Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1018 Meet TrueJaw with Christian Pusateri : Dentistry Uncensored with Howard Farran

1018 Meet TrueJaw with Christian Pusateri : Dentistry Uncensored with Howard Farran

5/15/2018 10:07:19 AM   |   Comments: 0   |   Views: 199

1018 Meet TrueJaw with Chris Pusateri : Dentistry Uncensored with Howard Farran

Christian Pusateri is head of sales and marketing for Dental Engineering Laboratories, a medical technology company owned and operated by Stephen Buchanan on Santa Barbara, CA. He has worked directly and as a consultant for implant companies around the world. Christian has worked in the medical technology and Implantology markets over the last 9 years and has facilitated more than a hundred oral surgery hands-on courses.


VIDEO - DUwHF #1018 - Chris Pusateri

AUDIO - DUwHF #1018 - Christian Pusateri

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1018 Meet TrueJaw with Chris Pusateri : Dentistry Uncensored with Howard Farran

Howard: It's just a huge honor for me today to be podcast interviewing Christian Pusateri. Thank you so much for coming by the house.

Christian: Thanks for having me. 

Howard: By the way, I never do commercials. No one ever pays me to come on the show. I had him come on the show because he actually works for an idol role model of mine, Al Steven Buchanan. We had him on the show. Obviously, one of the greatest endodontists that ever lived. 

I also think he was like the first endodontist who actually got a CAT scan. I mean, this is way back in the day probably before you were born. You’re thirty-three, I've been a dentist—that's sad. I was actually a dentist when you were three and when I graduated from college you were just a dream for your parents. You weren't even real, but man, he was taking CAT scans of molars and blowing my little walnut mind twenty, thirty years ago. Do you call them Steve or Steven?

Christian: We call him Steve. Dr. B.

Howard: Dr. B? Is that what he goes by? Well Dr. B, really before I met that guy you thought a molar was three little straw tubes and then he started injecting them with dye and taking CAT scans. You're just like holy shit and he was the one that really burned into my mind that when you mechanically debride a root canal, he's like, “Howard, you're maybe taking out forty, fifty, if you're lucky 60%?” All those little weaves and hey, you’ve got 40% more bacteria, fungi, viruses, microorganisms and irrigation is everything. 

And you were telling me, he's really big in ultrasonics and that was with Acteon? 

Christian: Acteon, yeah.

Howard; And what was he using so much from Acteon?

Christian: Well, he's using that to do canal access, apical surgeries. You can do a number of endodontic procedures with the Acteon. 

Howard: So it was more apicoectomy, more surgeries, it wasn't cleaning and shaping? I mean, it wasn't ultrasonic cleaning?

Christian: Yeah, you absolutely can as well, those procedures. 

Howard: And then I've been after seeing Steve one time. I went to his hands-on course which actually turned out at the end to be absolutely frightening because a classmate of mine was there named Chip Casteen. After the class, I was going to fly out the next day and Dr. Chip Casteen, Richard Casteen of Bakersfield, California said, “Well, hey, let's go to Bakersfield tonight.” And I said, “No, it's too far to drive.” He goes, “No, I fly my own plane.” So I said, “Cool.” So we went to the, what is it, Santa Maria, California?

Christian: Well, that would be up by San Luis Obispo, Santa Maria. 

Howard: What's the closest airport by?

Christian: Santa Monica.

Howard: Santa Monica. 

Christian: Oh, up by—yeah, Santa Maria is by Dr. B, you're right. That’s Santa Maria.

Howard: So Santa Maria airport and this is my classmate that I went to dental school with for four years. We're getting to this plane and we're flying back and everything and then all of a sudden he takes his hands off the wheel and he’s sitting like this and the plane started to wobble. He was like, “Hey Howard, you better grab that wheel or we're all going to die.” And I'm like, “What, what, what?” He forced me and oh my God, because there's a big mountain range over there and he said, “Howard, I keep saying pull back as far as it goes. At this point, you're going to crash into the side of that mountain.” And then I’m pulling back and it was so funny. 

Christian: That’s great.

Howard: So great times out there. A big shout out to Dr. B whose real name is Al Steven Buchanan.

So tell me, you've been working for him. So Steven's got a new company, Dental Engineering Lab and now you're working there. So tell us what you do? How are you helping dentists? 

Christian: I got really excited because I was in implantology basically for almost a decade. We were doing courses for various companies, teaching doctors how to place implants, usually GPs but also doing more advanced things like ridge splits and sinus lifts and lateral windows and Dr. B, just like he was the first one to get in the cone beam train, he was one of the first doctors I met nationwide to get his own Stratasys 500 3D printer, like the big one, the one that can print your head if you want.

Howard: And it's called what? A Stratasys...

Christian: It’s a Stratasys 500.

Howard: Stratasys 500. Okay.

Christian: And so it takes seven different cartridges of polymers so you can have seven different colors and types of polymers that it can inject all at the same time and he started fidgeting with it, figuring out how to make it what he wanted to make and we were working together. He was a customer at the time and I was blown away by what was going on and even though he does a fair amount of implants, especially a lot for endodontists. 

Howard: He's placing them?

Christian: He’s been placing them for a while. Yeah, he really needed someone to come on who's been just in that world and immersed in it. So enter me. 

Howard: Because you have a long history to implants. You've worked with Hiossen out of Korea, Implants Direct started by Gerald Niznick who has been on the show and now that's owned by Kerr.

Christian: Danaher. 

Howard: Well, Kerr—

Christian: Which is owned by Danaher.

Howard: So it’s Implant Direct is a division in Kerr which is a division of Danaher and then you were with (05:19 unclear) that Stan Bergman, who we've had on the show, swallowed up with Henry Schein. So Steve wanted someone with a big implant depth and breadth and got you?

Christian: Yeah. He brought me in and we actually took this model in the software and rendered it. 

Howard: So that's 3D printed out of his Stratasys 500?

Christian: It’s from cone beam file that we then rendered and sent to the printer so this is a real patient. 

Howard: So that's a real human? Unbelievable. So this is a real human. So the whole main advantage of a CBCT or a cone beam is just that at one year, you want a 2D pantograph you have all these overlapping images. So the bottom line of 3D is that you just don't have overlapping images. That's just it in a nutshell. 

So you sit there and so you took a cone beam of a human and then you printed out and you got this?

Christian: Yes, more or less. This is a mandible with a (06:19 unclear).

Howard: You know who it is? 

Christian: Yeah, I do know who this is. Well, it was actually an employee of Steven's and we kept the file. 

Howard: Missing all these teeth?

Christian: We take those teeth out. He had all of his teeth, thankfully. So we can render that file.

Howard: Sure. Is Steve hiring a bunch of hillbillies from Kansas?

Christian: He was a really good patient.

Howard: This reminds me back home of Kansas. So then you removed some teeth on the dill?

Christian: Yeah, just to make it good for drilling implants.

Howard: This person, is it a boy or girl? 

Christian: That was a male. 

Howard: So this isn't?

Christian: Well, this one is to scale. The sinus is to scale. This one we actually scaled up. We can make it about 30% bigger depending on—

Howard: So same patient, but you scaled this one up. So now it needs orthognathic surgery or a palatal expansion. So you're printing these out on your Stratasys 500 and why is Steven (07:15 unclear)? Why are you printing out models?

Christian: So historically, if you want to learn some sort of oral procedure, you're going to go to a course that either has injection mold models or you're going to go to the course a little more extreme. You're going to use pig jaw, goat head or human cadaver. So the problem with a goat head and pig jaw is that it's great tissue, but it's not human tissue and if you're doing any soft tissue management, it's not going to be the real thing at all. Injectionable models, they are models. They're like the real thing, but they're not the real thing. So this is actually, we call these replicas, technically to differentiate from a model because this is actually the patient's anatomy. So the way the soft tissue lies, how the crown is in the trabecular bone, the PDL, like this is all, it's a real replica. 

So the idea is that we're trying to control the anatomy so that we can really hone in on courses where doctors can go, they'll know what to expect and they can practice one procedure over and over and over again. So if you're going to do a ridge expansion or a sinus lift, you can get the same model and do the same sinus lift ten, twenty times and then you iterate. Then you move onto the next procedure. Instead of cadaver courses today, when you reflect the soft tissue and you go in there, you don't know what you're going to get if it's a cadaver or a pig jaw. 

So you've got twenty people in class and they're all having different experiences because they all have different cadavers, they have different specimens. So even if you go to a class that's made for implants, you're getting some wonky cases. One doctor is dealing with a nice wide ridge. Another doctor is dealing with a really thin ridge. Those are two totally different cases and if those are patients coming into your practice, you would not be dealing them the same. You might be saying yes to do this implant and no to that one. So we're trying to allow doctors to really control the anatomy and practice one procedure at a time before they move on.

Howard: I got my fellowship in the Misch Institute with implants and I got my diplomat in the International Congress of Implantology and this is in the nineties and my God, you'd have a 2D panel and you think ah, this is the easiest case, he has a inch of mandible. Then you get in there and you reflect it back and it'd be some paper, thin, knife edge and by the time you reduce that little knife edge so you could have something five, six millimeters wide, you lost half the damn height. It was just crazy.

And by the way, and this is what, if I was Steve, I would start talking to those boards because there is really going to be a lot of the lawsuits against those state boards for that very reason. They'd say, “Okay, we got to do a filling” and your patient doesn't show up. Mine shows up thirty minutes late, drunk and high and then this over here has perfect grandma who just sat still the whole time and that's a standardized test. 

I mean the didactic standardize, but the live patient is just bullshit and you take these dental students that have been paying $70,000 to a $100,000 a year for dental school. So some of these kids are $400,000 debt plus they’re undergraduate and then they fly all the way to this dental school.

 I was in Kansas City so to practice in Arizona, the only board at that time, Arizona didn’t have dental schools thirty years ago. So I had to go to Redland, California. Loma Linda. So I had to fly a patient and an assistant out from Kansas. I had no money back then I think my job, I was making a three dollars and twenty-five cents an hour and I got a fly three people out there and I pass and my buddy that I went with didn't pass for totally unfair reasons because it wasn't standardized.

So if I was Steve, I would just start working with all those state boards and just start saying dude, you've got to make this a standardized test. 

Christian: Well yeah, that’s the idea. 

Howard: Because it really is just not fair to these kids, $400,000 dollars in debt to have a—

Christian: And they're essentially not taking the same test. 

Howard: And then Loma Linda was kind of a Mafioso deal because when I got there, the upper grads told me that if you hired one of their dental assistance, you'll have an infinitely higher chance of passing than bringing your own. So I flew a damn assistant all the way out there and then on the day, it was a two-day board exam and then basically just said, “Well, I hired one there” and so I told her, “Back to the hotel, hang out and do whatever” and sure enough man from just the sample I saw back in 1987, the people who use the dental assistants who worked for the school, they had a really high pass rate and the ones who didn't hire them had a really low pass rate. So it needs to be standardized. 

Christian: So this could be a solution. That's what we’re hoping, I think. 

Howard: Well, you should start contacting those boards where all the world of boards are.

Christian: Howard, you're friendly with them. So maybe you can put us in touch.

Howard: Well the best way to get in touch with them would be a lawyer be. Because it's a predatory practice to prey on poor dental students and make them do that. 

So these, could they also be a training model or what do you call it when you're presenting to a patient when you’re using this for the surgeries? 

Christian: Absolutely. We're guessing and that's kind of what the bet that we're taking is that the way that the market is going is patient specific modeling. So as more GPs begin doing cases and as more advanced cases become available to the average private practice dentist, they will want to print out an exact scan of the patient first in practice. Practice the surgery on this first, then do the live. 

Howard: So right now, do you have dentists that are taking a cone beam and then sending you the file and then printing out a custom? 

Christian: We're just getting into that. It's still, we're on the border of it being cost prohibitive, but we're passing that border, the costs are coming down and I think that's what we're going to be getting into in the next eighteen months. 

Christian: By the way, Steve Buchanan was podcast number 446. You just got to watch the show. 

So the cost is coming down. Well, where's the cost at now if someone was going to?

Christian: These models go for about $225 retail and we're getting better, we're learning basically how to minimize costs and still get a good product. So it's like any new technology when the iPhone first comes out, it’s a $1,000 and then a year later it's $500 so.

Howard: My first DVD was $800 bucks. It was horrible and within eight years they were $35 and perfect. So your website is

Christian: That's it. 

Howard: So what are my homies going to find if they go to

Christian: Well, your homies are going to find not only our 3D printed jaws, mandibles and maxillae for a surgeon endo, they'll also find 3D printed teeth, which we have in universities around the world. We're the exclusive distributor of the True Vision 3D camera system for microsurgery and they’ll also find our file retrieval kit which Steve doesn't manufacture but assembles his own way and we also are the exclusive distributors of that. 

Howard: And it’s going to be an open sources and so someone takes the CBCT, they're going to email you the—?

Christian: Yeah and then we import it into our software and we render—

Howard: So first of all, we always hear that some systems are more closed like Dentsply Sirona GALILEOS, some are more open. Can your Dentsply Sirona GALILEOS export that file with you guys? 

Christian: As long as we get it in DICOM or STL file format, it's fine. 

Howard: But I mean, can they do that? 

Christian: Yeah, if they can export—I'm pretty sure CEREC Sirona can just export to a regular 3D image file which is an STL. So as long as we get it in that form.

Howard: And what does STL stand for? I’m only familiar with STDs.

Christian: I think STL is stereolithography, but it's just basically the acronym for a 3D jpeg.

Howard: But for the CEREC Sirona users right now, you're pretty sure they still work?

Christian: Yeah. 

Howard: Okay and so all 3D printers cone beams will work?

Christian: Well, the cone beam is a 3D imaging.

Howard: If they can export it? I think they all export DICOM, don’t they?

Christian: Yeah, they all do. So as long as we just receive the DICOM and then we render it in our own software so it has to basically be rendered into software before it's sent to the printer. So that's where a lot of the legwork goes in and knowing what to do because when we get the 3D image, it's a 3D image the same way you see the 3D image on your screen. We have to turn that into this in the software before it goes to the printer. 

Howard: So Steve's an intense dude. I mean, he doesn't do anything—

Christian: Nothing halfway.

Howard: If that kid got an A minus he'd be livid you know what I mean? So you're saying he's placing implants. What implant system does he, is he using one?

Christian: He can place pretty much anything but I think his favorite so far as the Nobel series, the Active.

Howard: NobelActive.

Christian: Yeah, that's a great implant. 

Howard: And why do you think he likes that one the most? 

Christian: You'd have to ask him. I know it's the top of the line implant. 

Howard: Well, Nobel. That was the first one. I mean, that was the one by Brånemark. You know his son is a surgeon in San Fran?

Christian: No kidding. 

Howard: Yeah, Ryan, we say get him on the show. Dr. Brånemark’s son in San Francisco, you know who introduced us to him? Ann Marie Gorczyca. Big shout out to Ann Marie. My God, she's my favorite orthodontist in the world and it's not just because she's so sweet and lives in what city she lives in? Antioch, California. But God, she's the most connected woman in dentistry. She knows everyone but anyway, yeah. Dr. Brånemark’s son is an orthopedic surgeon and actually, I think was Brånemark an orthopedic surgeon?

Christian: He was first. 

Howard: Yeah and so son followed his dad and basically, when they were doing the implants, you couldn't practice artificial hips on a mouse or a rat. So they thought what'd be really easy, you just make little rods, you just put it in the rat’s jaw and then when they went to pull them out, that was when they discovered it. It osseointegrates. But that is the most research driven. I mean, they were the first there was and Nobel because they’re in Switzerland. Nobel Peace Prize that's where Nobel came from. Did you know that? 

Christian: Oh, I didn't know that. 

Howard: Yeah, they’re in Switzerland. The Nobel Peace Prize and Nobel is a scientist so it's now Nobel Biocare, but they do have the most research and I've noticed that the people who start getting into All-on-4s and the oral surgeons, periodontal surgeons are doing a lot of big cases. Another thing they don't want is they don't want to get in a court case and say, “Well, where's the research for that?” and then you saved $100 on the implant buying it from Russia or some company. You're saying, “Well, titanium is titanium is titanium.” Yeah, until you live in a country of America that has one million attorneys, this country has more attorneys than MDs.

Christian: Wow.

Howard: So the guy who's on the bleeding, leading edge, they want some cover and I'll tell you what, you could probably place the lowest cost titanium implant and probably in at least a hundred countries and it wouldn't be a problem, but that's not how we roll here. 

Christian: Not so much here, no it’s a big problem. Nobel stays on top of it with all their—I mean, they have so much R&D going on, they are on the cutting edge of technology. They stay so sharp. So that's probably the big reason why. 

Howard: It's Switzerland or Sweden?

Christian: Switzerland.

Howard: I always get those two Ss mixed up. 

Christian: Well, their US headquarters is in Yorba Linda.

Howard: In Yorba Linda?

Christian: California, Orange County.

Howard: So can I tell you my Switzerland stupidity? First time they ever invited me, this is so embarrassing. There’s like four dentists, we’re up the international airport, they’re driving me and it was in Geneva. Pretty sure it was Geneva and I'm sitting there and I mean, it's just this gorgeous, huge mountain that looked like a picture and I'm sitting here looking at thing and I mean, it's just like, it's like if you'd seen it on TV and say it was a painting, it was just like the most gorgeous thing in the world and I just (20:08 unclear), “You know it almost looks like the Matterhorn at Disneyland.” They go, “That is the Matterhorn.” I was like, “Oh, I didn't even the Matterhorn, I just thought it was some magical kingdom out. I didn't know it was actually a real mountain.” They just couldn't believe that I didn't know the Matterhorn at Disneyland was the Matterhorn in Switzerland, but one of the most beautiful countries. 

So how long has Steven been placing implants? 

Christian: Oh, I mean, at least a decade. Probably longer. I don't want to misquote, but I mean a good part of his practice now. He still practices in addition to running this company and speaking all over the world, he still runs a practice and he does a fair amount of implants in his practice still.

Howard: But it's a real money is the answer, what's the question? My endodontists friends, they are just like my prosthodontist friends like right now, there's no training programs to be a prosthodontist that doesn't include the surgical (21:09 unclear). Hell, it's a requirement. So for the school to be accredited as a prosthodontist, you have to have surgery. But the endodontists and the prosthodontists, so many of them can't do it because it's a channel conflict. 

So if all these oral surgeons and periodontists are sending me these molar root canals and I started placing implants, they're going to find another endodontist. Same thing with the prosthodontist. All my prosthodontist friends say I get all these big cases and they're all from oral surgeons and periodontists and if I placed one implant, my phone would stop ringing.” So it's really tough that they have to get the trade and then a lot of these guys, they come into school and they go, “God, I graduated from prost school three years ago, I ain’t implant in three years.”

Christian: They're afraid because of team approach system and listen, that's totally regional. Some cities in this country, it's very team approach. So if you are a GP and you place an implant or if you're a prost and you go outside of your lines, yeah, the community kind of like they ostracize you. Then you've got places like, I mean most of Los Angeles, most of New York is basically a free-for-all. It's like everybody can do anything and that's totally accepted.

Howard: Really in LA and New York?

Christian: Certainly in the big cities. Yeah, I think. 

Howard: So if you're an endodontist in LA or a prosthodontist?

Christian: I came across many endodontists and prosthodontics, I would say far majority in that city, they place implants. 

Howard: Now see, I'm a referring dentist. So I sit on the other side of that and on my side, I have the exact opposite like I don't want to send like, you're married, you got three kids, you've got $400,000 student loans and your only tool is a hammer. Everything looks like a nail and so you're going to retreat this thing and maybe you even think it's cracked or it's never going to work and so I always sit there and say, “Well, will you warranty it five years?” 

I mean, if the average a woman right now in America is living into it's like seventy-nine and eight months. We'll round her off to eighty. So if you're eighty years old and your dentistry only lasted five years each time, you'd have to have everything redone sixteen times in your life. Because at five years the average American who's lived before us, bought twelve new cars in their lifetime because those cars only lasted five years. If those damn cars lasted ten years, they could get by with six cars. And that's why my last car, I had a bunch of American suburban and all this stuff and I mean, they should have come with a full-time mechanic. My last car was a 2004 Lexus suburban. It's 2018, fourteen years later that car hasn't farted. It's still perfect. So if I live to be eighty and my average car lasted fourteen years, I'm done down to only needing five cars. 

So the endodontist, they won't warranty it five years and so they're “Well, I did the best I could.” That's bullshit. You’re an undergrad degree, you're a doctor of dentistry and you had three years post-training in endodontist and you're saying you did the best you could do? She gave you $1,500 and a year later it's in the trash can. 

So I was thinking well, if I send him to an endodontist where he can feed his family by doing the retreat or extracting the tooth and doing an implant, I’d feel much better representing a patient if I can send it to you. And you can say, you know what? Because the bottom line, the only thing, your first name was Christian and your last name is Pusateri so you've got to be an Italian Catholic. 

If you study every major religion like my oldest sisters that are nuns have, the only thing in common in every major religion, there's no name, city, place, there's nothing. You know the only thing that you can find verbatim like plagiarism in Hinduism, Buddhism, Confucius, Christianity, Islam, the sixth biggest religions you know what it is? The golden rule, treat others. In fact, the first place that shows up is actually Judaism and it says, “Treat other people like you want to be treated.” That is the entire law, all the rest is commentary. I mean, you read that. 

So when I go to a doctor, I just want the doctor to represent me like he would treat himself, but if the only way he can pay his overhead is, “Well, all I can do is a retreat. It’s not the best idea, but I don't want to send you to the oral surgeon and pull and place the implant because I only got four patients today and I got to do four grand to break even.” I'm afraid of that. 

So I would prefer an endodontist that I'm feeding your family either way I can do the retreat, I can pull it and place the implant, but if it was my tooth. Treat other people like you want to be treated, I’d want to pull the tooth and do an implant and if the endodontist isn't going to get into that for whatever reason then I want to a five-year warranty. But asking a specialist for a five-year warranty. I mean, placing the implant in five years, 20% of them had perioimplantitis. 

So it's really bad, but incentives matter and incentives didn't matter then you need to tell everybody who got a Nobel Prize in economics that they're just a bunch of voodoo tooth fairies riding unicorns because it's a hardcore science and I think as an incredibly scientific as a root canal is or a coronary artery bypass surgery where you’re taking leg veins and grafting it into the coronary. Yeah, I think that's a whole lot easier to figure out then how the human mind works. Of why do you purchase this and why do you not purchase that? So the economist or kind of where the human beings meet math and that's a crazy intersection. 

So he's placing (27:19 unclear) that's amazing. So he didn’t have to practice surgery so I don't think he's, it’s pretty easy out for him, but what do you thinking, the first fifty implants, is that your target market? 

Christian: No, all into just what you were just saying. I mean, in terms of the team approach you have with endodontist that haven't placed the implants before, they are going to come in still far more prepared to cut than a GP because the GP hasn't cut. I mean, an endodontist knows how to get into anatomy; they know how to cut all those things so they're not in the starting place even though—

Howard: People who are doing all the apicoectomy you mean? 

Christian: Yeah, well just the general, root canals and getting to the tissue and accesses and all that stuff is they're starting a little bit ahead of a GP who's never placed before. So even though from the implantology side, they're both beginners, if they've never placed an implant, endodontists are a little bit of head and that's what we're doing with these models is we're allowing because we can control the anatomy, we can give both doctors a controlled experience and they're both starting at exactly the same place. Or if they want to start on a different procedure and they want to do. 

I mean, pretty much lay-up cases in implantology or the posterior sites, if it's already a denturelist or an immediate extraction, it's outside of the aesthetic zone with a nice fat ridge. Those are the 30% of cases that GPS can get comfortable doing in their first few years of practicing. But if an endodontist or if somebody feels like they want to, they've done a few of these and they want to start that. “I really want to do the meat and bones of my coursework to be on a harder site.” We can go into the aesthetic zone and you can still pick a nice fat ridge. We can print a nice, thick ridge but now you're a number seven. So you've got to watch out that you don't break the buccal plate, it's a thinner ridge. You've got to make sure that you've got a great pedestal space and they can do twenty of those the same way and really get that down. 

It's just like being a pilot. You don't learn to be a pilot one day and the next day or flying a spaceship or you're entering into the astronaut program. You do the same, you learn how to fly by day, you do that for thirty, forty hours, then you learn night flying, then you learn storm flying. You learned one by doing the same exact kind for hours and hours and hours and then you iterate and that's what we can do with this. We can print the same model, you can practice the same procedure over and over again. 

So it works for the team approach. I think it also works even if you're a surgeon and you've got plenty of experience, we can print this with the mandibular canal, which we just did actually. I came into town; I had been in LA for a week because we did was we decided to print a mandibular canal. That was a little bit tricky. They came up a little bit high right here in the chin so that it was something that if you took a CT and see that and it might scare some doctors into doing the procedure wanting to do that on purpose so that for an oral surgery course are some of the one to come in and try something that was a little not quite as beginner, they could take a stab at that and we can do that and then we can print thirty-six of them and you can practice over and over and over again, the same site. So, so far that you can't do that anywhere. The only place you can do that is with injection mold models, like I said and they're models, they're not real replicas. So that's the part that gets me jazzed about this. 

Howard: Another example about you're flying by day then you get really good then you start night flying, it reminded me that's how John F. Kennedy Jr., his wife Carolyn Bessette Jr. and his sister, Lauren Bessette all died. I mean, it was basically his first night flight and he died from that and the reason I tell you that, who's the father, daughter consultant? 

Ryan: Bill Blatchford. 

Howard: Bill Blatchford, that's another intense dude, one of the smartest guys I know and his daughter, Christina. He was in Oregon and he was lecturing, I think in Seattle and something happened to his plane so he saw a black field so he thought I’m just going to go land it there. The last second he realized it's a lake and the next thing he knows he was waking up and he woke up and he's like “Well, what's going on” and the water was coming up to his chin. He said if he would have stayed asleep like not even thirty, forty more seconds, he would have drowned. 

And the reason I'm telling you those stories is because guess which occupation has the highest small aircraft fatality? Doctors. 

Christian: Doctors?

Howard: So when I got here in 1897, you can't even make this story up it's so flipping crazy. So these two oral surgeons, what happens on an airplane and one of the oral surgeons had the day off so he tells his wife, “Let's go fly up to Sedona and have lunch.” They said okay. So they drive to Sky Harbor, they get in their plane, they taxi out and they take off and you just land there, it's between like he takes off and nose dives straight in the ground and they're all dead. 

Because his other partner had come and looked at the plane and decided it needs some scheduled maintenance. So he called this guy who took off the tail and it was getting repaired and at the crime scene they're like, they kept the road closed like all day because every day the FAA kept saying, “Well, where's the freaking tail.?”

Christian: How do he not see that the tail is gone before he flies it?

Howard: Because he jumps in that car like I jump in my Lexus. You just jump in and turn the key. You don't walk around your car and do an inspection and air tires and pilots all work from charts because if pilots had a 99.9999% success rate, that means four aircrafts would crash in America every single day. So they have an exhaustive checklist and they have to work by lists, but doctors don't do that because they got a nice plane and they just jump in there, don’t walk around it.

Christian: It’s a great stat for a dinner party. 

Howard: Yeah. So if you're a doctor Deb just call Uber, you don't need your own damn plane.

Christian: Well, Uber’s got choppers now I think.

Howard: So when oral surgeons are going down. So I always thought that the number one problem with implants is that we're pulling a three rooted molar and then we have to make the whole fit our manmade monkey implant, we’re drilling a cylinder down the middle. How long do you think it'll be before I take a cone beam technology of this molar I'm going to extract, send the file somewhere and they mail out a titanium implant or a ceramic implant that's the exact same shape of the molar so I pull out the molar and then you got this Stratasys 500? When do you think it'll have? 

Christian: Well, it's still milling when it comes to titanium, you can’t print titanium.

Howard: I’m talking about like maybe some ceramic, maybe zirconium, some other something to wear.

Christian: It would be custom fit for the patient, it would be done in the practice. We got to be seven years off, I got to say from that still. 

Howard: Seven years?

Christian: Yeah. I think before Dr. B or someone like him would get into that, it's probably seven years from that. 

Howard: It all comes down to is you're either going to have to take a titanium block, mill it down which that'd be crazy on the three rooted teeth or you’re going to have to print something up. I would think that would be the gold standard. 

Christian: I think it would, too and it's going to get tricky because that's hard. You wouldn't want to print that as a one piece, you’d want to print that in two pieces. Right now, the ceramic implants tend to be one pieces. So we're still way off from that. I mean, in some cases the abutment you'll be able to do in an office. PEEK is a polymer so if you're putting a PEEK abutment on your implant, you could pretty soon be able to 3D print that in the office.

Howard: Another thing I want to tell is when he was talking about a case, he was saying, “Start with posterior cases, a third of the cases are easy. Those are first molars, those are maxillary second bicuspids.” But one of the smartest oral surgeons I know in Phoenix said something so profound to me probably twenty, thirty years ago. He said, “You know what? Every oral surgeon I know, 99% of all their headache stress and bullshit is the 1% of their business that's orthognathic surgery.” So the first thing he did after he did like ten orthognathic surgeries. This is crazy, the insurance fees have come down, it’s not even worth it, he just gave that up and the thing about implants is you get a short fat, bald guy like me or some old man' with liver spot, do any implant anywhere you're going to be fine. But you get one woman with her anterior teeth, when she smiles it's curtains up and she shows her upper lip and you place an implant there. My good God, she's going to nitpick that to death. 

So I mean just do the easy stuff. Steal the low-hanging fruit, don't get some damn fire truck ladder and climb all the way at the top and have some hot woman knocked out her front tooth in a softball game. It's always a coed softball, that's what it is. Girls should not play with boys in coed softball teams. In thirty years it's always she was pitching to some man, some six foot two huge man who knocked that softball right in her face and clipped out. I've seen him come in within my thirty years with two, three, four teeth in her hand. 

But anyway, that's a case where it's just way too much trouble. If they're in the aesthetic zone and that lady is (36:40 unclear). Same thing with irrational cosmetics, it seems like women especially after they get a divorce. So they are going to be forty years old, they get their first divorce that's when the big surges in cosmetic surgery for every cosmetic surgery you can think of and they're coming into you and they're walnut brain. They want to look just like they did when they graduated from college and the irrational expectations are so high. 

So learn how to pick your cases in the profit zone and this is what you have to understand in implant cases. If every fifth implant case you did had to be redone, you're doing implants for free because the profit from the first four is what it will take to redo the fifth one for free. So the best way to double your profit in implantology is case selection and if you've got a periodontist or an oral surgeon that's placed five thousand, ten thousand, twenty thousand. There's oral surgeons in California that had placed thirty thousand implants. Don't be that guy. Don't be that guy. 

Christian: Well, working with some of the best courses in the implant companies teaching GPs. I mean, the best implant courses always teach case selection is the most important thing and when you're placing implants, take your low-hanging fruit, like you said. Take the 30 to 40%, the three to four out of ten that you can do competently because there's no point. Those other six you know what? You're still providing a great service to your patient if you take those four and you're making money while you're doing it and you're not taking on the risk of the other six that really should be sent to the periodontist or the oral surgeon.

Howard: It’s so funny because over the years like say you're doing a molar root canal on some fifty, sixty, seventy-year-old man and you're in there and it's a mess and something wrong or you (38:37 unclear) whatever and finally you just sit there and realize this just needs to be extracted. That's happened to me a couple of times last thirty year and every time the old man of say, “You know what, I told you to pull it, you're the one telling me to do the damn root canal. Hell yeah, pull it. That's what I wanted to do in the first place” So case selection, psychological profile and by the time you're fifty-five, you can see crazy in the eye.

Christian: And realize even if the implant is strong and oseointegrates and there's no resorption, there's no necrosis, he did a good job, you're still going to have to change that abutment and the attachment probably within twelve, fifteen years. Those things are not going to last the lifetime of a patient. So the patient gets a new implant at forty, you're going to be fixing that probably a few times as long as they stay in your area code. So something else to consider as well. 

Howard: So are you guys on Twitter? 

Christian: Instagram, Facebook, Twitter, YouTube, yeah. Dental engineering labs on all of them.

Howard: Okay. On, Instagram which Dental Engineering Labs. 

Christian: Same on Facebook.

Howard: I follow you on Instagram. You don't follow me on Instagram what’s up with that, homey? 

Christian: I don’t follow you back on Instagram? Let's do that right now. Oh, well I think I follow you personally but they don’t.

Howard: I’m just teasing you. But again, just a little social media deal. Probably the best business school teacher out today is Scott Galloway, professor at NYU School of Stern Business. I mean the guy is so data driven, he's got a consulting company called L2. But Instagram is massively pulling away as the fastest. When we did the lecture with Ryan McCall, McCall Dentures, I mean he's getting a four to five hundred new patients a month just from his Instagram page and the reason Instagram's pulling away and Facebook is because if you build up a hundred followers on Instagram, Twitter, Linkedin, Pinterest, and you make a post, all your followers instantly get it. But on Facebook like I have three hundred thousand followers on Facebook and if I make a post and I boost it for $1,000 and it will go to like hundred and ninety thousand. 

Christian: Right now you get a lot. It's a land grab in Instagram, you get a lot more traction there. 

Howard: Yeah and the only reason, because Mark Zuckerberg owns Instagram so you got to say to yourself, why is he doing it free? Why is he doing that? He's doing that because he's trying to drive Snapchat to zero and the party will be over the day Snapchat dies and then Instagram will be pay-to-play.

Christian: Right now $5 on Instagram over two days will get you like fifteen hundred, two thousand views. I mean, we're offering specials on our Instagram page that we don't offer anywhere else. Like direct just buy one, get one. 

Howard: I mean, it's crazy. And then the other thing that I don't understand what dentists do is they don't do Linkedin. Everyone on Linkedin has a job and dental insurance. Do you know how many of your friends on Facebook and Instagram are unemployed looking for work? I mean, look at the average person's profile on LinkedIn. It's the cream of the crop and I would say dentists what do you do for social media? “Oh, I do Facebook.” Okay. So pay-to-play I don't care if it's a social media or women if you're paying for it, there's a lot of drawbacks to that and Facebook is all pay-to-play. Don't do pay-to-play, do the free stuff where if you build up the followers, you get the organic followers, you put Instagram on your website and in your business cards and all that stuff. 

Twitter, I like Twitter but I'm almost every single person I know can't even count any patients they got from Twitter. I mean, I don't know anybody. We have done thousand podcasts. No one has come onto this show. So I get ten new patients a month from Twitter, but I hear it all day long from Instagram and then a lot of people think Facebook is good because first impressions are set and lead. I can tell you that Facebook was launched in 2006. 2008, it was a gold mine. It was all organic, it was all cool, it was all you know but that was 2000. It started in 2006. 2008, it was gold like Instagram is today but dude, it's 2018. 2006 was a long time ago. That was what twelve years ago, twelve years is a long time. I mean, MySpace and Friendster were but anyway.

Christian: Check us out on Instagram.

Howard: Check him out on Instagram.

Christian: I just (43:36 unclear) you again. You have two accounts by the way on Instagram, you got to clean that up. 

Howard: Two accounts? 

Christian: I think you have a bum account that you created on accident. 

Howard: Really? Find it. Can you find it? 

Christian: It's right here. See you've got this one which is fourteen and a half. That's yours. But then the one above it, that one. 163C8. The bio says you, but that's definitely not you in that one. 

Howard: Can you screenshot? 

Christian: I'll do it. 

Howard: Screenshot it and email to me Thanks for finding that. We have our director of continuing education. I'm Howard Farran, he's Howard Goldstein so I'm, he's  (44:23 unclear) online CE course and he’s kicked people off Dentaltown before and banned them and then they made artificial accounts on Twitter with his name.

Christian: So maybe that’s what happened to you. 

Howard: So he gets parody accounts but that's kind of funny. So again, one last I know I already asked the question but just say it again. So to contact you is

Christian: Correct or Christian Pusateri Dell.

Howard: You mean a website?

Christian: That's my Instagram and my Facebook. 

Howard: Am I following you on Instagram?

Christian: How do I go to Instagram? This is the big one. Yeah, you still have home button on your, I like this.

Howard: By the way and another thing to the millennials. So many of you are so sweet, you're so adoring. I would say always send me an email because I'm fifty-five. My computer screen is really big, but you always message me on Facebook, direct message on Twitter and dude, that's on my iPhone that's really hard to see. So what I want you to do this week in your homework assignment is to call your grandpa and I ask him how good he can read on his smartphone and email is just so much better when you're dealing with elderly people. 

Christian: So you already follow @DentalEngineeringLab and now you follow me as well. We have two separate pages but we both talk to each other. We send things to each other.

Howard: But the other thing is that the Dental Engineering Lab website, what is Steve Buchanan’s website?

Christian: It’s just Dental Engineering Lab. 

Howard: So that's now his main website?

Christian: Yeah.

Howard: If they want to do this, what would be the next move? 

Christian: Basically you can reach out to us at any one of those mediums; go to the website, call, email. Parker Poor and I both are running a sales and marketing. He was going to come today but couldn't make it. 

Howard: Parker who?

Christian: Parker Poor.

Howard: How do you spell poor? 

Christian: P-O-O-R. 

Howard: Is he poor? 

Christian: He's not. 

Howard: He's a rich, poor man. He's a rich man, Parker Poor man. So what's he do?

Christian: He’s in development for international so he's the guy going to trade shows all over the world. He works in tandem with me on all the sales and marketing objectives. 

Howard: And you guys all live in Santa Barbara?

Christian: He lives in Santa Barbara. I live in New York. 

Howard: Oh, you live in New York? I just moved to Brooklyn actually two months ago. 

Howard: So where were you born and raised in?

Christian: St Louis, Missouri. 

Howard: Wow. I went to dental school in Kansas City, Missouri. Yeah, I've been to St Louis so many times. So born in St Louis?

Christian: So and you started your career right when I was so we were probably there at the same time when I was like one.

Howard: Yeah, when you were one. Who was the best shortstop in the whole world that played for the St Louis Cardinals?

Christian: You're not talking to a baseball guy.

Howard: Ozzie. What was his name? Baseball player, St Louis Cardinals, Ozzie. 

Ryan: That would have to be Ozzie Smith. St Louis Cardinals.

Howard: What year they put them in?

Ryan: San Diego.

Howard: No, no just put Ozzie, St Louis Cardinals baseball.

Ryan: Yeah, St Louis Cardinals, Ozzie Smith, baseball shortstop. 

Howard: Okay. Because Kansas didn't have a baseball team, Wichita, Kansas.

Christian: That’s where you’re from?

Howard: Yeah, born and raised Wichita, Kansas. So it was either the Kansas City Chiefs, but for some reason I always liked St Louis Cardinals. 

Christian: They've got a great following. 

Howard: During the game, he'd always walk out there and he got to his position on Game Day or the first—he did a lot of games. It was always the first game he always did it, but when he got to the shortstop, he'd do a standing backflip and land planted on his feet. But when he had his little boy, his little boy would go out with him and his little bitty baby boy and he'd do it. So they’d walk out there holding hands in unison do a backflip and I missed that. And that's why my boys, I have four boys and we did kind of the same thing. We’d all go to McDonald's and eat a Big Mac together and then we'd all eat a Big Mac and then we’d go to to Krispy Kreme and we'd all eat a donut in unison. 

Is there anything I wasn't smart enough to ask you, anything else you wanted to cover? 

Christian: No, this was a blast. That was everything I wanted to talk about. It's great talking to somebody who's a big fan of implants and sees the coolness of this technology and the impact it can have. 

Howard: So when did you move to New York City? 

Christian: Two months ago.

Howard: From St Louis?

Christian: No, St Louis I was born. That was only for a year. My Dad was also a salesman so we lived all over, but I was in Maryland for most of my childhood then was in LA for six years.

Howard: Where in Maryland? 

Christian: Annapolis. 

Howard: DC? Where Air Force is?

Christian: Naval Academy. Yes, sir. 

Howard: And then you just now just went to New York?

Christian: I went to Los Angeles? That was with (49:32 unclear) and was there for six years.

Howard: So what made you go to New York? 

Christian: I got engaged recently and my fiancé’s family is from New York. Most of my family is still around the DC area so we wanted to be closer to the family to have some kids. 

Howard: So do you consider us friends? 

Christian: Now yeah, definitely. 

Howard: So what if I said to you: you still want to be my friend?

Christian: Yeah.

Howard: Sign this contract. If you ever decide not to be friends again, I get your house. So your fiancé? That's awesome. I'm so happy for you. But why would you bring your lawyer to bed with you and your fiancé? I mean, can you imagine your mom and dad saying by the way.

Christian: Oh, you're talking about marriage. Why get married? Oh, interesting.

Howard: What a rag. Half of them fail and you're going to buy someone a house. So if you really love her and she really loves you, then live happily ever after. But if someone says, “Hey, we need to get a lawyer involved and you need to sign right here,” sign it. And then buy her a house. Just saying, dude it's bat shit crazy. The only time I recommend signing the contract and getting married is if you bring that little Ozzie junior in because that's a long-term, that's a twenty-year project. I mean my boys are twenty-two, twenty-four, twenty-six, twenty-eight. I mean, that's a long-term project. 

Christian: Did you plan that? 

Howard: Yeah, we had four boys in sixty months. So if someone says you need to sign a contract—

Christian: Your mom was pregnant for five straight?

Ryan: Yeah, I guess so right. She must have (51:17 unclear). 

Christian: Six years straight?

Howard: Well, we both came from big families. We were both raised Catholic, we both came from families of seven and when you come from a big Catholic family of seven, my family of four seems like a really small family and then I noticed if you come from a family of two, a lot of them have none or dogs or one. 

Christian: We do; I was one of two. One brother.

Howard: So I recommend that you don't get married unless you make a baby. If make a baby then if someone says we need to sign a contract, you’re just like why. 

Christian: Howard, we’re making a baby. We got one in the oven. 

Howard: Oh, you got one in the oven. Oh, congratulations. Congratulations, man. 

Christian: Okay. So is this okay now that I’m doing this? Sign away? 

Howard: Sign away because it is, it's a really long-term project. I would say it's a twenty-five-year project. 

Christian: Well, you never really stop being a parent, right? I mean, you're not cut off next year. He's still got to be around.

Howard: Well, I decided not to be a parent and then my four boys got real mad at me so I had to come back around. 

But my final word of advice to you is NYU. 7.5% of all the dentists in America came from NYU. I think their graduating class is like three hundred and fifty, but I would immediately start going into NYU. It’s the biggest dental force in America. I mean, you can't go to any city, in any state, anywhere and not find a NYU grad. 

Christian: You have a friend there?

Howard: Lots of them. 

Christian: You have one that would talk to me?

Howard: Absolutely, shoot me email say who's your NYU homeys and I'll reply and give you some contacts. The other thing about NYU, you said your other business partner is international. NYU is the biggest foreign grad per year. Anyway, long story short here's another big deal with NYU. They got a foreign program for dentists from other countries come and so instead of the whole four years, I think it's like a year, a year and a half or something like that because if say you're from anywhere in Central and South America, Africa and Asia and you've been practicing dentistry for ten years, so you come to America and you get an American degree and then you go back to San Paul. 

Now you're downtown in the high rise and you're trained in America. So now you're just going to treat because what people don't realize between the first world in the third world is in the first world country, the richest is like 1% because the middle class is the majority and then below the poverty line is about 14%. Well, in the third world, there's almost no middle class so the rich 1% is rich 5% minimum and it could be a maybe 6 or 7%. So when you go to poor countries the Beverly Hills market is five times bigger, but they always go to the American trained doctors.

So America is number one in healthcare, healthcare medicine, military, insurance, banking, finance, music, movies.

Christian: Number one as far as the biggest industry is? 

Howard: Around the world. I mean, so like number one in cars is Germany and Japan. 

Nobody anywhere in the world sends their—say the other two hundred countries besides the first world, when they send their students abroad to learn engineering, they sent them to Germany and Japan and then no government's going to say, “Oh yeah, I go to America because we want to make Buicks here.” So America is not number, but it a number one in military medicine, insurance, banking, finance, music, movies and you go anywhere around the world America dominates those deals. In fact, in all throughout Africa, Asia and South America, I've heard so many people say that in my country, when you get sick, you don't want a doctor you want a pilot and you want to fly to America. 

So when those dentists go to NYU and they spent two years there and then maybe they were in a middle class, poor, did a lot of extractions, removables, flippers and then they go back. Now they're now they have an Al Steven Buchanan office right downtown charging two to three times in US dollar for a crown. So it has so many international connections. So there's a gazillion NYU grads in every country on earth and I’ve met them because I've lectured in fifty countries and so many of them come up to you and the ones that know perfect English. I would say, “Where did you learn English that good?” “Oh, I went to NYU”

Christian: NYT, that's why. Well when you come out to New York, we'll go together. What do you think?

Howard: Yeah, I love New York man. It was my first lecture, April 4th, 1990 Sheridan, Manhattan. 

Christian: You’ve just had your eighteenth anniversary of your first lecture. 

Howard: You know how Kansas stupid I was? 

Christian: Well, I doubt that.

Howard: My receptionist made me a reservation and it was at the Sheridan, so I fly into LaGuardia or JFK, I forget which one. I think it was LaGuardia. Yeah, it was LaGuardia, because JFK is in Jamaica. Flew to LaGuardia, getting a taxi, “Where you going, buddy?” and I said, “The Sheridan.” He goes, “Which one?” I said, “The Sheridan.” He goes, “Dude, there's hundred Sheridans in Manhattan.” I'm like, “What, what?” and I got in there late, so then I'm calling back home and like do you have an address on that Sheridan and she’s like, it’s the Sheridan in Manhattan and I’m like I'm twenty-seven and you're a hillbilly and evidently, there's more than one Sheridan in Manhattan. God, that was hilarious.

Christian: That’s so great, coming to New York story. 

Howard: But tell Stephen, thanks so much and best of luck and get on Dentaltown and tell the story and get Steven to get on Dentaltown. I mean, there's a quarter million dentists on Dentaltown. 

Christian: Yeah, we know. We’re aware.

Howard: So get on there and if you—

Christian: Write something?

Howard: Yeah, if feel like you don't want that it's too promotional. Just say I just finished a podcast with Howard and Steve did one earlier and you can repost that podcast and Howard wanted me to get on here and explain that. And by the way, it's Dentaltown, it's not Dentistown. I owned Dentistown in the beginning and a lot of dentists just wanted dentists only and the reason I said no and I held my ground even though Orthotown to this day doesn't, is that if you took away five hundred companies, you're not a rocking hot dentist. You want to see what dentistry looks like when you don't have five hundred dental companies, you can follow me to some third world countries where they're sitting outside on a rug and their equipment was all bought at Home Depot. It’s the CBCTs...

Christian: Are you doing any missionary work? 

Howard: Yeah.

Christian: Do you do mission trips for dentistry. 

Howard: Yep.

Christian: (58:30 unclear) supporting that, I don't know if you want to talk about that after.

Howard: Well, we have a whole thread called Humanitarian Dentistry where people are asking for help or volunteers. 

Christian: On Dentaltown?

Howard: Yeah, it's one of the fifty categories. Humanitarian and we broke it into two because it's two distinct deals; there's charitable and missionary. In the missionary dentist, that's a whole different deal. They're doing it for Jesus and they’re fixing teeth and converting and then the other one's charitable. So I'd say it's about half and half on Dentaltown; half go down there just for the charitable dentistry, income inequality, helping the underprivileged and half are doing it for religious reasons. 

All right buddy, thanks so much for coming. 

Christian: Thanks for having me. That was a blast.

Howard: It was fun for me and I learned a lot.

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