Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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928 Practice with Passion! with Marco Antonio Brindis, DDS : Dentistry Uncensored with Howard Farran

928 Practice with Passion! with Marco Antonio Brindis, DDS : Dentistry Uncensored with Howard Farran

1/23/2018 2:45:06 PM   |   Comments: 0   |   Views: 229

928 Practice with Passion! with Marco Antonio Brindis, DDS : Dentistry Uncensored with Howard Farran

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928 Practice with Passion! with Marco Antonio Brindis, DDS : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #928 - Marco Brindis

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AUDIO - DUwHF #928 - Marco Brindis

Dr. Marco Brindis is a full time faculty in the department of Prosthodontics at LSU School of Dentistry where he maintains an intramural restorative practice devoted to

esthetics and implants with an interdisciplinary approach. He earned a D.D.S from the

Universidad Intercontinental in Mexico City in 1998. He did a Preceptorship in Dental

Implants at the Universidad Intercontinental in 1999 and a Preceptorship in Dental

Implants at the Dental School at the UT Health Science Center in San Antonio in 2002.

He completed a surgical Implant Fellowship at the Biotechnology Institute in Vitoria

Spain in 2003. He got his Certificate in Prosthodontics at LSU School of Dentistry in the

Department of Prosthodontics in 2007. He then completed all the Esthetic and

Occlusion courses at the Pankey Institute in 2007. Dr. Brindis is very passionate in the field of interdisciplinary dentistry for full mouth reconstruction, esthetics and implant dentistry.

Also he is involved in the development of new implant protocols to treat the edentulous

patient. He has lectured in the United States, Mexico, Canada and Spain. He is member

of several organizations including the American Academy of Restorative Dentistry, Academy of Osseointegration, American Dental Association, American College of Prosthodontist and the Pierre Fauchard Academy.

HOWARD: It's just a huge honor for me today to be podcast interviewing Dr. Marco Antonio Brindis, all the way from New Orleans. He's a full-time faculty in the Department of Prosthodontics at LSU School of Dentistry where he maintains an intramural restorative practice devoted to esthetics and implants with an interdisciplinary approach. He earned a DDS from the Universidad Intercontinental at Mexico City in 1998. He did a Preceptorship in Dental Implants at the Universidad Intercontinental in 1999 and a Preceptorship in Dental Implants at the Dental School at the UT Health Science Center in San Antonio in 2002. He completed a Surgical Implant Fellowship at the Biotechnology Institute in Victoria Spain in 2003. He got a certificate in Prosthodontics at LSU School of Dentistry in the Department of Prosthodontics in 2007. He then completed all the Esthetic and Occlusion courses at the Pankey Institute in 2007. Dr. Brindis is very passionate in the field of interdisciplinary dentistry for full mouth reconstruction, esthetics and implant dentistry. Also, he is involved in the development of new implant protocols to treat the edentulous patient. He has lectured in the United States, Mexico, Canada, and Spain. He is a member of several organizations including the American Academy of Restorative Dentistry, Academy of Osseointegration, American Dental Association, American College of Prosthodontics and the Pierre Fauchard Academy. Man, thank you so much for coming on the show today.

MARCO: Thank you very much for inviting me. Really, it's an honor to be here with you today.

HOWARD: You know, a lot of people say that your success rate of dental implants for your first hundred: the failure rate is twice as high as the first hundred, as it is in the second hundred. I know a lot of dentists my age, 55, who hired some young associate, they start taking some weekend warrior implant cases, placed a bunch of implants and then-- associates only, they only last on average. Two years is considered good in corporate dentistry or private practice. And then that dentist leaves and goes away to another state and then this dentist is eating these implant failure cases and sending them to periodontists and having to pay out of pocket and have the whole damn thing redone. I know one guy who's had to pay for seven implant cases to be redone at the periodontist. What are your thoughts on that?

MARCO: Well, I have to say, you're absolutely right. My most successful hybrid implant supported  case that I have done in my life, it was back in 2002 when I place my implants myself and I did the loading myself, the needle loading and everything and that's the most successful one because I moved to New Orleans in 2004. So, I didn't get to see all the failures after and all the complications after. So, that's where we called it a geographical success. And it is true and that is why so many times people tend to say like, "No, I have really good success with my implantsand everything,” it's because they don't have to follow up. So, definitely, it happens to me in my first year. Perhaps I have a hundred and something implants, and I didn't have any, any failures. But then I moved out and then I never got to see my mistakes. I  happen to see on the case that I did after a couple of thousand cases that I have done after. That's when I have seen all the (inaudible 03:41 failures and all the) complications. You're absolutely right. It's just a matter of time until you start seeing something going on prosthetically as well as the diminishing of soft of tissue and bone.

HOWARD: Yeah and it's a big problem in implant training because these dentists are going outside the country, so they'll go to Mexico or Dominican Republic and they'll place a whole bunch of implants, but they don't ever get to see them again. So, I mean--

MARCO: Exactly. That's correct. They don't get to see them again and the technique-- (inaudible 04:17) at the industry of dentistry, that's what happens when you go to a big meeting. They bring much focus on the technique on how to do things more than the complications that you deal after.

HOWARD: You know what I like about you is you go to these major meetings and when he gets the implants they want to talk about all these big, sexy, All-on-4 cases, and these round houses and all that stuff. But that's lifestyles of the rich and famous. What’s far more beneficial to the most Americans is what you're doing with treating edentulous ridges, implant supported  dentures, talk about-- do you agree?

MARCO: Well yes. Well, I do a lot of cases with edentulous patients and it's getting very-- I started more in to esthetics and for many years-- and it was because I was very frustrated for many years on the edentulous patients because they were not happy, they were very frustrated. And then when we came up with All-on-4 routine prosthesis, it's a great solution but to be honest, it has a lot of complications and has a lot of failures, a lot of difficulties to maintain. And so, it's been, really, we want to find new techniques where we can have the patient wearing something fixed but at the end of the day they can remove and clean. And to have a spare one just in case something breaks. So, I am always concerned-- I'm always-- when I tweet somebody, I'm always thinking of what would happen, what would be the best-case scenario, and what would be the contingency plan with something fails. And that has been the approach. And we have been developing better and more reliable techniques and more affordable type of prosthesis for the edentulous patients nowadays.

HOWARD: Well, Clear Choice is the mothership of all the All-on-4s and they're only doing like 18000 arches a year in a country that has 324 million people. I would just think that there's probably-- I mean by age 64, 10 percent of America's edentulous and by 74, 20 percent of America's edentulous. So that just means an implant supported denture, has got to be the biggest part of the implant market.

MARCO: That is correct. There is a statistical number in 2012 that there are 35 million edentulous patients in the United States and that is going to reach 40 million by the year 2020. So yes, we are definitely not taking care of not even half of the population that is edentulous. And normally before the implant supported type of prosthesis, it was just dentures. And as we know that really doesn't take care of the problem, that doesn't take care of the emotional portion or the patient, the function, how do they eat, the chewing efficiency is not the proper one. So, implants are very important for the edentulous patients and to come up with better and more affordable solutions, that's one of my goals and the goals of my team.

HOWARD: You know podcasters are young. I always ask my homies: send me an email, shoot me an email, and tell me your name, how old you are, things like that. I'd love to get demographic feedback, but it sounds like about 25 percent of them are in dental school right now listening to you and the other 75 percent are under 30. So, they come out of school, they've maybe never even done a lower denture and they certainly haven't placed an implant. How do you get to them... and say they're going back to real world America where there's more poor than the rich? How does she learn how to do an implant retained lower denture?

MARCO: Oh, well first of all--

HOWARD: How would you start her out on that journey?

MARCO: First of all, the first thing is you need to know how to make a denture because that's the beginning. That's where you set up the teeth on the face. You need to know about the smile design based on the face and on the face design and integrate the teeth with the rest of the face. And there are many different courses to do that. They're very popular - DSD Digital Smile Design by Christian Coachman when finally integrates in a digital way, all the features of the face to set out the teeth on the right position. So that's a good start-- this technology is making things a lot easier and better to restore the edentulous patient. But to go back to your question, the number one thing is you need to know how to make a denture. If you don't know how to make a denture, then forget about doing another denture with implants. There is no way. That's the first thing that you need to do: to do the denture and based on the denture, how do you plant, or where to place implants-- how many implants into type of prosthesis is needed for a particular case. We got to start with a diagnostic portion which is a denture.

HOWARD: So, you would build the complete denture first, try to get him happy in the denture?

MARCO: Yes--

HOWARD: Or would you have placed designed implants first before you even started the denture?

MARCO: No, it's first to set up the teeth and not necessarily the cover of full completed denture, all processed all the way to the end, but at least the setup of the teeth where you can have a combined C.T. scan done with that setting, knowing exactly where the teeth are going to be because then you need some restorative space. To get that restored the space you need to know where the teeth are, and based on that with the computer, we can create virtually the details of how much bone do we have to remove to create that restorative space, how much bone we have to graft to get the implants in the right spot. So, everything has to be-- How do you say it? It is a reverse engineering. You have to start with the aim in mind and then from there, you design your case for the prosthesis to function, and not the other way around. Unfortunately, we get a lot of cases where the implants are already in place and we have to do really heroic things to make this type of prosthesis work. Because of that as well, we have to have protocols that are a little bit more forgiving on the position of the implants. So, that's important too but ideally always it's starting with the aim in mind and always starting with setting up the teeth in the right position based on the face.

HOWARD: What is the sweet spot? Is your average implant supported edentulous person grandma and grandpa? I mean, is it usually someone over 65?

MARCO: Not really. I would say it varies a lot. Of course, we have probably average would be in the 60s. And that places a bigger concern on how long that type of prosthesis is going to last and how much maintenance you're going to need for the rest of your life. But it is not not very uncommon that we have patients with abuse of drugs, where they have to early in life even early 40s early 30s that we get to actually restructure all the teeth. But yeah, I will say on average, they are 60-year old patients, in the late 60s.

HOWARD: And how many implants would your average implant retained denture? How many would you use?  And would they mostly be on lower? Or are you still using them on the uppers?

MARCO: Do both. I think that to get a hundred percent of quality of life is to have something fixed, something that doesn't rub, doesn't move, and to give that goal. We need at least four implants in the mandible and at least four implants in the maxilla. Ideally, at least four implants in the mandible and six implants in the maxilla. That's just a baseline because every patient is different, the quality of bone has to do a lot with it, and sometimes we have to over-engineer because of the quality of bone. So, we have to go on eight implants but I'm just talking about average. Average probably about four implants in the mandible, six implants in the maxilla for a good success rate and that’s for a fixed type of prosthesis, implant supported, when it's 100 percent implant-supported. Then we have the other kind, where it's assisted by implants where you still have soft tissue and bone support and then you assist the prosthesis in retention like in implants with another denture for the mandible. And that's a wonderful treatment and that takes care of a lot of people that don't have the means to spend more than that in a more complex type of prosthesis. The maxilla, that's another animal that in my opinion, it's just personal, just opinion. I think implant assisted prosthesis is not a good option unless the implants are splinted together and the maxilla, it's a complete different animal. However, for the mandible as we know, dentures by itself, they work a lot better in the maxilla than the mandible. So, with two implants in the mandible, it just makes a huge difference for the patient's quality of life.

HOWARD: I mean when I when I started getting into placing  implants way back in the day, I had so many denture patients that I was saying I'll do them free because I want a teaching case, I want a learning case, I'm just getting into this. And they are still my patients. 30 years later they're still there, and they say, "No, I've never had a problem with my dentures," period. I got a lot of those patients that I couldn't even do the case for free. But the rest of the denture patients, seems like almost none of them have problems with the upper denture. It's almost always the lower denture. I want to go back to the million-dollar question: If I came to you and you did an All-on-4 fixed on my mandible, what would that cost versus if you did an overdenture on two implants? I mean, what is the cost difference? (inaudible 15:27) for you?

MARCO: Well, it depends on the type of prosthesis and how many implants. But let's go back to the basics of the implants. (inaudible 15:37) is the cost of the implants. And I think that the average cost of the surgical part is about $2000  per implant. And then it's the type of attachment-- the most popular one nowadays probably is the Locator type of attachment an abutment or the O-ring and that one, it varies, it could be-- I don't know like a couple hundred dollars, $300, $400 per attachment in the denture. So, you know you're talking about the price of the denture which averages nationally to about $25000 for denture. And you're talking about probably 800 dollars to $1000 for the attachments plus $2000 per implant for the surgical portion of it.

HOWARD: So just ballpark what would a total be for a denture on the mandible on two  implants versus fixed on the mandible on four implants. I mean just ballpark on average.

MARCO: Well it's a big difference. The type of prosthesis that I'm using, that is a Telescopic Fixed Prosthesis instead of the Screw-retained. I'm going to give you the three ones, the three types that I do, okay? Locator ones. Let's say the prosthetics-- I'm just going to talk about prosthetics, okay, to keep it simple. Okay, so we know that implant, surgical is 2000 each. So, let's put it that aside. Now the prosthetics. Prosthetics in overdenture we with two locators, it's about $4000. We go to four implants in Telescopic Fixed Prosthesis, that's about... it's about 8000 to 10000 dollars. But the $10000 includes a spare one that is made of just plastic. And then, when we go to Screw-retained, All-on-4 type of prosthesis, we're talking about $15000  average.

HOWARD: $15000?

MARCO: Yes, for the prosthetics, it's about that.

HOWARD: So, that's a big difference in price. I mean, it's why GM sells a low-cost Chevy then (inaudible 17:51) and a Buick, and a Cadillac. GM has five price points, but you have three price points.

MARCO: Yeah. So, it goes from denture, let's say 2500, with overdenture with two implants 5000, when you go to four implants, fixed detachable, let's put it that way, 10000 dollars, and for the screw-retained and All-on-4 is 15000.

HOWARD: And would you... So, do you obviously... So, every time you do-- So what is the percent of the market there in your practice? Is it like 25 percent each one of those four-price points, or is that heavily weighted towards the $5000 for overdenture? How many $5000 overdentures would you do, compared to one $15000  screwed All-on-4?

MARCO: Most of the time... I do very-- and to tell you the truth, personally I do very little of two implants overdenture. In general patients find a way, if they already are able to pay 5000 dollars, to go the extra mile with 3000 dollars more, and get something fixed, that completely doesn't move at all, that is a 100 percent implant-supported... When you talk to patients and really give them  good education and good explanations, what is one versus the other, in general, the patients make the extra effort to go for  one that is fixed.

HOWARD: So, if they're going to go all the way to the dentist for five grand, they're going to find a way to go even further to 10000 or 15000?

MARCO: That's correct. I think like I was saying before, the technique that I use now, I'm not longer using or really rarely, I use a screw-retained. I use more fixed detachable just for the maintenance issue. Because it's not only what you pay, it's again, it's always thinking of how much is it going to be when it fails? And how much is going to be the repairs? How much is going to be the maintenance? And how often are you going to need maintenance? And which one is easier? So, when it comes to that, then it's not  only 15000 dollars. How much more they're going to pay through the years? Because those teeth are not going to last forever. The structure may last forever but not the teeth. So, I always think of what is the biggest-- the worst thing could happen with this type of prosthesis. So, with the one that we're doing at 10000 dollars, it is cheaper on the maintenance side as well, and you have a fixed prosthesis that is more maintainable and more cleanable than the other type screw-retained prosthesis.

HOWARD: So, the 15000 dollars one is the best you're saying.

MARCO: The 10000 dollars.

HOWARD: The 10000 dollars one is the best in your opinion? Wow, that is very interesting. Some people are saying that in the United States at 16 months, 20 percent of implants have peri-implantitis. Do you agree with that number? Is that what you're seeing in the field?

MARCO: Well... it's just, I agree with if you put in the bunch, if you put in the bag everybody. If you put in the bag everybody, the trained dentists and the not very well-trained dentists altogether, I would say yes. That number is a lot better when you have all the right training and the right follow-up and the right technique and the right... I mean, it requires a lot of knowledge and requires a lot of training. It requires a lot of CE. Every year, there's something new. Before these numbers, as well they were related with excess cement. Now we know more excess cement than before. So, we are avoiding that type of problems nowadays. It depends on the implant system as well. It depends on the surgical technique. It depends on so many things, it depends on how you work with your team and having a team. It's very different the results that you get when you work in-- when you don’t work in  an interdisciplinary way than when you work separately. When you work in an interdisciplinary way, things work a lot better because you are using the brains of different specialists. They work together with the same treatment plan versus having separate entities working in a separate way - and that's when problems arise. But I would agree with you because it's not very common when dentists work in an interdisciplinary way.

HOWARD: Yeah and there's going to be a lot less of it because when these kids are coming out of school 350 000 dollars, they can't refer out molar endo, perio surgeries and (inaudible 22:57). I think the level of debt is going to put extreme downward pressures on interdisciplinary care. Do you agree or disagree?

MARCO: That's correct. I agree 100 percent with you. It's outrageous how much debt  they graduate with. And they have to do something, they have to start making money out of school right away. It's incredible. Yes, that really makes a difference on what you should do. However, I would say, you always have to make your decisions based on money and just based on what is best for the patient. And we all know that the best for the patient is to work as a team. It might require a little more training a little more effort. But at the end, actually, it’s going to be an investment because at the end you're going to be a better clinician where you are going to have less problems because as you know, problems in the long term are going to take a lot of your money. If you don't plan properly, you're going to have way more problems than if you do it in the right way. It sounds like in the beginning, it's a larger investment when you work with different specialists, but at the end, in the long term, that's actually more profitable and having less problems in the future.

HOWARD: Hilt Tatum, I did a podcast  with  him. He said something very profound. He thought a lot of the implant peri-implantitis is because the surgery wasn't done right, and they didn't handle the tissue correctly, so the attached gingiva was all sewn back around. He sees all these peri-implantitis and he just thinks the implant wasn't an attached gingiva. And that started out as a failure. Did you see that?

MARCO: I would say... I guess it's easy to point fingers and perhaps if you ask a surgeon, periodontist or oral surgeon. If you ask what's the biggest reason for periodontitis, they're going to tell you, "Oh it's  the design of the prosthesis." And it's because of the cement. And it's because of this and that on prosthetics side. And if you ask a (inaudible 25:32) dentist, it's easier to say, "Well, it's because they didn't  perform the surgery. They were not careful enough on the drilling (inaudible 25:40), they overheated the bone, they didn't place the implant the right level." You know, stuff like that. They always try to point fingers. And in the end, it's all of the above. And in the end, there's a third entity and it's the patient compliance. There are so many things and as you know many of these patients especially edentulous patients, most of them they lost their teeth in the first place for a reason: because they were not good maintaining their teeth. There was really poor hygiene, and, in the end, we have a big responsibility on educating these patients and training these patients to change those habits. But it takes a lot of effort. First on our side to train them and on their side to really comply to that. But at the end, what's easier to clean, to floss between your own teeth or to go on their need for a large prosthesis implants with a super floss and everything. That takes 15 minutes versus two minutes that used to take you to doing your own teeth. You think patients that were not taking care of their own teeth for one minute or two minutes a day... Now they're going to do 15, 30 minutes a day? That's another problem. So, it's all of the above. Yes, you need to have a great surgical technique. Yes, you have to understand biomechanics and you have to understand the signs where cleaning easier. And then you have to invest a lot of time and effort on training the patients for them to maintain the prosthesis.

HOWARD: That sounds so great. And dentists need to do a better job of letting them know that these implants won't last forever. I noticed that every one of my patients that goes in and gets a total hip or total knee replacement, I would say well, "Did the docs say how long that would last?" And they'll always have a number there. So, "Yeah, doc said should be able to get five to 10 years out of the hip," but they never walk out of there and think "Oh, I got a brand-new hip, I'm good to go for life." And I watched this TED talk of a psychologist and she was saying that it's considered over-the-top success if you can change like six percent of people's behavior in a year period, like only one percent of smokers quit. It's considered a miracle if you can get 6 percent of a population of couch potatoes to actually change their behavior and join a gym. So, you're right, these people that ended up losing all their teeth for a myriad of reasons, to think that you're going to get more than six percent of these people that change or home care their lifestyle, all that stuff, so you just got to start planting seeds that a hip, a knee, an implant in your jaw... It's a success that they last five to 10 years. How long are you telling them? It's five or 10 years about your window? Or do you compare it to a hip or a knee?

MARCO: I think it's very dangerous to say any number. To tell them a number, I think is very-- you're putting yourself in a really tough position. Because like I said, it depends on many, many factors. And it's just like kind of taking away their responsibility on the maintenance. So, I tell them, especially on the edentulous patient, "Listen you're here with no teeth and the implants are not better than teeth. It's a good option when you don't have teeth, it's not a replacement for teeth. Teeth, they were designed to last forever in your mouth and they're not in your mouth anymore. So, with the implants now you've got to be way more careful, way more careful. So, it means that it's not enough to go back to spend the time that you would spend cleaning your own teeth. Now it's even more than you have to spend on the maintenance, on the follow ups." I never give them really a number because it varies so much. This type of prosthesis, the All-on-4, the plastic, the teeth were designed to function in dentures, not to function with implants on a fixed prosthesis. So, the teeth are going to break at some point.  And how often they're going to break? It just varies so much. Sometimes, it happens two months after they break a tooth, sometimes used two years after. 

So, I tell them, I always tell them these either going to break. And perhaps on the first year you had these kinds of warranty but at the end, we're going to have a maintenance plan for the rest of the years. I always talk to them in terms of our car. The analogy that you presented before is perfect. And I always tell them when you ask me if your car is going to last forever, you're buying a car, and you're telling me that car is going to last forever. If you buy a car as soon as you get out of here, you can have an accident and you can break the car. Or if nothing happens, eventually you're going to have to change the tires, eventually you're going to have to change the timing belt. I always talk to them in those terms. Nothing lasts forever, and everything is going to need maintenance. So, I cannot guarantee you-- I really never guarantee anything.  I always give a grace period of a year when I-- whatever breaks on that first year, I cover it with no charge. But after that, they have to be responsible for the maintenance.

HOWARD: It's tougher when you go around the world because so much of implant training is driven by the manufacturer. You almost really got to decide what implant system that you want to go with before you start taking the courses. What is your short list of implant systems? Make it easier for her, she doesn't want to go out there. I mean there's literally-- I mean, you're not going to believe this but there's over 700 different dental implant systems around the world. In fact, Italy, just the country of Italy has like over 75. Just crazy over there in Europe. She doesn't want to research 750 different companies. What implant system would you recommend that she decides to use because that's going to be where a lot of the courses and training material in her city is going to be?

MARCO: I would select a serious company that has been in the market for at least ten years, okay. Because there are many companies that just disappear. Like we keep saying, maintenance is a factor and when you have an implant that perhaps is very cheap and for you to start implant dentistry and perhaps, it works perhaps integrates well, but at some point, something is going to break, an abutment, a screw or something. And then company is no longer in the market, then you are in trouble, all right. And then you've got to (inaudible 32:54) the implant. So again, it's always thinking about the contingency plan. That's one thing that-- a company that has been in the market for more than 10 years, a company that invests money on research, a company that really has a lot of-- And those companies in general, are not going to be the cheapest implants because those implants, they have to invest a lot of money on  research. So, I'm not a fan, it's just my opinion, but I'm not a fan of the Mickey Mouse implants. They're replicas that came out but have the price of the original design, right? Quality control for-- you cannot tell, nobody can tell just by watching an implant and seeing an implant if the surface is clean or not. That's quality control and quality control is expensive. So, the main companies that have that research background, those are the companies that I would recommend to use for your implants. It's just every time you select an implant, just think of what implant would you select if you're going to put it in your mouth? That's the thing. Or you're going to put the implant in your mother's mouth or your son or your kid's mouth. That's how select  your implant. And there's a handful of companies that they have CE courses, a series of CE courses, that they have really good background, they have a long term in the market, their implants have been in the market for more than 30 years that stay there. They've been there for more than 30 years for a reason. Nobel, Astra, Ankylos, Zimmer, Biomet, BioHorizons, Straumann - those are the main companies that I can come up with, that I've been working. I'm very fortunate that being in academia, I get to work with all of them.

HOWARD: So, you would put every one of those in your mouth?

MARCO: Any of those, yes.

HOWARD: Nobel, Astra, Ankylos, Zimmer Biomet, BioHorizon, and Straumann?

MARCO: Yes--

HOWARD: Okay, that narrows it down from 750 to six. That's a nice condensing.

MARCO: That 6, that's yes.

HOWARD: How would you guide her to go from 6 to 1? What should she be thinking about?

MARCO: Well, it depends. There are certain implants that preserve the bone better than others. There are certain that implants that are more(inaudible 35:55 robust) than others. It depends on the area where you are working at. For example, Astra is a very good, robust implant that has been proven in the (inaudible 36:08 literature that) preserves bone. It's a good design and it works well. The other thing, I forgot to mention, the customer support, that's very important. That's the only reason I select the companies that have a rep in the area that is going to assist you in any time you need something. I know of other great implants in the market in Europe that are wonderful but unfortunately, because they're not so big, they don't have support in every location. So, that's another thing. You need to have good service and... good customer service and good support in the area. That's why-- I narrowed it to those companies that we get their support immediately.

HOWARD: Yeah, I like your list of six. And I also believe strongly, you talk about what you're designing implant cases that are, they're built on contingency. And I think the best implant training is by your own periodontist in your own zip code. So, if you're periodontist up the street or your oral surgeon is using an implant system, and they're teaching you how to place implants. And say you placed the implant system, and then five years later it needs to... Something needs to be done to it and you need to refer to periodontist or surgeon, they're familiar with that system. So, it seems like when I ever meet a dentist who passed the 100 mark, they've got a hundred implants in the jaw, they always are very close to a rep. You never-- I never meet that dentist who goes from zero to 100 buying all these implants online. He always has an in his backyard relationship with a rep. And more times than not at least two-thirds of them, have a relationship with that rep that introduced that dentist to other dentist places implant for maybe periodontists or implantologists, whatever. So, they have that human capital in the field and that's a big part of the equation.

MARCO: Yes. That is correct. And me being a prosthodontist, it's actually more important the restorative options because all the names that I gave you, I think that the implants are pretty damn good. The implant itself is going to integrate their success rate. They have really good research, they have really good support. But it's also important to select the implant system that is going to be more friendly to you prosthetically. That is going to be versatile, that is going to give you options, that is gonna be supported by the companies that make custom titanium CAD/CAM abutments. I want a system that I can just make an impression and I can digitally have a CAD/CAM abutment. If you have an implant that is now very popular, they're not going to have that option. So, in other words I do have the luxury of being a prosthodontist that when I work with my specialist, they actually ask me, "So what implant do you want me to work with you." And because the prosthetics is a really, really important part. At the end, the implant in general that the companies that, the names that I gave you, at the end, the surgical technique is going to be very similar. It's going to be very similar. So, it's not going to be a big difference for the surgeon to place one versus another. But for the prosthetics, it can vary a lot and it depends on where you are focused on in your practice.

HOWARD: Explain this , Dentsply owns Astra and Ankylos, and Danaher owns Nobel Biocare and Implants Direct. Why do you think big old Dentsply Sirona would want to own Astra-- two implant systems, Astra and Ankylos, and why do you think Danaher through (inaudible 40:19 Sybron ) wants to own Nobel Biocare and Implants Direct?

MARCO: Well, they both, they have those implants because... they bought the company because it was a good (inaudible 40:32) and it was a good implant. These companies are not where they are for nothing. They do their research and they're not going to select an implant that is not going to work. So, they do their research and if it is not going to work, they're not going to buy it. So, these big corporations buy these companies because they're good implants and been proven to work very well in the market.

HOWARD: Well, you mentioned both Dentsply - Astra and Ankylos, but on Danaher you just mentioned Nobel Biocare, does Implants Direct make that list?

MARCO: Well, Implant Direct was born as being-- as doing replicas of other implants in the market. I have not been-- and probably because I was in academia that I, we didn't have access to those implants. I have nothing to say about them because I have never worked with them. Doesn't mean that they don't work. But to hear that now it has become a part with the Nobel family, that gives me a good feeling about them, for sure.

HOWARD: Right on. You're a prosthodontist but you use orthodontics in some of your implant cases. What makes you put on your orth...-- And that's what I love about dentists going out and getting their FAGD or MAGD, went out to learn different areas of dentistry. I mean, everybody should do an implant surgery to understand implants, right? Even if you don't place them for the rest of your life. And ortho, when do you put on your orthodontic hat in an implant case?

MARCO: Well I started-- It was really back in the days when I had my surgical training in my practice before I moved to New Orleans and do my prosth residency in my practice. I was at practice with my dad and my brother and my dad was a prosthodontist and I was the one placing the implants in the practice.

HOWARD: And where was this practice at?


MARCO: It was in Mexico City.

HOWARD: So, your dad and brother are practicing dentists in Mexico City?


MARCO: That's correct.


HOWARD: Oh my god. So that--

MARCO: So, my dental education only started when I was 6 years old. Going to my dad my dad's office, and I was a weird kid because instead of playing soccer outside with the kids like every other guy, I was doing wax-ups, (inaudible 42:55) technique in my dad's lab, then casting stuff and everything. So, I was born in dentistry. But anyway, later in life, I got the surgical training and I was placing the implants in the practice. And my brother is an orthodontist. And in the practice, we'll have an endodontist--

HOWARD: Your dad was a general dentist?

MARCO: My dad was a general dentist with not a formal post-grad prosthodontic training; however, he was trained early in the 70s with oinaudible 43:35) school here in the United States with B.K. Thomas, Lloyd Miller, Raymond Cantino... He was trained with them and he was only doing prosth. He was doing complete dentures. He was doing full mouth cases. He was dedicating his practice to prosthodontics. So, I call him a prosthodontist because that's what he was doing. He didn't have the certificate for prosthodontist, but he was at some point, the president of the Prosthodontic Society in Mexico City. So... it was funny. Anyway, early life, my brother was really impressed with the Team Atlanta in working interdisciplinary with the Salama brothers, with Goldstein and Dr. Garber. So, with him really early in my dental career, I started working with interdisciplinary dentistry. So, we were doing a lot of cases together where we were moving teeth to create bone, we were using implants to move teeth around. So early in life, I really believe a lot on orthodontics. I love orthodontics, that's my other passion, older than prosthodontics. And when I came here in the residency, sometimes there were not too many people that I could work with on that kind of approach. So, in my residence I was very fortunate that we had training as well. Once a week, we were having training with the ortho department. So, we were learning how to place the-- how to make minor movements and everything. So, I started getting into doing a lot of forced eruption to create bone and soft tissue and be more predictable in the aesthetic result on implant dentistry.

HOWARD: So, what made you leave Mexico City which is just 25 million people. That town's got more class, and culture, and things to do, and your dad's there, and your brother's there. They say you only leave your country for a job or a woman. So, I'm assuming that there is a hot little girl in New Orleans that caught your eye. Is that what it was?

MARCO: No that's not what it was. I ended up marrying somebody here. And but at the beginning she was not in the picture. I was not-- I didn't know her yet. I didn't know anything about her yet. My plan was-- My dad as a practitioner prosthodontist, his dream always was for me to be a prosthodontist. So, he was doing it-- supporting me in every way possible for me to get my certification. When I was having a great practice, really successful practice in Mexico. And then I got to see Dr. Jerry Shish in a lecture together with Dr. Michael Black and when I saw that lecture I feel like I need to know more. And that's when I got convinced that I needed to move to New Orleans because that’s where Dr. Shish was in the Department of Prosthodontics. So, I moved to New Orleans, not to the United States, I was very selective, I wanted to be here at LSU in New Orleans. So, my plan was to come here-- Our plan, my dad and me, and my plan was to come here, study three years and go back and practice with my dad and my brother. That was the plan. It happens that after a year moving to New Orleans, I just fell in love with New Orleans. In this case it was love, not for a woman. It was love for a great city. And I love my school and LSU. I was very happy here. And after the first year, I realized that I wanted to stay here in New Orleans. And even though it was very painful for my dad to see me leaving because he really wanted to have-- He always had a dream to work together. But at the end he was very happy that I live here. It was a fun place, a quiet place, in comparison to Mexico City, with still great food as you know  New Orleans, has I have to say probably the best food I have tried in the United States. So, that was the other thing, the food, the people, and then the last thing that make me stay. It was when Katrina hit New Orleans, the hurricane. And to see the heart and the courage of the people of New Orleans and my beloved Saints, my New Orleans Saints. Then it was a whole package. After that when I finished my residency, that's when I met my wife, which-- She's not from New Orleans, she's from New Jersey. But I met her here because she was doing dental school here in New Orleans. And that's how we met. And in her case, I have to say-- She's going to kill me for saying this but in her case, it was me, the reason why she decided to stay in New Orleans.

HOWARD: How do you pronounce that, Seech?


MARCO: Shish.


HOWARD: How's he doing?


MARCO: He is doing great. Great teacher, great mentor. He goes to Georgia and he lectures pretty much every week all over the world and all over the country. And he's doing fantastic. I get to be in touch with him constantly. He has been a great mentor in life and in my profession and always taking care of me and learn and I owe him a lot of what I know in dentistry to him of course.


HOWARD: That is so cool. Yeah. That's why we'll talk to him, Tom. I've been trying to get him on the show for two years.  I've done a thousand shows and he was one of my first five or six that I tried to email. I know he's busier than a one-armed paper hanger. But if he ever has an hour, tell him I’ll do it 24 hours a day, seven days and-- I'll do it the middle of the night.


MARCO: I will, I will definitely let him know. I know him very well; an hour is a long time for him. I can tell you that. He's a really busy man, he's very committed with the profession and my god, there's a reason why he's so renowned and there's a reason why he's so good. And there’s a reason why he changed the way we do things in Esthetics. It is because he is a hundred percent committed to this business and that's why he really doesn't really have a lot of time to have interviews. I know him very well. And even for me, I call him, he always returns my calls but probably a couple days after. And mostly it's when he's traveling, when he's time in the airport, sometimes that's when he calls me. It's hard to get him. 


HOWARD: He's an amazing man. And I'm also surprised that when I asked which implant system you use, that you didn't go with Straumann for one obvious reason. Your name is Marco and the CEO of Straumann is Marco Gadola. I figured the Marco's would just stick together. Did you ever meet him, Marco Godola?

MARCO: I never had the pleasure to know him. You know, early in life I had two options, when I just started in Mexico City placing implants, I started placing implants with 3i. That's the system. But I had the option, I had training with Strumann and with 3i, and at the time, it was when Straumann was really hard on tissue level and not bone level. And that's why-- that's what made my decision to move and get training with 3i in the system. Not that he was not a good system, it was just a little more complex for my understanding at the time.

HOWARD: Yeah. And then 3i-- They all rolled up into Zimmer, right? Zimmer swallowed up three. 3i got sold by Biomet or--

MARCO: No,  Biomet got swallowed up by Zimmer.

HOWARD: And then Zimmer got swallowed by Biomet or something. But yeah, a lot of mergers and acquisitions industry isn’t there.

MARCO: Absolutely, yes, it's a lot of that.

HOWARD: So esthetics on implants... ceramic materials for restorations and implant abutments or you're doing porcelain fused to metal still... Is there-- when are you, what is your ceramic materials?

MARCO: Okay, for the restoration-- okay, for aesthetics. No, I don't. I don't use PFM anymore at all. It has been probably six years.

HOWARD: That's the one thing... I never it saw coming when I was in dental school that the PFM would go the way of the dinosaur. I mean that was just, I came out of left field.

MARCO: I lecture a lot on material selection. I do because it's very, very-- the first time I got invited to talk about that, it was for oral surgery group, for the (inaudible 52:58 AMOS). They asked me to talk about material selection and I was like "Are you kidding me?" I'm going to bore them to death. They're going to die with my lecture. So, I need to come up with-- you know Einstein used to say: if you don't explain it clearly, in a simple way you, it's because you don't understand it all or enough. So, I had to really merge myself into it, to really explain in a simple way. And it was during that time that I realized that PFM was no longer an option. And that things are changing. Back in the day, it was easy to select ceramic materials in the 80s. It was just PFM, that's it. It was the only option for esthetics. It had their time and everything, but we haVE better materials now that are reliable, that are durable, that are going to last as long.

HOWARD: But then, I want to clarify, you said that the only option you had early in your career for esthetics was a PFM. But, it's funny because Ryan and I, tomorrow we're on a plane to Toronto, Canada. We were in the five-- we're usually going to lecture in five continents a year. And gold in the Anterior, it's only a taboo in about 20 countries. I mean they love gold on their front tooth. I don't care if it's a full gold crown. There's so much in Africa, Asia, and Latin America, and Central America, where the most rocking hot woman in the bar might have a gold central incisor or a lateral.

MARCO: Oh yeah. And that's pretty much a fashion. When I was (inaudible 54:40) esthetics, I was probably just kind of say mimics nature, mimicking nature. And that would be the concept of my esthetics. But I understand that fashion, there's a trend of fashion of having gold in the front, even  jewellery bonded to the teeth.

HOWARD: Gold is more common in anterior teeth on pretty ladies in Mexico City than New Orleans, would you say?

MARCO: Yes, I would say so. Even though in New Orleans, there's a lot of people. But the trend (inaudible 55:11). We do have a lot of patients that come with a gold window or a gold tooth that they want to replace. But you still get from time to time even the denture patient, they want to have in their denture, a gold tooth.

HOWARD: I know, and I've had this ethics problem. I get it about every-- maybe every five, six, seven years, some young beautiful girl wants me to file down a completely perfect anterior tooth and make a gold crown. And I'm just like, "You know what, I'm sorry. You’re a kid" Yeah, I raised four kids. You're all excited about this new gold tooth or this tattoo. But are you going to be excited about this gold tooth and a tattoo five years from now? I'm sure you can find anyone to do it, but it's just not going to be me. So, I'm thinking, that's an impulsive buy, go take a chill pill.

MARCO: That's exactly my answer. You're absolutely right. You think  it’s cool now but I'm not going to do something that is irreversible. I can do anything that they want as long as it's reversible. So, for example I have a friend here that is a faculty that he's going to give a table clinic at the AGD on jewellery on teeth, on having the bonding technique to put some jewellery. But it's always reversible. As long as it is not invasive, as long it's not going to damage the soft tissue and it's reversible, I can do that. But anything that is irreversible, with gold for example, like you said, I said, "No, you can find somebody else to do it for you."

HOWARD: Yeah. Exactly. My gosh, I can't believe we went over an hour. That was the fastest hour ever. I could talk to you for 40 days and 40 nights. I sent you that, my podcast on Marco because I think you should take another look at Straumann since you have the same name with him. You guys might be buddies for the rest of your life. But hey, any chance we could ever get you to create an online CE course for us on Dentaltown? We put up 400 courses and they're coming up on a million views, cause these millennials would rather just watch an hour course on their iPad or on their iPhone instead of traveling across the country. And when Ryan and I are in Asia, Africa, and South America, those dentists are so grateful. There was a dentist in Tanzania and she was crying. She goes, "I could never afford to fly to the United States to see any of these lectures." She was like, "I couldn't even afford the plane ticket" and I'm watching  them in Tanzania. But I sure love to get a course from you someday. I know you're busy as heck, too. But if you ever have time, we sure love to have an online CE course from you.

MARCO: Let's talk about that. And you know I really love that 20 minutes type of lecture when you can really give them something to take home and go in-depth in a very simple concept... And go in-depth for 20 minutes. Because as you say, the new generation, the millennials, they have a very short span. They cannot spend too much time on a concept. So, there are studies showing that after 20 minutes, that's it. You don't have their attention anymore.

HOWARD: And cut it in half if they're on caffeine. I have a teacher friend. But anyway, the research. Are those your two daughters in your background?

MARCO: These are my twins, my boy and my girl.

HOWARD: Oh my God they're so adorable. How old are they?

MARCO: They just turned four in October. And they are my everything. Let's put it that way.

HOWARD: Yeah and I was reading, there's a lot of research that's going to change their education world. There's a lot of research that says that you almost can't-- children can't induce long term memory till like 9 or 10 in the morning. So, getting them up at 7 when they're tired and drop them off of school when they're groggy, they just sit there in a fog and they don't even come alive until like 10 o' clock. And then when you're teaching them a concept you're exactly right, fifteen minutes max. To get them to listen to you and focus. And cut it in half if they drank a Mountain Dew on the way to school. And that's where I think our online CE because it's kind of... sometimes it's overwhelming to say, "Gosh, I want to block out Friday and go to a course from eight to five." And it's like oh my god. But if you said, hey how about instead of eight to five, just one hour and you can watch it on your iPad. They can (inaudible 59:49 If they have to go to the bathroom ), they can pause it or whatever, or re-watch it. So, I think it's really the future.

MARCO: And I do believe in online education. I still believe as you are traveling, I still believe in the human contact, and I really enjoy when I lecture, and I have a full day lecture and I use pretty much the same concept of... every 15 minutes, I change the dynamics. Every 15 minutes, I come up with music or a joke or something and change the dynamics and move to a next topic. And I can spend eight hours like that and it works if you go 15 minutes at a time.

HOWARD: Well that is amazing. You have dentistry in your blood from your dad to your brother. And I wonder if one of those twins will be a dentist, a prosthodontist--

MARCO: I don't know.  Because it's built in my DNA. I breathe, I eat, I live dentistry and that's going to be... it's my life. For some people it's not their life, for me it's my life.

HOWARD: Well, I'll tell you what, it was a huge honor to have you come on the show today. It was a privilege to podcast you. Thanks so much for coming on my show today.

MARCO: Oh, thank you so much. It was great to meet you and to spend time with you. Thank you so much for the invitation, the honor is all mine.

HOWARD: Oh, have a rocking hot day and give those two kids a kiss from Grandpa Howie.

MARCO: Okay, I will. Take care. Bye-bye.

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