long time ago, that I still use is, you know, hydraulic pressure. You couldn't lift the Empire State Building, but if you put it into a beaker of water and shoved a Number 2 pencil in the bottom of the beaker, it would lift up the Empire State Building for the volume of that pencil, and this old guy taught me this. It was so cool. He said, "You know, when you start to elevate, you start to ...

Steve: Yeah.

Howard: ... rupture all these ligaments and arteries and veins and they start loading fluid into the area." And he says, "Sometimes, if it doesn't budge or you're having a hard time, just sit there and have them bite on a [00:27:10] [SOUNDS LIKE: gusset] [0.0] and say, "I need to let this soak for ten minutes", and then you can go do a hygiene check, go seat a crown, and you come back, and it is significantly ...

Steve: Yeah.

Howard: Have you ever noticed that in your career?

Steve: Absolutely, yeah. You know, one thing we notice, especially a lot of doctors who are in corporate dentistry, man, they're fast! They're like greased lightning! And in implant dentistry, sometimes you have to slow down just a little bit. So, that's another thing that we notice with the new doctor coming out of General Dentistry. Slow down, you know, take a breather. Do exactly like you said. Yeah, 'cause that's an amazing technique. Just take a breather, and sometimes those teeth will almost come out themselves.

Howard: Oh, yeah. Yeah. So, talk about 'Meet Mr. Lindemann'.

Steve: Okay. Yes. So, you know, most of these ... well, not most, a good percentage of these implants that come through our program every year I end up restoring, and the number one problem that I see are these implants are placed right on that buccal plate, alright. And if you look at many C.T. scans, that damn tooth, especially in the maxillary anterior, it lives right on the buccal plate and there's a little potato chip of bone that is encased in that tooth and that bone there is getting blood from the periosteum, it's getting blood from the PDL, it's very happy, but once that tooth goes, that little potato chip of bone does not have the blood supply anymore, and if you use that as a wall to try and get primary stability with your implant, that bone goes away in about three weeks, the tissue follows it. It's a nightmare. So, we use a little bur called a Lindemann. It's a side cutting bur, and one of the things with the C.T. scan is, you can look at the C.T. scan, you can see where that extraction socket is, and then you see all this beautiful bone apical to it, and we want to redirect that extraction socket, alright, and that extraction socket is lined with the hard, cortical bone that won't let your drill just redirect. You need to go in there with a Lindemann and you need to break through that hard, cortical bone on the palate and then redirect your osteotomy where you want it to go. If you don't have a Lindemann, your complications are going to go through the roof. So, that's one of the things that our doctors learn, is when you look at these extraction sockets, you know, immediate placement - I love immediate placement - but most of the time we got to do a little bit with that socket in order to create enough space buccal to your implant, and we fill the gap, we fill everything. So, you want a millimeter and a half, two millimeters of buccal bone if you want nice, stable tissue and a nice, stable implant. So, the Lindemann is a side cutting bur. It normally doesn't come with most implant kits. You need to go buy one. But it changes everything. It's magic.

Howard: And where do you get the Lindemann bur at?

Steve: You can order it. You know, I think you can just order it from any dental supply guy.

Howard: I know Salvin Dental Specialties carries it.

Steve: Salvin definitely carries it, yeah.

Howard: Do you ever use ...

Steve: Don't ...

Howard: Go ahead. What?

Steve: I was going to say, don't do implants without a Lindemann.

Howard: So, do you buy many surgical supplies from Salvin Dental Specialties?

Steve: Absolutely. Salvin's one of our sponsors.

Howard: Oh.

Steve: Yes, so they're at every one of our programs.

Howard: He's a ... I've noticed all the hard-core implant junkies use Salvin Dental Specialties. Have you ever notice that?

Steve: Yeah. I know all the junkies I come in contact with do, yeah.

Howard: Yeah.

Steve: And he's a helluva guy too.

Howard: Yeah, he's got a cult following with implantologists. Well, why do you think that is?

Steve: Was he there in the beginning with everybody?

Howard: Right.

Steve: I mean, he's been around forever, right?

Howard: Well, I'm sure he doesn't want to hear that.

Steve: Yeah, I get to meet all the [00:31:03] [SOUNDS LIKE: machine] [0.3] guys riding Louie Al-Feraje's coattails, and I had dinner with ... is it, Bob Salvin?

Howard: Yeah.

Steve: Yes, super-generous, nice guy. He told us his story. He used to drive around, pack up his family, and go to these different meetings and just basically grew a business from the ground up.

Howard: Yeah, and he's always at all the surgery courses. Like he's a sponsor of yours. I ... he's on the road, he's always touring, and I always think about that when I ... my favorite show of the year is always the Rock and Roll Hall of Fame. It's usually in, like, late April and, you know, they only let about six or seven guys in there each year. I just had the honor to lecture there for Patterson in Cleveland, where they have the Rock and Roll Hall of Fame. But I love the acceptance speeches the most, because these guys, you know, are successful in music as opposed to dentistry, or getting into the Hall of Fame for football, which is also in Ohio. And the one thing I always think it's so amazing is, when those guys are getting inducted into the Hall of Fame, not only are they still old, they're still touring! I mean, when ... the week that Cheap Trick got accepted in the Rock and Roll Hall of Fame, they had done, like, three countries. They were in, like, Japan, Taiwan, somewhere in America, and I thought, "Man, these guys are still hustling all the way to the end."

Steve: Yeah, you know, I mean, like, I mean, I guess the Stones are putting out a new album.

Howard: Yeah, it's always, like ...

Steve: And that's who they are, right?

Howard: It's always their final tour. I think I've seen them on their final tour three times.

Steve: Yeah, yeah, it's not for the money anymore. It's who they are. That's what they do.

Howard: But, you know, the ... speaking of that, you know, the Rolling Stones, you know who the most amazing Rock and Roll Hall of Famer that I ever met in my life, or ever saw in my life? This lady gets to the Rock and Roll Hall of Fame and she makes it, and nobody even had heard of her. And I asked one of my friends, "Who is that?", and no one really even knew. What it turns out, she made a movie. Did you see that 'Ten Feet from Stardom'?

Steve: No.

Howard: The Rock and Roll Hall of Fame figured out that there were the eighty/twenty rule. All through the '70s, the megastars like Mick Jagger - you were just talking about the Rolling Stones - they found the most talented backup singers from these Gospel singing churches all throughout the South and they would just let them go. And most people didn't like that. They wrote sheet music and they told them to read the sheet and quit overpowering the lead singer, whereas, you know, Mick Jagger, when this lady started to just rip, he would, like, take ten steps back and just let her have it. David Bowie said that the high self-esteem singers would know, you're getting outsung by this lady, so shut up, and they ... and that movie, 'Ten Feet from Stardom', they take some of David Bowie songs and they take her out of it and he's just singing it and it's dull and flat.

Steve: Yeah.

Howard: And then you add in this amazing lady, and this lady had showed up on so many of the most amazing albums. They just said this was a big part of the success. And now let's go to dentistry. They won't even take their dental assistant with them to the implant course. You know, I mean, they don't even train their dental assistant. They won't let their hygienist diagnose when they're in there for an hour even though, you know, you're not going to go in there and do a filling just because she said so. You're going to co-diagnose and check. But, man, having the greatest backup assistant in the world is a big reason why the Stones - and on that last Stones concert, they had that ... they had another backup singer and I forgot her name. I don't know who she was ... she's drop dead gorgeous. But, I mean, she was ten times the better singer than Mick Jagger.

Steve: I know, yeah, you know, just get it done. You know, share the wealth, share the glory. Yeah, absolutely, I mean.

Howard: And Bob Salvin, that's another thing I was just talking about, the cheap trick. I mean, he's been on tour at all these surgical implant training seminars for as long as I've ever been going to them, for thirty years.

Steve: Yeah.

Howard: And he has met and had dinner with everyone who's anyone in that ... and he knows so much because he's seen them all.

Steve: Yeah.

Howard: And he's not a dentist and he can sit there at dinner and probably teach you more about implant dentistry than anyone.

Steve: Yeah.

Howard: I notice you also use Nobel Biocare. Talk about that. I know my homies. She's sitting there saying, "Well, that's the expensive one. Shouldn't I get a ... should I get a cheap one?" I mean, you guys could have got anyone. Why did you use Nobel Biocare?

Steve: Oh, I mean, you may p*ss a couple of people off. We think Nobel Biocare's the king, and when they came knocking, you know, absolutely, we were just honored to have them sponsor our program. Louie Al-Faraje was with Nobel way back in the beginning and he's very well connected with them. You know, I've restored a lot of implants. Nobel is just such a treat to restore the, you know, depending on what cases you're doing, if you're doing a lot of immediate load, the, you know, the NobelActive is, you know, second to none for initial stability. We also do the NobelReplace. That's another great implant. They happen to have the same internal connection so, if somebody was going to ask me, I would say, you know, I get the luxury of restoring these Rolls Royce of implants every day. But then again, you know, we've used other implants in the past too and implants integrate. I think really where it comes down to separating the men from the boys when it comes to implants is just your restorative options and the precision of the abutments. And when you're doing a full mouth reconstruction, I know there's a lot of other implants out there, but, boy, the Nobel products just work, you know, they just work.

Howard: And what's the difference in your mind when you use a NobelActive versus a NobelReplace?

Steve: Well, a couple of things. You know, the NobelReplace is tapered. The NobelActive is a little more parallel. They both have their places. The initial stability is where you really get your money's worth when it comes to the NobelActive, you know, immediate load, the immediate load cases.

Howard: Well, it's interesting. Another observation I've made on these implants over thirty years. Everyone I know that uses Nobel, one of the ... we were talking about Bob Salvin, you know, been on the road doing this forever. It's because of the rep, and they've had this rep who's been in the business such a long time and it just seems like if you don't have that human in your backyard, if you don't have that connection, whether she's fixing you up to have lunch or drinks after work with other implantologists, but it just seems like the only ones who get it done and get to that critical mass of one implant per week, if you're not doing an implant once a week I don't think you really ever going to get fast, predictive, profitable. It's never going to get faster, easier, higher quality, lower cost and profitable. Same thing with Invisalign or sleep apnea, if you're not doing a case once a week ...

Steve: Yeah.

Howard: ... you just never get there.

Steve: Right.

Howard: And it seems like everybody I know that does more than one a week, fifty implants a year, they have a tight relationship with a human in their city, their town, their county, and that's a big part of it, you know.

Steve: Yeah. Yeah. And, I mean, you see a lot of different implants. They integrate, but it's ... when it comes to restoring, that's really where some of these giants in the industry really stand out.

Howard: Yeah. So, what do you mean when you talk about hold the handpiece like an implantologist and not a general dentist?

Steve: Okay. This is something we see all the time. You know, in general dentistry we use our wrist a lot, alright. We're doing it, we're prepping. In implant dentistry, that wrist has to be frozen and you bend at the elbow. You don't bend the wrist. So, that's something that will keep your implants parallel, straight up and down. If you start bending the wrist, no [00:39:29] [SOUNDS LIKE: bueno]. [1.4] Yeah, so, you know, whether you have to drill extensions or come from the side if you're in the posterior mandible, keep that wrist frozen and bend from the elbow, and that's going to keep your implant straight up and down. So, that's something we talk about.

Howard: Okay, so, are you doing this ... do you place your implants and extractions standing up or sitting down?

Steve: I'm a general dentist - I sit down! Yeah. Everything's sitting down. As a matter of fact, Dr. Feraje, he doesn't use a mirror. He doesn't know how to look through a mirror anymore. He's lost that ability. Everything he does is ... he teaches everybody to sit down, and if you have to put the patient on their head to treat the maxilla, you do. You get comfortable and you sit down, you flap where you see what's going on. He talks a lot about, you know, enjoying the surgery, being comfortable. Sit down. Absolutely. Yeah.

Howard: I could tell you the creepiest story in the world that relates to this. So, we know this guy who was too old and had prostate cancer. He's in his nineties, and no one was going to work on him, and he had to go around because, you know, the anesthesia, the age, he just ... they just said, "We're not going to do this." He finally found a guy that would do the prostate surgery, and guess what that guy did to him? He hung him up by his feet and said, "The bleeding'll be out of control, so I want the gravity to take the majority of the blood down." But he goes, "When you're hanging by your feet and I'm standing there, the blood's below, I have perfect vision and everybody who won't do this procedure has him laying horizontal on a bed, and when he first decided he was going to hang these patients by their ankles, and you have that board ... what's that board? Some people have lower back pain where they strap in their ankles.

Steve: Yeah, yeah, yeah.

Howard: That's what he's doing.

Steve: Okay.

Howard: That's what he's doing.

Steve: Okay, it makes sense.

Howard: And you said when you're working on the maxilla, put their head in your lap and look right down at it. I mean, these ankle chairs that your buddy has for helping the lower back, there are oncologist surgeons who use that just because the surgery comes first, and patient position is second.

Steve: Yeah.

Howard: And he hangs them upside down by their feet in one of those special deals.

Steve: Yeah.

Howard: And everybody thought he was nuts when he started doing that and now he's the only guy that will do these most advanced cases and it's because of patient position.

Steve: Yeah, and you can see. I mean, think about how often as general dentists are we standing on our heads looking up into the patient. I mean, come on, you know. I mean, get to a position where you're comfortable, get to where you can see everything, and you're going to have a good time doing surgeries and you're going to be successful, you can predict what's going to happen, you can predict your outcomes, and you don't go home with a major backache.

Howard: You know, I'm kind of a hybrid because when I was in high school in 1980, one of my mentor dentists who I adored was Dr. Pelzer, on the west side of Wichita, and he did all of his dentistry stand up.

Steve: Yeah.

Howard: And then there were a lot of dentists who were starting to sit down. And I had this hybrid deal where I have to stand for all implants and surgeries ...

Steve: Yeah.

Howard: ... and then I have to sit down for everything else. But I am wicked at leaning them back and putting their head in my lap, because when I learned from crown and bridge people that they could tell on these full mouth reconstructions if the dentist was right-handed or left-handed. They said they could tell you every time, you know, they can tell the angle that you're ... so ...

Steve: Right.

Howard: ... so, 12 o'clock straight down in your lap.

Steve: Yeah.

Howard: You know, you've got to be able to prep that thing, so the lab man can't tell if you're righty or a lefty.

Steve: Yeah, yeah, and we're constantly, you know, acquiescing to it. I mean, we've got to make our patients comfortable, but at the same time, you know, general dentists, we're constantly not leaning them back far enough, we're doing whatever it takes to get the procedure done but we're not in ideal positions. In implant dentistry, you just, you know, "Hold your breath for a little bit, this is going to take a couple of minutes, but I'm gonna stand you in a position that I can see, and I can get the job done right." That's a huge, huge part of this.

Howard: Yeah.

Steve: Yeah.

Howard: So, when you talk about when the extraction is done, you're almost home, you know what I mean?

Steve: Yeah.

Howard: Because that's the big part, the atraumatic extraction and all that. And then when you get done with that, placing the implant's easy. But, g*d, after you place that implant, it seems like the longest part of the entire procedure is suturing. What are your thoughts on suturing? I mean, I can't tell you how many times I pulled a tooth in thirty seconds and then spent ten minutes on the suture.

Steve: Yeah. Well, and I see a lot of sutures a week and a half later when they walk in my office and a full arch has unraveled and the tissue's flapped open and there's bacon and, you know, eggs down stuck in there and we have to get in there and clean everything out and re-suture, so suturing ...

Howard: That's not from the dentist, though. That's because that patient, after they were done, went and got on a surfboard and ate a wave.

Steve: Probably. Yeah. Yeah. Or, you know, a lot times we'll have lower anteriors, you know, and they'll be ...

Howard: How many waves have you eaten in your life?

Steve: Oh, we get lots of nasal flushes in that sport. Yeah, it's good. It's good. But, yeah ...

Howard: But what's your advice on suturing?

Steve: I love horizontal mattress sutures. You know, I place one in the anterior mandible, a couple on side. If you want to do your continuous interlocking is good. Sometimes if you take that loop and you twist it twice and you do a double interlocking, or you go ahead and do single interrupted. But it's such an important part of the procedure. And usually by the time you get there, like you said, you may be tired, and you may be thinking, "Hey, this is just a formality", but, you know, getting that case closed up properly is huge for the long-term success. So, we teach that as well. We, you know, show you some basic techniques that anybody can do, and then that guarantees you're going to have a high probability of success.

Howard: I saw the greatest suture job in my entire life. Somebody posted it, where they had a big cut on their arm, and whoever sutured the incision perfectly spelled out, "Ha, ha, ha, ha, ha." I mean, it was like H-A-H-A-H-A-H-A. I mean, I don't know if they did it on purpose or it just looked like it, but it looks like ...

Steve: Yeah.

Howard: ... it looks like they absolutely did it on purpose, so, I thought it was just really artistic, the way it was done. So, what ... go ahead.

Steve: I was going to say real quickly, my mom just had open heart surgery. She had two open heart surgeries within ten days. We were on Lake Powell and she had an aneurysm go. We had to life flight her out, they cracked her open and did an aortic replacement. Then they had to go back in a couple days later and replace some valves. Anyways, they used surgical superglue on her chest! They used to put these big staples in and now they're using superglue. So, hey.

Howard: Isobutyl cyanoacrylate.

Steve: Yeah.

Howard: And what sets it up is the hydrogen ion. So, when you use superglue the, like, a millionth of a second it touches free [00:46:52] [SOUNDS LIKE: hydrodyne], [0.5] it totally sets.

Steve: Yeah.

Howard: And I have been reading where they use it in tumors too, where they're going to go and remove a tumor, but they don't have really good boundaries or borders. So, what they do is, they put in a cannula through the artery to the main artery that's feeding this tumor and they put out a glob of superglue to block the main one and it'll take, like, twenty-four hours for that tumor to make another small artery be the main one again, to build it from a, you know, two lane road back to an interstate. And in that twenty-four hour shock, then when they go in and do the surgery, the surgeons say they have more defined borders and can get it all and just ... but, yeah, superglue is amazing.

Steve: It's amazing.

Howard: But no one will FDA approve it because no one’s going to go through the multimillion Dollar FDA process for something you can buy at Walgreens for a Dollar.

Steve: Interesting. Yeah.

Howard: So, that's a weird quirk in healthcare. How do you spend millions of Dollars on something ... I remember when bleaching came out. Remember when bleaching came out? It was by Omni. Omni out of Arkansas. Yeah, I think it was Arkansas.

Steve: Yeah.

Howard: And it was nine hundred Dollars for six bottles. And then everybody was like, "But, wait a minute, we can just go to Walgreens and buy the ..." What was that canker sore medication?

Steve: Like, Zilactin?

Howard: Yeah, yeah.

Steve: Or something.

Howard: I mean, you had a substitute at Walgreens where you could fill that bottle back up for under twenty bucks. So, why were you paying nine hundred Dollars for six. I thought that was ...

Steve: Yeah.

Howard: ... that was kind of interesting. I want to talk about something personal - and you don't have to talk about if you don't want - but you married a dentist and so, you've got two dentists. So, how do you navigate it - and now you're going to have a daughter that's a dentist. My g*d, how do you navigate your dad's a dentist, your grandfather's a dentist, your wife's a dentist, she's fourth generation dentist, now Alexis is going to become a dentist. How do you balance work/play? Do you ... how does that ... what advice would you give? 'Cause how long have you been married?

Steve: We ... let's see ... married in '95.

Howard: My g*d.

Steve: Twenty-two?

Howard: Twenty-two years! So, right now ...

Steve: Yeah?

Howard: ... you know, a lot of kids are listening this at school or they're commuting to work and they're dating their lover and they're both dentists. What advice would you give them, twenty-two years later, about making it work in dentistry and family?

Steve: Good, yeah, great question. You know, I mean, I think the family has to come first. I mean, you know, dentistry is fun, and you want to be successful, but you've got to be able to turn it off and just have fun and relax and have a beer and, you know, like, my wife and I, you know, when we get home, we may talk dentistry for about the first five minutes, but then there's no more dentistry. We're going to crack a bottle of wine, we're going to go watch, you know, some mindless show together. You know, we like to watch 'Deadliest Catch', because we look at those guys on those boats in thirty-foot seas and they're freezing their ass off and we say, "No matter how bad dentistry gets, you know, it's never this bad." We like to watch, you know, some of those reality shows, 'Naked and Afraid' - it's like, no matter how bad dentistry gets, at least we're clothed and at least we're not getting eaten alive by bugs. Anyways, find something you like to do together and lighten up. I mean, my g*d, you know, sometimes we're are so motivated to try and reach that million Dollar point and we want to reach the one point five and then we want to reach the two million point. And, you know, the incremental increases in income really don't affect your life that much. Just be friends and find things you like to do together and lighten up. Just fricking lighten up. Don't go in debt. My g*d, I've heard you talk about this a hundred times. You know, I feel the same way. There's enough stress as there is. You don't need to have the stress of having to close a case 'cause you know you've got to make your net that month. You know, save money, spend less than you make, drive a used car. You know, try to pay your house off. I mean, I always think of it ... look, if sh*t hits the fan, at least I got a house and I can probably survive on, you know, three thousand a month if I had to. And you just don't have that extra strain of having to make your financial net every day and, like you say, what does it come down to a lot of times? Money, sex and drugs. Is that ... am I quoting you?

Howard: I think 'money, sex and drugs' has been quoted by a million people.

Steve: Yeah, but, so, yeah, and give yourself, you know, give each other margin. I mean, you know, sometimes you're going to fly off the handle a little bit. Forgive. Forget. Move on. Don't hold grudges. You know, after the fight, man, hopefully you're going to come back stronger than before. Don't let the business of dentistry, you know, get into that relationship because, at the end of the day, I mean, you know, our dentistry's going to end up in a coffin one day. Right?

Howard: Oh, yeah.

Steve: Oh, you know, but the people we interact with, I mean, those are, you know, if you believe in an afterlife, that's the only thing these eternal - people, their souls go on. But, so, invest in people. You know, I hear you talk about it all the time too. You know, I talk to these people who are ready to go to a full mouth situation and they want to ... first of all, they want to tell you about, you know, why their teeth are jacked up and you got to listen. You got to listen. Let them tell you their story. But treat the human being first, and then after they trust you and they know that you care about them, then you can do whatever you want with them as far as leading them down the dentistry path. But, as far as your relationship goes, at least, especially your wife, you know, the pressures that come with running a practice are great. But try and leave it at the office and come home and just relax and have fun.

Howard: Well, you know, oral health is secondary to mental health, and most of the main reason people are only trying to save their teeth and their smile is for their mental health, and they need ...

Steve: I believe it.

Howard: They need oral health just because they're trying to get mental health, and there's no worse emergency in the world than when a woman loses her front tooth.

Steve: Oh, my g*d. Yeah, yeah.

Howard: Yeah, and I mean, her whole world stops, all she wants is her mind to be repaired. So, I want to continue on. So, both of you ... is your wife's dad a dentist? Is your father-in-law or mother-in-law a dentist?

Steve: Father.

Howard: Father-in-law.

Steve: Father-in-law.

Howard: And your dad's a dentist?

Steve: Yes.

Howard: So, did you and your sweetie go work with one of them at first, or ...?

Steve: Well, so, no, my dad wouldn't let me into the practice until I knew what I was doing. So, she went to work for another office. I joined the Public Health Service and got stationed in a federal prison in downtown San Diego. So, that was kind of cool for a couple years. I learned how to shoot firearms, and learned a little self-defense, and got to, you know, treat some interesting people, and then we went for loan repayment for four years up to northern ... central California and we worked in a migrant health center for four years. Did loan repayment, got our loans under control, did a lot of extractions, a lot of endo, just got, you know, fast, and then, when we came back six years later, then we kind of started slowly integrating into my dad's practice, then we bought him out a few years later. And, so, here we are now.

Howard: So, then your dad, being a successful dentist, decided he wasn't going to pay for your college, so you had student loans then?

Steve: Absolutely, student loans, man, and when I look at that diploma on the wall, I want to kiss it because I busted my ass for that thing.

Howard: So, did you do the same thing to Alexis?

Steve: We're going to.

Howard: You're going to make her pay for it?

Steve: Yeah, yeah.

Howard: I mean, that's ...

Steve: Yeah, I mean, work. I'm sorry. Yeah, we're paying her undergrad. But, you know, she's going to pay for her graduate school.

Howard: So, you paid undergrad, and she's going to pay graduate school. Yeah, I mean, every economist that ever won a Nobel Prize talks about incentives matter, and you want people to have skin in the game. And, I mean, look at the difference to when you go to a dental seminar, the owner/dentist's behavior versus the associate dentist. You know, the associate ... the owner's taking five pages of notes and the associate dentist is surfing Facebook the whole time, and ...

Steve: Right.

Howard: ... when human beings have skin in the game, it changes their behavior.

Steve: Yeah, yeah, debt's a great motivator.

Howard: So, I want to go back to your father though. Any lessons learned? A lot of Millennials, they're posting on Dentaltown, they're stressed because they're going to get out of school and Dad wants them to come work for them, and they just feel like, you know, what is it like having a business partner who's also your dad? I mean ...

Steve: Yeah.

Howard: You're mixing family and business, and would you say there's more quotes saying, 'Don't mix family and business', or more quotes saying, 'No, that's a really good idea'?

Steve: I think, if it works, it's beautiful. If it works, it's the most beautiful thing in the world. If it doesn't work, it can be the worst scenario possible. So, you know, my dad was probably fifty five percent personality and, you know, people people, and he was forty five percent dentist. So, he was really easy to work with. He wasn't real ... he wasn't a taskmaster or anything. He just did bread-and-butter dentistry. He just love, love, loved people. I think that's a different scenario than if you walk into somebody who's God's gift to crown and bridge and is, you know, whipping out his 4X loupes to look at your prep and, you never ... nothing's ever good enough. I mean, come on, you know.

Howard: Well, yeah, nothing's ever good enough until they switched from ... when it was the lab man making it, nothing was ever good enough.

Steve: Yeah.

Howard: But then when they buy chairside milling and they start making it themselves, they loosen up real quick.

Steve: Yeah, yeah.

Howard: I mean, they see chairside milling crowns that they would have never accepted from their crown and bridge guy. And when you say that ...

Steve: Interesting.

Howard: ... my hate mail flies off the charts, but I don't care - it's Dentistry Uncensored - it just is what it is.

Steve: Yeah, yeah. You know, I'm still double arch with heavy body, light body and, you know, I get that impression going and I walk away, and my RDAs take it out and make the temp. I guess I'm still in the Stone Age, but I don't see anything changing my practice.

Howard: Well, how old are you?

Steve: Fifty-two.

Howard: Fifty-two. Are you looking at oral scanners? I mean, are you thinking or are you still going to stay old school? I mean, look at my car. My Lexus turned a hundred sixty thousand miles today, and I'm gonna tell you that these Millennials, they don't realize, they get out of school and they go buy an expensive Beemer and a two-bedroom house ...

Steve: Oh, man.

Howard: ... and then that makes them have to eat out more.

Steve: Yeah.

Howard: ... then all that psyche makes them have to take vacations that are in Maui instead of going to the lake up the street with a trailer you pull behind the car that your Uncle Eddy's ...

Steve: Don't do it - it's not worth it.

Howard: I know. They just ... because when they buy the Beemer, they feel good for about a minute.

Steve: Exactly.

Howard: And then their diarrhea switches from solid to blood, and they don't realize it, so.

Steve: Yeah.

Howard: It's great, but the same thing goes for oral scanner, because you've got a lot of young kids listening to you right now, and saying, "Right now I'm taking a seventeen Dollar, 3M SP Impregum impression and sending to the lab, and now people are saying, 'Don't send it to the lab - buy a hundred and fifty thousand Dollar chairside miller or buy some thirty thousand ... seventeen thousand Dollar True Definition scanner and sign up for a two hundred Dollar a month maintenance program and update program.'" I mean, so, how is your walnut brain going to wrap around switching from a cheap vinyl polysiloxane to a digital scanner?

Steve: I mean, you know, the one benefit that I see to an oral scanner is, if you are doing - getting back to implants again - if you're doing a lot of implants, trying to capture an accurate impression so you can get this passive fit bar or substructure, that is a pain in the ass, that is very difficult to do. And there's this new scanner, a lab across the street has purchased it, it's called a PIC. A P-I-C. It's out of Spain and this thing can go in and this can scan a full arch of implants and give you a bar with passive fit that is amazing. I don't know where they are on the FDA approval list over here yet, but they use it in Europe and we've experimented with it a little bit, so, yeah, I can see, you know, paying for a scanner for that purpose. But that's about it in my book. I may be, you know, changing my mind in the future, but not as of today.

Howard: Hah, and it's called PIC. P-I-C?

Steve: Yeah, they put these little scanning things into the implants that look like a golf flag with a domino on it, and these dominos have different white spots and the scanner can triangulate on these different flags and give you this kickbutt impression.


Steve: Yeah.

Howard: CAD/CAM quality control out of Spain, huh.

Steve: Yeah.

Howard: Nice.

Steve: Yeah, that impression is unbelievable.

Howard: So, it sounds like you're going to stay with ... somebody across the street has one from you, so you're going to send out your impressions?

Steve: Yeah, yeah. I think they're about thirty-five K. If you're doing a bunch of this stuff, then it might be worth it. But he'll come to my office and take the impression for around four hundred bucks.

Howard: Oh, he'll come to your office! Interesting, interesting.

Steve: Yeah.

Howard: Interesting. That's four hundred bucks to take the impression. So, this is just going to be on full arch implants.

Steve: Full arch, yeah, but it will eliminate all these return appointments for indexing and [01:01:14] [SOUNDS LIKE: soldering] [1.1] and all this other stuff that goes on. So, it really helps to simplify it.

Howard: Yeah, so I re-tweet my guests. So, yeah, they're @PICDental. PIC Dental provides the world's most precise impression technology, guaranteeing the passive fit over the patient's implant, out of Madrid, Spain. I think I'd rather go hear about this in Madrid, Spain! I don't think ... I think that would be the best thing. G*d, I love Madrid.

Steve: Yeah.

Howard: And Barcelona. And you know what you were talking about earlier? Well, San Diego reminds me a lot of Barcelona and a lot of Spain. I mean, it really does. What's that big mission? The San Diego mission? What's that called?

Steve: Yeah, g*d, I've lived here my whole life - I should know this.

Howard: With all the birds.

Steve: I know what you're talking about. Yeah. Oh, oh. Oh, San Juan Capistrano, where the swallows return?

Howard: Yeah, yeah.

Steve: Okay, that's a little north of us.

Howard: But, the thing about Spain though is, they're just so much more laid back than anybody in America, Japan or Germany. I mean, it seems like the dentists in Germany and Korea and Japan and America are just ... they're just so intense. And then you go to Spain and they're just so well-rounded, they're just so laid back. They just have a better attitude, a better work life deal. They don't want to work as hard as Germany or Sweden or Switzerland.

Steve: Yeah.

Howard: They really enjoy a bottle of wine and being from Spain, and you really learn a lot from going around the world and realizing that, you know, when you spend your whole life in one tribe and drink all their purple Kool-Aid, you really don't know what's really what and what's really just your tribe, and you start seeing these dental tribes from around the world and there's a lot of tribes that are a lot happier than dentists in America, Germany and Japan and Korea, and most of them live in Spain.

Steve: Interesting. Yeah.

Howard: Oh, my g*d.

Steve: And, you know, Howard, alone along those lines when you, you know, this trying to get the passive fit for these bars, another system I'm looking at is the [01:03:23] DENTCA-4. [1.4] You know, DENTCA, they do the digital dentures?

Howard: Yeah.

Steve: Well, they also ... now they have a full arch implant restored solution, where they use these interesting abutments that are segmented, so it's not a solid bar. You have these little T-bars and then you screw a superstructure over it. It can be PMMA or it can be zirconia. And, you know, I'm doing some cases with these guys and, man, I mean, that can cut your full arch restoration down to, if you don't count the Stage 2 [01:03:55] [SOUNDS LIKE: surview] [0.3] where you put the [01:03:56] [SOUNDS LIKE: healing] [0.7] abutments in, in three visits these people can be going home with a final zirconia solution.

Howard: So ...

Steve: Interesting.

Howard: Now what is that? Denca. That's D-E-N-C-A?

Steve: Yeah, yeah. DENTCA.

Howard: What is their website?



Steve: Yeah, and, you know, they're like, you know, full dentures in two visits. Everything's CAD/CAM.

Howard: Yeah, High quality value for money solutions that enhance production performance. No, that's not it - that's a software deal. What ... did you find it, Ryan?

Off Camera: [01:04:38] [unclear] [0.1]

Howard: That's Denca ...?

Steve: D-E-N-T-C-A.

Howard: D-E-N-T-C-A?

Off Camera: [01:04:48] [unclear] [0.2]

Steve: Yeah.

Off Camera: [01:04:49] [unclear] [0.1]

Howard: Yeah, yeah. Dentures.

Off Camera: [01:04:53] [unclear] [0.1]

Steve: Yeah, so, we're doing some full implant supported restoration with their system. It's slick.

Howard: And ... "Introducing the new interactive impression manual, DENTCA provides high quality, one hundred percent accurate dentures using award-winning computer-aided design and computer-aided manufacturing, with state-of-the-art 3D printing technology." Wow! So, now you're using ... so, how does it work with them? Are they ... where are they located at?

Steve: They're up in Irvine, I think, just north of us. But did you look at the DENTCA-4? That's the full arch implant.

Howard: Yes.

Steve: Yeah. Take a look at that. I'm excited about that. It's ...

Howard: And they are @Dentcain, or DentcaInc. So, @Dent - D-E-N-T-C-A - DentcaInc, for Twitter. So, I like to re-tweet my last guest, what they're doing, so my homies can find it easier because they're commuting to work, and it really gets difficult, changing lanes and tweeting and texting.

Steve: Yeah.

Howard: So, what website do you want them to go to, to learn more about you? Is that ... would you have them go to implant education, or ...?

Steve: Yeah, well, they go to, if they're interested in coming to one of our programs, and they can be there as a surgeon or they can go there just to observe. It's half price if you want to go observe. If you want to bring the patient along, you know, this patient can be surgically treated, then you can take the patient home and restore, help pay for the cost. Anybody who's interested in restoring full arches, I'm ... my office is open to somebody if they want to come in and see what we're doing. But I think, as a profession, we should look and see how we're going to take care of these millions of people who are being edentulated young and are too young for dentures. And if we can get some of these full arch solutions going, we're going to change lives and we're going to be profitable. I mean, there's ... it's a win/win. You can go to our implant page if you want to learn about our program,


Steve: Yeah.

Howard: Was it also your site,

Steve: Yeah, yeah, yeah.

Howard: Is that just for ... but you also have

Steve: Yeah,

Howard: So, do you have two websites for search engine optimization or why do you have more than one website for you and your wife's office?

Steve: I don't know. I'm not sure. The guy we hired to do our implant page thought we'd get more clicks if we had San Diego in there and stuff, so.

Howard: Right.

Steve: So, but, is usually what we tell people to go to and then it clicks on to that.

Howard: Well, I'll tell you what's really amazing. We put these podcasts on YouTube for the video and Facebook for the video and Dentaltown for the video, but it's sound only on iTunes. But I've had several guys like you, where I've podcast on implants and they've gotten patients from them. I mean, just Chris Winterholler, I mean, he loves me. He said, "G*d, it wasn't even a week after this video went live and I already got to complete all-on-four upper and lower arch just from driving over to your house and doing a video." And I've had several of these dentists, because the consumers are getting more sophisticated, and they start doing these search engine optimizations, and they get to hear you and hear you talk and all that kind of stuff, and it's amazing. So, you might even want to put this video on your website.

Steve: Okay.

Howard: But, yeah, ask Chris Winterholler about it, and then a bunch of the dentists. But, anyway, so, my gosh, I can't believe we've already gone over an hour and thirteen minutes. We went way over. I just want to tell you, seriously, I think what you're doing is so amazing. I think these kids coming out of school three hundred and fifty thousand Dollars in debt, and they might walk out of school and say they hate molar endo and are afraid of implants, but, you know, when you get three hundred fifty thousand Dollars committed into a profession, you've kind of got to learn how to do it.

Steve: Yeah.

Howard: And I say, the thing about orthodontics and implants is the PPO monster isn't setting the fee, the NHS isn't setting the fee in the UK. I mean, and a lot of these major most advanced civilizations on Earth in Tokyo and Paris and London, the government's only giving them a hundred Dollars for a molar endo. So, when you turn the podcasts off, they say, "Yeah, I can't do the molar endo for a hundred, but I'll extract the tooth and place a fifteen hundred Dollar implant, so I can pay my overhead.

Steve: Yeah.

Howard: But, so, that starts ... and that's what makes me scared about government socialized medicine, because I don't know anything about that, but I know dentistry and I see how insurance reimbursement really changes treatment planning, you know what I mean?

Steve: Oh, yeah, yeah.

Howard: And, you know ... you've got one of the best hospitals in America in your backyard, Scripps, right?

Steve: Yeah, absolutely.

Howard: Is that the most famous one in California? Is that where the ...?

Steve: I would say so. Yeah, at least in San Diego.

Howard: Well, I mean, who would be better than that in all of California?

Steve: It's a good question. Like, L.A. has, like, what ... Cedars-Sinai? Is that ...?

Howard: Well, I know people from Scripps. I mean, I've read like thirty percent of the patients at Scripps aren't even from the United States.

Steve: I believe it. I mean, just the square footage of their facilities is amazing up there. It's right in La Jolla, you know, you're almost looking over the cliffs there and it's beautiful. If I was a surgeon, I'd want to live here. Yeah, so, it doesn't surprise me.

Howard: Oh, yeah, I mean, as a worldwide brand, I mean, there's dentists have heard of that in Cambodia. I was afraid of getting that laser keratotomy because all my ophthalmology patients in their eighties are saying, "I wouldn't do it, I wouldn't do it", you know. But they kept getting it bigger and bigger and they went from a two ... you know, they just kept bringing it. And finally, when my first ophthalmologist got it done on himself, I said, "Okay, now it's gone from bleeding edge to leading edge." And I went to [01:11:14] [SOUNDS LIKE: Cahill and Sutton], [0.3] mainly because people had flown to have him do the surgery from, like, fifty different countries, and you walk in his waiting room, and he has this global map, and he has pins where all of his patients are from, and the guy says, "Yeah, not even half of them are from the Phoenix area, and thirty percent of them had to take an international flight to get here." And I said, "Okay, you're doing my eyes." You know, but ...

Steve: Yeah.

Howard: ... so that's amazing, so. Well, hey, thank you for all that you do for dentistry. Thank you for sharing an hour of your precious life to come on the show and talk about dentistry and being married to a dentist, being the son of a dentist, having a dentist father-in-law and a daughter dentist. I think you're an amazing man. I sure really enjoyed talking to you.

Steve: Thank you, Howard, and everything that you do for our profession. Man, just, words can't express it. Thank you so much. Yeah.

Howard: Alright, buddy, and San Diego's got to be ... g*d, I love that town, mainly because in Arizona when it's a hundred and eighteen, it's usually only eighty degrees there.

Steve: Yeah.

Howard: I mean, my g*d, that is such a difference, and you don't realize how hot it is in Phoenix until you come back from San Diego, and the first three days are horrible because you just felt beaten by the heat.

Steve: Yeah.

Howard: The best thing to do is just not go to San Diego and you're not aware of how hot it is. Man, I can't tell you how many times I've come back from San Diego. Oh, last final question.

Steve: Yes, sir.

Howard: Last final question. Demographics matter. What would you say, you've got five dental schools, no six dental schools in L.A. - I mean, six dental schools in California, what would you say to a senior in dental school, or maybe she's working for Western Dental right now, and she wants to set up her own practice and she really wants to live in San Diego, but has that gotten to be an almost impossibility, and would you advise her to drive an hour out of the city limits and go find a town of five thousand that doesn't have any dentists? Or do you think that it still doesn't matter, and you can still just walk out of Midwestern Dental and open up a dental office in downtown San Diego, in the Lamp Light - is it Lamp Light district?

Steve: Yeah, the Gas Lamp.

Howard: Yeah, the Gas Lamp district and still crush it or is it a different game than when you and your wife graduated twenty years ago?

Steve: Yeah, it's a different game. I think, you know, is it [01:13:30] [SOUNDS LIKE: AFCO], [0.0] where you can kind of decide or see how saturated the market is? You know, if you have an established practice, I think, you know, join that, but starting one from scratch - good luck.

Howard: Well, that is an excellent point, that if you're going to go into a highly saturated area like San Diego, then it's better to acquire a practice than it is to start a de novo.

Steve: Yeah.

Howard: We both totally agree on that. And if you're going to start a de novo from scratch, it's a lot easier to do it where the supply/demand ratio is going to offer you over twenty-five or twenty-eight hundred patients per dentist. But, man, you start a de novo in an area that has a dentist for every five hundred people, that is a slow, rocky start.

Steve: Yeah.

Howard: And those are the people who say, "You know, marketing doesn't work. Marketing doesn't work.

Steve: Right.

Howard: Yeah, yeah, your demographics didn't work. So, I would agree, if you're going to go into the Gas Lamp district, which has got to be ... g*d, that's a cool area. And then, last one, are you sad you're losing your football team?

Steve: I'm p*ssed! Yeah, oh, we're all p*ssed. Big time. I've followed the Chargers my whole life, and, you know, that just the way that the owner left the city. I mean, I see more people driving around with, you know, the lightning bolt on the back of their window with a circle and a line across it. I mean, anybody but the Chargers now. We're ticked!

Howard: Yeah, and people don't realize. I saw, you know, you look at these major athletes and baseball and football that stick out their whole career in one city and it's priceless the way the city adopts them. And then I've seen so many famous people in the NFL or the NBA, like their final year go somewhere else because they gave them a bigger paycheck. So, they sold out the hometown ...

Steve: Yeah.

Howard: ... to go get this big paycheck for, like, a year and then they lost their hometown.

Steve: Yeah, it's business to them, it's emotional for us, right.

Howard: Right, right.

Steve: You know, and you got, you know, you have businessmen making decisions and then you have, you know, we're supporting the team, you know, where it's a heart thing for us and it just ... it doesn't mix.

Howard: I remember the last ... the only time I went to a Chargers football game, I remember walking in there with four dentists, and there were some policemen standing out there, and we were talking to them and we said, "Hey, we're just curious. We're dentists. What percent of your trouble in this stadium is just from people drinking too much?" And they go, "Well, that's all of them. It's all of them."

Steve: Yeah.

Howard: They go, "I'm not going to drag some sober guy out of this stadium because it's all of them." And I thought that was funny. When the cardinals came here, the city was very against them having alcohol, so they didn't have any alcohol in the stadium when they were playing at ASU. And it wasn't until they got their own private stadium, where they brought out all the beer and liquor, and it was a totally different football experience watching the Cardinals in a dry arena, than it is going to the Arizona Football Cardinals Stadium in Glendale ...

Steve: I bet.

Howard: ... where the homies are drinking beer. That's a totally ...

Steve: Yeah, yeah. I mean, don't take your kids to a Raider game when they're playing the Chargers - it's ugly.

Howard: Yeah.

Steve: Yeah.

Howard: Okay, well, thank you so much for coming on the show. Have a rocking hot day.

Steve: Absolutely. Thank you. Take care, Howard.

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