Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1023 The Future of Implant Dentistry with Randolph Resnik, DMD, MDS : Dentistry Uncensored with Howard Farran

1023 The Future of Implant Dentistry with Randolph Resnik, DMD, MDS : Dentistry Uncensored with Howard Farran

5/18/2018 8:03:57 AM   |   Comments: 0   |   Views: 429

1023 The Future of Implant Dentistry with Randolph Resnik, DMD, MDS : Dentistry Uncensored with Howard Farran

Dr. Randolph Resnik is a leading clinician, educator, researcher, and author in the field of prosthodontics and oral implantology. Dr. Resnik received his dental degree from the University of Pittsburgh School of Dental Medicine. Upon graduation from dental school, he continued his training at the University and received a specialty degree in Prosthodontics. Dr. Resnik then furthered his post-graduate education at the University of Pittsburgh by completing a fellowship in Oral Implantology, while also earning a master's degree for his research on dental implants. He has spent the last 30 years working alongside Dr. Carl Misch, serving as surgical director of the Misch International Implant Institute and Chief of Staff. During that time, Dr. Resnik established himself as one of the world's experts in dental implant radiology, while also continuing to improve educational protocols in implant dentistry through the Misch Institute. Dr. Resnik serves on faculty positions at numerous universities, including The University of Pittsburgh, Temple University, and Allegheny General Hospital in Pittsburgh, PA. 

Along with his passion for lecturing and education, Dr. Resnik is also an accomplished author, having published numerous research articles across his career. His recent textbook “Avoiding Complications in Oral Implantology” is a best seller.  He has also been a contributing author to all three editions of Contemporary Implant Dentistry and two editions of Dental Implant Prosthetics. 


VIDEO - DUwHF #1023 - Randolph Resnik

AUDIO - DUwHF #1023 - Randolph Resnik

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1023 The Future of Implant Dentistry with Randolph Resnik, DMD, MDS : Dentistry Uncensored with Howard Farran

Howard: It's just a huge, huge honor for me today to be podcast interviewing Randolph Richard Resnik, DMD, MDS. He is a leading clinician, educator,  researcher and author in the field of Prosthodontics and Oral Implantology. Dr. Resnik received his dental degree from the University of Pittsburgh School of Dental Medicine. Upon graduating from dental school, he continued his training at the University and received a specialty degree in prosthodontics. He then furthered his post-graduate education at the University of Pittsburgh by completing a fellowship in Oral Implantology while also earning a Master’s degree for his research on dental implants. He has spent the last thirty years working alongside Dr. Carl Misch, serving as surgical director of the Misch International Implant Institute and Chief of Staff. During that time, Dr. Resnik established himself as one of the world's experts in dental implant radiology, while also continuing to improve educational protocols in implant dentistry through the Misch Institute. Dr. Resnik serves on faculty positions at numerous universities, including The University of Pittsburgh, Temple, and Allegheny General Hospital in Pittsburgh. Along with his passion for lecturing and education, Dr. Resnik is also an accomplished author, having published numerous research articles across his career. His recent textbook “Avoiding Complications in Oral Implantology” is a best seller.  He has also been a contributing author to all three editions of Contemporary Implant Dentistry and two editions of Dental Implant Prosthetics.

I'll tell you what this book was so- Show me the endo book too. I'll show you the two best books I read last year. It was "Pathways of the Pulp" by Stephen Cohen. It was his eleventh edition and we had him on this show and Misch's "Avoiding Complications in Oral Implantology" by Randolph Richard Resnik and the late Carl E. Misch. What I loved about this is- Do you remember the late prosthodontist who, I think his final days were at Green Laboratory in Arkansas?

Randolph: Charlie English.

Howard: Charlie English. 

Randolph: Yes.

Howard: What I loved about this book so much was Charlie was the only one who had so much self-esteem. He says, "These guys that teach implants or veneers or bleaching, bonding, they go around the whole world with the same ten cases that they did a hundred million years ago and they're almost lecturing for their own self esteems." He said, "I'm going to show you every dental mistake I ever made. Every screw up, every lawsuit, every-" He called them dental abortions because his deal was that if you do something and it's predictably and it's repeatable and every time you do the same, he says you don't learn anything. He says you only learn when something fails because if you just do something, the same recipe every time, and it never fails, you don't even know what's going on. And that's what you guys did. You and Carl, "Avoiding Complications in Oral Implantology". My God, it's eight hundred and sixty-four pages of everything that can go wrong, could go wrong. It was like reading Beethoven. Congratulations on that. It's just a huge, huge honor that you came on the show today. How are you doing today?

Randolph: Great.

Howard: How is the Misch Institute doing now that Carl's passed on. 

Randolph: Actually, we're doing great. We just had a complications course in Miami last week. We had over a hundred for that, which is the second course we'd given this year, so it's going very well. Our surgical programs actually sold out for Orlando this year, so we're doing great. Very well. 

Howard: I was in Orlando last week for the Townie Meeting and I kept saying if I found an hour I was going to jump on an Uber and run over there and surprise visit you. I love Orlando. You like living down there instead of Pittsburgh?

Randolph: I don't live there. We just give the courses in Orlando and the other spot is Vegas now, so we give them in Orlando and Vegas and then sometimes we'll stray and do like a complications or a CT course in another city like Miami or Arizona, somewhere like that. 

Howard: So your book is available on Amazon. It only has five-star reviews. You don't even have a single four-star review. You can get it next day, you get it same day, you can buy it new and you could also buy used ones that are very good. How's that?

Randolph: Wow.

Howard: You can buy a new or used.

Randolph: (unclear 00:05:15).

Howard: So, the Misch Institute's doing well.

Randolph: Yes.

Howard: And you're selling out.

Randolph: Yes we are.

Howard: Talk about the Misch Institute. When I did it, I got my fellowship in the Misch Institute and that's when I earned my diplomat in the International Congress of Oral Implantology.

Randolph: That was back in the late nineties or…?

Howard: I actually took the course with Fred Flintstone. Back then it was seven three-day weekends at the University of Pittsburgh. What does that look like today? Is that seven three-day weekends or is it-

Randolph: About six two-day programs. So, what we-

Howard: So, I had (unclear 00:06:03) then I had to take seven three-day. Now you're doing it faster, easier, higher quality, lower price. You've really improved.

Randolph: It's funny. In the early days of the institute, we would end the institute lectures on Sunday at six PM and then people were having trouble with flights and then we started ending at one o'clock. Then we decided, "Let's try to do it in two days." and what we found was we do to nine- or ten-hour days and doctors like it more. Some leave Saturday night, some leave early Sunday morning, but now they're able to get back to their office for Monday, so it works out pretty well. 

Howard: My favorite memory of the- Well, I have so many amazing memories of the seven three-day weekends. The first was I was placing these implants and you're all scared and you're laying a little flap and you're doing all this and then you go down and watch you guys and I mean there you were doing retromolar pad to retromolar pad, placing eight implants in the lower, eight in the upper in like thirty minutes. I told everybody, I said it's kind of like you're at home with this twenty-two rifle and you're afraid of it and you're scaring, you're trying to upgrade to a twelve gauge shotgun and then you go to a war. You just go to implant war and it's just blood and guts. You were just so numb that then when you went back and you're placing your little dinky implant and in a first molar or maxillary second (unclear 00:07:40), you almost felt embarrassed. You hope no one was looking at your little- It was like going fishing and catching a minnow, and you guys were just hauling in whales all day long, so it was really, really amazing. The other high point was- You'll never guess this story, Ryan. When you go through a curriculum seven three-day weekends with the same bunch of guys and gals, it kind of turns into a fraternity party and I think it was like the fifth or six one or whatever, I heard that a Kiss concert was that night. Somehow, we all got ticket, and after the course we went and saw Kiss in Pittsburgh and that was one of the craziest funnest nights ever to go rocking out with Kiss, with about twenty dentists. That was so much fun.

So basically, 25% of everyone listening to you today right now is in dental school. The rest are all under thirty. I get like one email a week. Send me an email: Tell me how old you are, what country you live in, if you like the show, if you hate the show, who you want to hear on, whatever, and they're all gonna say the same thing. They're going to say, "Randy, I just graduated from dental school. I didn't place one implant." So, it's easy for Randy to go from placing his ten thousandth implant to ten thousand and one, but how do you coach a kid coming out of dental school to place- How do you go from zero to one? Walk them through that. 

Randolph: I'll tell you we changed the curriculum to now where we start with basically extracting the tooth, determining if it's a four- or five-walled defect, grafting it, taking a CT scan, treatment planning that area with the CT scan and then determining whether to do the surgery guided or freehand. Then we go into multiple (inaudible 00:09:41), so a multiple edentulous site and then we only go into edentulous or fully edentulous patients. So, it's changed a little bit from when you went through. Now we start with the basically the Division A patient, which means that there is abundant width of bone, abundant height in a bone, and no vital structures in the area. So basically, we take small steps and then we gradually get into the more complex cases. Now, back when you went, some people would start with the subperiosteal implant or start with eight in the maxilla or a sinus lift.

Howard: Dude, when I was doing it, there were still Ramus frames. 

Randolph: Yes, so we now take it Division A weekend, which is again abundant bone, then we go to Division B where there is a minimal amount of width and you have to build up the bone in width, so you make it Division A. So, we take small steps and it's interesting you said about the young doctors. Actually, this year we have GPR residents. They're actually taking our course and we do see younger and younger doctors coming in. Back when you went, most of the doctors were established and had large practices, but now we're seeing them right out of dental school, which is great. 

Howard: They're driving to work right now so they can't take notes or anything. We always do a transcript of every one of our podcasts and put it on Dentaltown where we posts podcasts, but I always retweet. You guys are @MischInstitute. Okay, I just retweeted 'ya. Thanks for following me at @HowardFarran. It's an honor that twenty-five thousand of you follow me. So, it's six two-day weekends. How much would six two-day weekends cost? How much would the whole kit and caboodle cost and what time period would they do? Would you recommend they do all that in a year? Would you space that out over two years? What would you recommend their journey be? 

Randolph: Okay, interesting. When you went through, everyone started at what we called S One, then went to S Two all the way up the six or seven weekends. We still have the S One, Two, Three up to basically S Six, but what we have done is we have made it to allow doctors to come in basically if they want to start at S Three, S Four. Like for instance, we'll get some specialists who will just want to come in for S Four, which is the sinus grafting weekend. Someone who's early on their learning curve is going to want to start at S One. The interesting thing is no matter where doctors start, they usually end up taking the whole curriculum, which is the six or seven courses, and we have two programs, one on the East coast, which is in Orlando, and then one on the West coast, which is in Las Vegas.

Howard: Which ones were popular with dentists? Because basically 75% of America lives east of the Mississippi River and 25% lives west. So which courses more popular and sells off faster?

Randolph: You know what? They're both very, very popular. This year in Orlando, we were sold out rather quick. We can only take about seventy doctors because of our hands-on program and it's so detailed, the laboratory programs. That sold out rather quick this year. A lot of people from the East coast like to go to Vegas. So we get a lot of people from the East coast who would rather travel to Vegas. So, to be honest, they're both very, very popular. 

Howard: Right on. Another thing that I think that's very bizarre about implantology is ClearChoice, the dental implant. Can you give me the link to ClearChoice? Are you very familiar with ClearChoice?

Randolph: Yes.

Howard: Work with them much? Everybody keeps talking about All-on-Four, All-on-Four, All-on-Four, at twenty-five thousand arch, but in my walnut brain, what I mostly see is the big money and I found huge money in this with a lot of my graduates that I went through the Misch Institute with. They would go back to their town and in their town, in the poorest part of town, was this Denture World that had been there for like forty, fifty years and they had a lab tech and they were doing upper and lower dentures for four ninety-nine and these things would be for sale for like $350,000 and nobody would want it. They'd all want to go to Beverly Hills and Scottsdale and Key Biscayne and do dentistry on lifestyles of the rich and famous, and these guys would buy that little Denture World that had a brand name and all these recurring seniors always come in to get a reline and get new dentures, and then they would go add the implant. They started upgrading and say, "That denture is upper and lower for four ninety-nine, but we have a better one that's nine ninety-nine with these really beautiful upgraded Ivoclar teeth and they're a little prettier and then for a twenty-nine ninety-nine we'll just put two little ball and sockets down there and then for- They had it all the way up to a $25,000 an arch All-on-Four and they would go in there and they would start placing a hundred implants a month and this little thing doing $350,000 a year was now a $3,000,000 to $4,000,000 business because it was kind of like adding peanut butter to chocolate. They came out with silent films in 1891 and it took forty years before one person decided to add the phonograph to it and take it from a silent movie to a movie with sound, so it took forty years to see that. And I'm telling you guys out there, don't take forty years to see that goldmine. In every major town, there's this little Denture World there and the best DSO that's got this figured out, it's actually Aspen. Aspen has a denture lab in every one of their locations. Do you know many dentists who did that in their career? 

Randolph: Definitely, and you're 100% right. You know the other thing, Howard, that when you're talking, everyone wants to do All-on-Four now and part of the complications, if you look in the textbook in this past weekend, I do a lot of lecturing on the All-on-Four technique and not giving these patients all the treatment options- I mean if you look at almost every state board now in the country, you're obligated to give every patient every option. That could be a denture, that could be a overdenture. You remember there's two overdentures, RPFour, RPFive, or it could be an FPThree, a fixed prosthesis. So, it's interesting when you say that you have a patient who's been in a denture for a long period of time. I can't tell you how many patients come in and say you start with two implants, then they upgraded to a fully implants supported overdenture, then they upgraded to a fixed prosthesis. You're 100% right. Those practices, I've seen so many people flourish with those (inaudible 00:17:51).

Howard: Ryan, can we just state in this podcast Dr. Randolph Resnik said Dr. Howard Farran was 100% right? I just want to name the whole show after that. Can you hand me that? You know my only claim to fame in dental implantology?

Randolph: What's that?

Howard: I'm the only person who ever placed an implant underwater.

Randolph: Underwater?

Howard: Yeah, I had this bottle of water on my head during the whole procedure, so I'm the only human on earth who placed an implant under water.

Randolph: I like that.

Howard: Yeah, that's my only claim to fame. You just wrote a textbook. I did an implant underwater. But back to business because when I (unclear 00:18:32) and my career was a dental degree from UNPC with an MBA for ASU and everybody talks about this All-on-Four, but how many All-on-Four cases are done- How many All-on-None cases are done every day for an All-on-Four? What do you think that ratio is?

Randolph: It's so hard. Now it's going to All-on-Three. I don't know if-

Howard: But (unclear 00:18:57) All-on-None. An All-on-None is a denture. I don't know, I don't have any stats, but I'm thinking there's a hundred dentures made for every All-on-Four done. Would you agree with that? It's a hundred to one?

Randolph: Yeah, probably.

Howard: And your journey of what you said that first, you take that All-on-None and you upgrade it to All-on-Two and then they get it, so then a couple of years later they sit there, they want to have fully All-on-Four ball and socket and then eventually they want it fixed and they want it to come out. The mind is a journey and it's not just dental health, it's mental health. At first they don't like the denture because- In fact, most people don't even complain about the chewing efficiency of the denture. It's the psychological, the mental deal. Well, what's wrong? Well, I'm afraid to laugh. I was at a party the other night. It slipped. It seems like they have more emotional trauma. I've had several ladies tell me that the reason they went to fixed with a perfectly fine denture is because they can't sleep with it in their mouth, and their husband has never seen them without their teeth out, and then the sadness one I ever did- And when she told me this, I literally almost had to take a knee and cry. You know what she told me? She's like eighty years old and she had a perfectly fine denture, but she couldn't sleep with them in. She told me that her friends, her three best buddies now have all died and they all died in their sleep and she didn't want the paramedics to come into a room and find her dead in her bed without her teeth. And this lady got — back in the day it was six implants on lower and upper — so I did six implants so that some hillbilly paramedic doesn't find her without her teeth. I mean, I'm a man. If you found me dead on bed, you fully have permission to throw me in the Arkansas River and feed me to the turtles. I don't believe in putting yourself in an aluminum casket or anything — that's pollution. I don't think it's fair to cremate someone and just turn me into heat radiation. I liked the recycle thing. I tell my boys, "Dig a hole six feet, throw my ass in there, populate it with a couple of maggots and I'm done." But I couldn't believe she was paying me all that money so that no one would find her dead in her bed without her teeth. So, it's All-on-None. When you upgrade that to All-on-Two what type of implant would you do? Would that be ball and socket?

Randolph: The most popular now is locators or O-ring type of attachments. When you went through, we did a lot of O-rings back then, which is great attachment.

Howard: And what brands?

Randolph: Either BioHorizons, now we're using the horn implant from Glidewell.

Howard: That's what I love about Jim Glidewell. You know who Jim Glidewell reminds me of?

Randolph: Who's that?

Howard: When he got out of school, I went down the Pankey Institute and they're telling me how there's A patients, B patients, C patients and you want to just hang out with them and they were describing how you want to just network with the A patients. When he described the A, B, C, D, I raised my hand and said the entire Farran family out of Parsons, Kansas, we're all D patients. I'm not that dentist. I didn't go to Scottsdale. I went to Phoenix. I want the D patients, and what I loved about Herb Kelleher- And all the dentists, they always throw Glidewell under a bus. It was like they'd make fun of you have used Glidewell and then they'd recommend these labs that are like three hundred and fifty a unit and then I watch Herb Kelleher go out there and focus on costs. The only secret to lower prices is lower costs, and he focused on cost so much that he gave so many Americans the freedom to afford to fly, to go to their grandchildren's baptism or a bar mitzvah or birthday or whatever. And Jim Glidewell, good Irishman, he just squeezed every single cost he could out of there, and the quality I think is amazing and he's given so many Americans the freedom to fix their teeth. My Dad always told me, you have one eye on your customer and you have one eye on cost and you use your God-given talent to drive down costs so your customers can afford to buy what you have. I took big notice when Jim Glidewell latched onto that Jack Hahn system. Talk about Jack Hahn and Glidewell.

Randolph: Yeah, Howard, we had a problem probably starting about ten years ago where we started seeing doctors coming through our program, they would pay for this whole curriculum and then to outfit their office to serve cheaply-placed implants. It was cost prohibitive. By the time they got a motor system, stock their office with implants, it was very, very costly. A lot of these doctors are associates and it wasn't working out too well. Jack Hahn, who's an amazing individual, one of Carl's closest friends-

Howard: Out of Ohio?

Randolph: Yes, out of Cincinnati. Took the replace implant which he designed over at Nobel Biocare, and he took it over to Glidewell, made it platform switching and then they made it so ideal for the starting practitioner, cost-wise, it was perfect. So our doctors now can get a motor, they can get thirty-five implants, they can get a surgery kit (unclear 00:24:51) steady kit for $6,000. Ten years ago the motor that they were buying was $6,000. So now, these doctors can get in at a very low fee and then they send the case to Glidewell for the prosthetics and Glidewell's already very inexpensive, but they give them 20% off on that. So it was a win-win situation. It's a great implant and it's a great company to work for. If you look at any of the R&D now on lab materials, they have a monopoly on it. I mean monolithic zirconia, they developed it. Most labs by their lab supplies from Glidewell now.

Howard: I'll tell you a Glidewell story that'll blow your mind. So when I first went to China, labs are very labor-intensive and you went to these big labs like Modern Dental, they'd have like four thousand techs and every hour a UPS truck would come up, and I noticed that all these crowns were from all these little small labs from around the United States, who were telling their doctors, "I'm making everything," and they were probably making some, but they were packing up the majority and sending them in China. I talked to a lot of them and a lot of them said, "Dude, look, I've had an ad in the paper for a model trimmer, (unclear 00:26:11) trimmer, porcelain (unclear 00:26:12) that dental schools quit teaching lab techs. Imagine if all the dental schools quit teaching hygiene. Where would you have a hygienist?" So, all the dental schools closed down their certified dental laboratory deals. There is no labor, so they're all sending them to China. Fast forward ten years, the CAD/CAM, the digital making at Glidewell. You go back ten years now, it was silly. The labs are sending it to China and for China it was cheaper to ship them back to Glidewell. And this is what Jim told me. He said, "When I started, I would hire five people and it would take me a year to bring them up to speed to pour up a model, trim a (unclear 00:26:59), wax a coating, cast it, put it on, stack the porcelain, and after about a year's training, they could do five a day. Now with CAD/CAM, I can hire five people on Monday and by Friday they're completely trained and they can make fifty a day, so it didn't matter that China had low-cost labor. These people were making five a day. Now Jim, they can take that same person and make fifty a day. So now crowns are going from labs in America to China and then they're being shipped back to Jim and then Jim ships them back to China. Then China sends them back to the lab.

I mean it's just a crazy world, but you tell Jack Hahn he's missing the obvious. He's from Cincinnati. He's got that $6,000 kit, a motor, thirty-five implants. He's in Cincinnati, the Rock and Roll Hall of Fame. He should throw in two tickets to the yearly Rock and Roll Hall of Fame, which will be on HBO May 8th. It's my favorite show of the year. They always have the Rock and Roll Hall of Fame. HBO doesn't carry it live, but that is my favorite show every year from HBO, the Rock and Roll Hall of Fame. Tell Jack if he threw in two tickets to the Rock and Roll Hall of Fame, he would increase the sales a gazillion percent.

Randolph: I will do that.

Howard: And tell Jack to come on the show. I would like to hear that story. So, the Hahn system and the BioHorizons system out of Alabama would have the two locators are the O-rings. You like locators now and not O-rings? 

Randolph: Yeah, I mean either one. I think O-rings are still easier to use, but the profession really has gone towards locators as the number one attachment.

Howard: And then you say they start with two and then after a while, how long does it usually take do you think before grandma and grandpa upgrade to four locators? 

Randolph: The way that we teach this is we place implants in particular areas for a reason, so like in the mandible, between the foramens, we divide it up into A, B, C, D, E — five positions. Usually like for two implants, we'll do the B and D positions. Then it might be a year. I've had them six months later come back and say, "This is great, but I don't want it to come out." So all that we do is go back and because we put them in the B and D positions, now we put them in A, C, E, and now it's five implants and-

Howard: And the A, B, C, D, E is all anterior to the mental foramen?

Randolph: Yes.

Howard: And how forward to the mental foramen do you like that to be to miss the mental foramen of the anterior loop?

Randolph: What we do is we started our first (unclear 00:29:57) A on the right side, E on the left, five millimeters from the most anterior part of the mental foramen. That will allow a two millimeter safety zone for four or four and a half millimeter implant, so we always want to be two millimeters away to determine if there's an anterior loop. What we'll do is look on the CT scan and look in the axial plane. It's a step-by-step in the textbook on how to do that. The anterior loops, most are less than a millimeter, but there can be some up to six millimeters if you have to be very careful. 

Howard: Is doing this with a CBCT, do you think... America has one million attorneys. If you hit that anterior loop on and you had a (unclear 00:30:47 pano), is CBCT the standard legal standard of care do you think? 

Randolph: Carl and I used to go back and forth on this and back when we were residents, Carl and I were residents together in (unclear 00:31:02) and he selected a different Master’s topic with force-related biomechanic issues, and he thought I should do the same. I'd picked CT scans and that was back in the late 1980s. I'll never forget, there was a MD radiologist on my committee and he turned to me and he said “CTs will never come into dentistry. They're too expensive, too much radiation, this and that.” Now, when we have a course, I'll ask our course attendees, how many people have CT scans? I'm going to say 85% have CT scans. So your question was, has it become standard of care? Carl never thought it would, but I have to say I do believe it has become standard of care. If you look at some of the studies on nerve impairments, here's one (inaudible 00:32:00) nerve impairments, a CT scan was not used. A couple of other studies show about 50% in nerve impairment cases had inadequate radiographic assessments. So it is basically become standard of care. 

Howard: And what CT scan- Do you have any favorites? 

Randolph: Yes. So, Carl and I both, when he was practicing, it was an i-CAT and I have an i-CAT also. i-CAT's top of the line. 

Howard: The bottom line is whenever you meet someone who's placed five thousand implants or more, they always got i-CAT. It's like they kind of own the oral surgeons, the super producer, the super implant user, oral surgeons and periodontists always have i-CAT's. Why is that? 

Randolph: It's just the best CBCT unit for many, many reasons. Number one, you can collimate it so you don't have to take a full field of view on a patient if you're doing a sinus graft and you just want to look at it post-operatively, or if you're looking at a number nineteen edentulous site so you can call collimate it to decrease the field of view. Two, it is very, very accurate. It's one-to-one. A lot of the generic CBCT units now in the market, you have to be very, very careful. They have a smaller sensor size, but then they'll take a larger picture, so it'll actually take it on more of an angle. Where i-CAT is definitely one-to-one, meaning whatever you measure on the image, you're gonna see clinically. 

Howard: Who were the superheroes and already had X-ray vision because you wouldn't need an i-CAT if you could actually hire- Who was it? Was it Superman? Who had an X-ray vision, Ryan? It was Superman? So unless you're Superman with X-ray vision, you're recommending a CBCT and you'd recommend iTero.

Randolph: i-CAT.

Howard: I mean, i-CAT. iTero was bought by Align who owns Invisalign. So you like i-CAT and how much are those costing today? 

Randolph: I believe they go anywhere from about maybe eighty-five thousand all the way up to a full field of view, which is probably about a hundred and forty-thousand.

Howard: They're not trying very hard to sell. I noticed their last twitter tweet was September 14th last year. You can follow them at @iCAT Three D. So you should call your buddies at i-CAT and say, "Dude, you should send out more than one tweet every six months," if they want to sell, but they're selling on word-of-mouth. 

Randolph: Yeah, believe it or not, their biggest sales are to orthodontists now. The i-CAT has a full field of view, so it's perfect for orthodontics. The amount of radiation is very, very low. So, it's a perfect scenario for an orthodontist. 

Howard: So for the CBCT, you like i-CAT, for the implants, you like Glidewell's Jack Hahn system, Alabama's BioHorizons, which by the way, when you go down there, I mean Alabama, that area, they made the solid rocket fuel boosters for the shuttle. It's like a miniature Silicon Valley up there in Alabama, isn't it?

Randolph: Wow, I haven't been there in a while.

Howard: My God, you think of Alabama, you just think, "Oh, just country. It's a country state or whatever." Oh my God, it's so high-tech. I'm again trying to hold your feet to the fire for the young kids under thirty, trying to go from zero to one. Another big confusing thing they did is they never got to place the implant in dental school. Ryan and I had dinner the other night with two recent grads from dental school. One had graduated in four hundred thousand debt and never did one root canal and the other person did one. Can you imagine that? I did fifteen root canals in dental school. Can you imagine paying $400,000 to become a dentist and he didn't even get to do a root canal? So obviously they haven't placed implant, but in their lectures they're just told over and over and over about the health history. They can't be smokers, they can't be alcoholics, drinkers, diabetics. Your yoga instructor usually isn't the one that needs implants. When they come into my office from Phoenix losing their teeth, they're usually drunk, Irish, smoking, drinking, probably their last vegetable was Beanie Weenies. So, how do you start doing all these implant cases when the people that are most likely to lose all their teeth in a patchy junction up street- It's from meth. You didn't meet that patient at lifetime fitness. So review the health history because everybody in her town that needs an implant isn't going to pass the health history.

Randolph: If you look at the complications book, I wrote that chapter with my brother who's an internist and what we looked at is basically all the systemic diseases and a lot of the medications that affect implants. What people don't realize is every disorder- Let's say diabetes. Diabetes can be no contraindication at all, or it could be an absolute contraindication. If they have A One C of ten, you certainly don't want to be putting an implant in them, but if they're diet-controlled diabetic, there's no problem at all. So what you have to do is you look at any positive findings on the medical history, but then ask the question, "Do you smoke? How much do you smoke? How much do you drink? How much do you drink per day?"

Howard: I told you they were Irish! They smoke and drink every day. 

Randolph: Yeah, so smoking and drinking is not an absolute contraindication in most cases. In a lot, they are. Part of our complications course that we just gave this past weekend in Miami, we have Frank DeLuca who's a dentist and an attorney and he comes in and he talks about the medical history, how important it is. You'd be surprised how many people get the medical history taken, but they don't even look at it or ask the patient any further questions, which is very problematic. 

Howard: So another thing that scares them is again, who are these people that are losing all these teeth? A lot of them had periodontal disease, and then these kids are reading that after five years, 20% of implants have peri-implantitis and there are some studies that are showing that at nine to fourteen years, over half of the implants have peri-implantitis. What's your thoughts on peri-implantitis?

Randolph: Well, peri-implantitis is definitely an issue. If you look at the etiology of it, basically the same bacteria that causes periodontal disease in natural teeth cause peri-implantitis with implants. Therefore, you have to be very, very careful, even placing implants in someone with active periodontal disease, but a lot of the peri-implantitis is caused from implant positioning or treatment planning. If you don't put the implant in the right position, if you put it the wrong angle, the prosthesis has to be compromised and then the patient can't clean it, etcetera, etcetera, and then you end up with peri-implantitis. But it is a problem. Treatment planning is huge in implantology and unfortunately dental students don't get that, and that's why our course is so popular because everything is about treatment planning to prevent you from getting into trouble. So when you look at that complications book, the reason why we wrote that is for doctors to understand how to avoid getting into that complication. It's a lot easier to avoid it, than to get into the complication and not know how to get out of it. 

Howard: Some of them are hearing that a great way to treat peri-implantitis is buying a $85,000 millennium dental laser who started off with LANAP protocol — laser assisted new attachment procedure — and now they have an implant protocol. Do you think that that's worth the investment at $84,000 to treat peri-implantitis with a laser? 

Randolph: To be honest with you, I don't have a lot of experience with the laser. Studies are kind of all over the place on that and I'm more the conventional flap it if it needs it, detoxify the implant. I really don't have a lot of experience with the LANAP or anything like that. 

Howard: Oh, and Ryan want to know on that health history- I don't know why he keeps asking me. He wanted to know on that health history if erectile dysfunction was contraindication for implants. He says he's asking for a friend. So what's your answer to Ryan? Is ED an issue?

Randolph: I think you should answer that one.

Howard: We'll talk after the show, buddy, we'll talk after the show. There's also people on the circuit today saying that this medical-grade titanium really isn't all that medical-grade, that it's heavy metal, there's a lot of titanium ions, it's causing inflammation and that they're seeing less peri-implantitis with ceramic dental implants, and you see some of the major companies like Straumann buying a ceramic implant companies. Do you think ceramic implants are going to have less peri-implantitis than titanium? 

Randolph: The interesting thing about titanium implants, back when you went through the institute, we would always talk about commercially pure titanium, which most of the implants were back then. You'd never have a reaction to those. There wouldn't be any tissue, it was a biocompatible — the ideal material. And then they made six four titanium, and in dentistry you're starting to see a lot of articles, case studies, starting to pop up about allergies. I have a couple in the textbook that where implant's been placed, hypersensitivity reaction until they're removed that doesn't resolve itself. So there is definitely, I think in the future, a role for ceramic implants. The problem is right now, the question is the longevity of the implants and the fracture problem that they do have. Not only the implant, but the fracture, the abutment that goes into the implant.

Howard: There's just a few a world-class dental implant companies, but one of the biggest ones in the world is Zimmer Biomet and I read the wall street journal that they've retained Bank of America and Merrill Lynch and they want to spin off Zimmer Biomet Dental, they want to sell it away. Why do you think one of the biggest implant company- I mean they make hips, knees… Most of the dental implant companies, they just make dental implants. Zimmer makes every prosthetic component that could be implanted in the human body, so why do you think they would be spinning that off? 

Randolph: I have no idea, but implants, if you look at the projections on implantology, it's been one of the fastest growing areas in medicine and it's shown to become continually a growing business. If you look at exposure in different countries, the United States, they're still about 15% of patients who need dental implants had been treated with dental implants, and then you look at a country like Israel where it's almost 50% had been treated. It's a treatment plan that has not been 100% accepted yet, but I believe in the younger dentist coming out. They're going to have no choice but to get involved with dental implants. 

Howard: I love the Wall Street boys the most because they don't have any emotional dogs in this game. They just read the numbers and whenever they're talking about implants or like Invisalign, Align Tech that owns Invisalign, they just say the number of people that will eventually get Invisalign. That market is just growing so fast. When we were little, you had to have a malocclusion so bad that your mom didn't think you'd ever get married. Back then I think in 1945, the average American family had over five and a half kids. Now it's down to basically under two but now they're coming in to get Invisalign just because they got this little crooked thing right here, and same thing with implants. The implant placement rate in Israel, South Korea, in Germany, not only is it several times higher in the United States, but what's also the most mind-blowing is that in South Korea and Germany and Israel, three out of every four dentists surgically placed an implant last month and America is light years from that. Why do you think in South Korea and Germany and Israel, three out of four general dentists placed an implant last month and in America we're not- What do you think it is in America? Out of a hundred and twenty-five thousand- So two hundred and eleven Americans have an active license for practice dentistry, a hundred and fifty thousand are general dentists, thirty-two hours a week or more, thirty thousand are specialists, thirty-two hours a week or more. Of those hundred and twenty-five thousand dentists, thirty-two hours a week or more, what percent of them do you think placed an implant last month? 

Randolph: If you look at the statistics, 1999, there was a study that showed 7% of general dentists surgically placed an implant. In 2015, which is the last study that I have seen, it's around 15%, 

Howard: 15%. When I'm talking Germany, South Korea and Israel, I'm talking three out of four placements last month, not every placement in their lifetime. I mean placed one last month. 

Randolph: Exactly, so if you look at the statistics in Europe, 90% of dental implants replaced by general dentists.

Howard: Say that again.

Randolph: About 90% of implants are placed by general dentists in Europe. So if you look at the United States, implants have been specialty-driven for many years. You know the early days of the institute were mainly specialists taking it. Now, it's almost 100% of our attendees are general dentists, so I think that's gonna change dramatically with the costs coming down, with the easiness of placing implants, and the education out there. I believe that the general dentists are going to be doing a lot more of the implants, and definitely taking over the specialty there. 

Howard: The other thing, these young kids coming out of school and I really feel they're misguided when they say they want to go to Beverly Hills and Scottsdale and Key Biscayne and be a cosmetic dentist and get into bleaching, bonding veneers, and I'm like, "Dude, the people that make the most money are oral surgeons extracting teeth and placing the implants at $411,000 a year on average, I know several that take home $800,000 a year more. And next up the bat is these endodontists at $374,000 a year doing molar root canals." And what's neat about that is you have to sell veneers and you got to have the look. If you notice all the people crushing it, selling boob jobs and tummy tucks, they look like Bill Dorfman who is a TV star. They're sexy and they've got a six-pack and all that stuff and it's part of the pizzazz, and then you show me some guy that looks like Fred Flintstone after he fell off the beer wagon and he thinks he's going to do that in Salina, Kansas and I'm like, "Dude, it's not going to happen," but all those people are going to come in with pain and want those wisdom teeth extracted. They're going to want them replaced with implants and they come in with a toothache and you do the root canal and I say you gotta get into oral surgery. You got to extract teeth, place implants, do root canals.

If you can do oral surgery and endo, you're gonna pay back your student loans and you're going to do fine. And they say to me, "I don't like molar endo." And it's like, "Dude, you should've thought of that before you walked out of dental school $400,000 debt." I mean, if you didn't like root canals, you should've been an electrical engineer and worked at Intel, but you're a doctor and they're coming in in pain and imagine if you went to the hospital and you said, "I broke my leg," and the hospital said, "We don't do legs. We just do arms." Say what? You're a doctor. They've got a toothache — fix it. Either pull the damn thing, do a root canal and if you'll pull it, maybe you'll replace an implant, but that's where all the serious money is. And if you don't like surgery and blood and guts, well for one you shouldn't have become a doctor. I mean, what do you think? I was intel inside? What do you think? You cut me open and find some Intel pentium chips? We're filled with blood, goo, fecal matter, that's doctor stuff. This is Dentistry Uncensored, so I want to throw you under a bus right now and get you into all kinds of trouble. You know how no one agrees with their parents. Everybody thinks their grandparents are crazy, I'm normal. Like my grandparents. My parents are batshit crazy and so are my children. I'm the only normal one at a friend, family reunion. But the older guys, almost everyone that's placed five to ten thousand implants in their life does them all freehand, and then all the millennials say, "Oh on, you got to have a surgical guide," and it's like, how many of you placed? And they're like, "I placed thirteen." So, a lot of the older guys tell these kids- It's like training wheels. If you got to be a surgeon, you need to learn how to lay a flap, look at the ridge, treat complications, throw them damn trading wheels away and start doing it freehand. But it's a huge debate and it's a huge controversy to surgical guide or not to surgical guide. In fact, I'm willing to say I'm willing to bet your first ten thousand implants weren't done with a surgical guide. 

Randolph: Oh, not at all, and we even teach doctors not to use the surgery guide because you develop skills by doing it freehand. Now, some cases you definitely do need a surgical guide or it would be better, but not every case. If you looked at some of the studies, Howard, I mean 38% of implants are pushed to the buckle with a surgical guide when it's done flap-less. So now what we see is doctors want to do a surgery guide, they want to do it flap-less and that's not the best way to do it. Definitely early on your learning curve, you need to be able to open that tissue up, look at the bone, look at the angulation, and that's where you develop your skill sets. 

Howard: I gotta go back. You used the term- I always circle words that you use that I know some kid in dental school doesn't know what that means. Do you use the term platform switching? Can you go back and explain to that kid what platform switching is? You said that at Jack Hahn and he started the replace implant with Nobel Biocare and it had platform switching. So explain platform switching. 

Randolph: If you look at the latest studies, now the best type of implant is going to be a tapered implant; Jack was far ahead of the game on that, so he had that. And then secondly, platform switching, which means the neck of the implant is narrower than the body. Normally when you place an abutment or the post on the implant, it will be the same diameters as the implant body. For instance, if you have a four millimeter implant, you have a four millimeter abutment that goes onto that. What platform switching does is it has a smaller abutment, so basically the connection is not at the same level as the implant and abutment connection. So the theory being when you have the same size abutment, same size implant body, you have a micro gap there that harbors bacteria and that can cause peri-implant issues. We're platform switching because the connection is away from the top part of the implant, less bacteria is there also, you get a better seal, thus less peri-implant disease with those types of implants. 

Howard: And talking more about peri-implantitis, how come these kids can buy implant prosthetics cement with an ADA seal of approval, yet if there any excess flesh on it, it's toxic and can cause a peri-implantitis? How do you actually make a dental implant cement when actually excess is toxic. and then that brings up the bigger question: to cement or screw? Are you a cementer or a screwer? 

Randolph: A screwer now. Actually, the profession is really getting away from cement. I know that's a lot different than when you went through the program, and mean we cemented almost everything in the past, but now the progression is definitely going to screw-retained. The problem with cement is you have to be very, very careful. You can get the cement down in the area and it's very difficult to see. People say, "Well, take an X-ray," but you can't see it on the buccal or lingual and only on a part of the mesial and distal, you'd be able to see it. Wilson's study showed that 80% of peri-implant disease was caused from a retained cement, so it is definitely a problem out there.

Howard: Another one is- This is very confusing. So, you extract the tooth and they just want to extract it for now, but the doctor's thinking, "I'm going to bone graft this." The question remains- Number one, the bone grafting, that stuff's more per gram than cocaine or heroin according to Ryan/ There's cheaper ones, so it's very expensive but the other question is how long does it last? Because some people are saying if you bone graft that extraction site and they don't get an implant for a year or two, you're wasting your time. So talk about those questions. 

Randolph: Well Howard, the way that we teach this is the number of walls that are remaining. So if you have a five-wall defect, basically you have the buccal plate in all the walls after the extraction meaning you take out the tooth cleanly, you have all the walls surrounding that defect and a lot of times no bone graft material will do just as well as putting bone graft material in. Secondly, you have to determIne what type of bone graft to put in. There are so many different types of bone graft material. That's why I just wrote an article in the Glidewell magazine listing all the bone graft materials because everyone is so confused on what you should use. Do you use a xenograft, do you use an allograft, do you use an alloplast or an autograft? So you have to determine. Ideally you don't want a bone graft material that's going to resorb too fast and you don't want one that's going to resorb too slow. So the bone graft material that we advocate now is a Cortico-Cancellous mineralized allograft with about two hundred and fifty to a thousand micron pore size. That is about the best material that you can do now for a bone grafted socket. However you have to take into consideration a lot of extractions, we'll remove the buckle plate. When you remove the buccal plate, now you have a huge problem and you have to place a longer acting membrane in there because you have to build that whole buccal plate backup prior to the implant being placed so that a four-wall defect- And we have a recipe for that with a longer acting collagen membrane that we place along with that bone graft material. 

Howard: So, we have an autograph for one part of the body to another, like a trunk or an arm. We have an isograft between genetically-identical individuals, a monozygotic twin, or within an inbred strain. When they say inbred strain, because that just mean my family in Kansas or is that- Allograft, between different members of the same species and then a xenograft between members of different species, like a monkey. What's the highest quality, lowest cost?

Randolph: First lowest cost would be an autograft. The advantage of autograft is it heals by osteogenesis, osteoinduction and osteoconduction. That is the ideal bone graft material. However, a lot of times it's difficult to obtain, so you usually have to go to a second surgery site. 

Howard: What about Megagen new pulverizer where you take the extracted tooth and you- Have you seen that?

Randolph: Yes.

Howard: When you take the extract teeth, you put it in, it looks like a garbage disposal, then just purifies it to mush. What do you think about that? 

Randolph: The dentin grinder, again, I don't have a lot of experience with that, but my question would be, number one, you can't use it with a tooth that's been root canaled or has large restorations, anything like that, or that's been infected. My question is you grind this dentin up and you put in the socket, how long does it actually take to resorb? The goal is for you to get new bone growth in there. So that means that dentin needs to be resorbed in new bone, needs to be formed in the place. And the studies I just don’t think are out there yet to 100% support that. 

Howard: Do you think they stole that idea from the last scene in the movie Fargo, where she put her husband in the wood chipper?

Randolph: Yeah, that's what it looks like.

Howard: I told them when they came out with it, they should call it the Fargo machine, and then have that picture- Was it a man or a woman with the legs sticking out? Do you remember that scene?

Ryan: It was Steve Buscemi's character.

Howard: Steve Buscemi was in the wood chipper? Oh yeah, that was the greatest. That's one of the greatest scenes of one of the greatest movies of all time with his legs sticking out of the wood chipper. When I saw that thing I just said you should call this the Megagen Fargo wood chipper. The other question is how long do you think those last? 

Randolph: Well, there's a lot of factors and generically people like to say, "This is the best material," but it depends on the actual situation. You mentioned allograft. Allograft is probably the most utilized bone graft material now that's basically cadaver bone and there's mineralized and demineralized. Most people now use mineralized but still xenograft, which usually comes from another animal, some people still like that and some people still use alloplast so it's all over the place. Like I said, that's why I wrote that article to kind of go over the advantages and disadvantages of each one because it is so complex. At the Misch Institute, what we do is we come up with a recipe and a protocol for each situation. So depending on the location of the graph, depending on how many walls, depending on blood supply, things like that, we will differ on a recipe for the bone graft materials. 

Howard: Again, it's Dentistry Uncensored. I'm trying to get you in trouble. You're not going to be able to make everyone happy. There are some famous people out there that swear that with bone grafting, everything, you gotta draw bloods, you got to centrifuge it, you've got to get these platelet-rich plasma involved, and then there are other people that say that that's just voodoo, that, there's no studies that say that that's even worth your time. So, PRP to draw blood, centrifuge, is that going to increase my implant success rate? 

Randolph: I'll tell you what, Howard, we've been teaching platelet-rich plasma or what is now called platelet-rich fibrin for over fifteen years. In fact, our third course, we teach doctors how to draw blood, spin it down, and how to utilize it. I believe there is definitely benefits with that. What I've seen clinically myself is better soft tissue healing with that, but people take it to the nth degree. They will be spinning down their blood and they'll put it into an extraction socket and they'll think that's going to grow bone, but if you think about it, how long does PRP or PRF stay around? It's usually a week or two, so it might help with the initial healing, maintaining the blood clot there, but to just put that into an extraction site or some people advocate just putting it into the sinus with no bone graft material and it magically regenerates new bone, I think that is kind of far fetched. But we use it as a membrane. We also use it to add into our allograft bone graft material because studies do show it does help with healing and you get better quality of bone. 

Howard: Man, we're already seventeen minutes into overtime. Are you still okay? I still haven't finished so many questions.

Randolph: I'm good.

Howard: You're still good? Thank you so much for- So, should we just all quit ever saying platelet-rich plasma and PRPand just only use the terminology platelet-rich fibrin and PRF?

Randolph: Yeah, PRF, number one, it's easier, the technique. Basically you just draw the blood. You don't need any anticoagulants or coagulants to utilize for the final product. Basically all you do is draw blood and spin it and it has three layers. You take the center layer which is the PRF layer, and then we modify it to use as a membrane and to use in our bone graft material. So yeah, I definitely think there is a place for it. Does it need to be done on every case? No. If you have a five-wall defect for an extraction site, there's certainly no reason you need that. However, if you're trying to build a large area bone, regenerate new bone, it probably is a good idea to do it.

Howard: It sounds like officially that you might be a vampire. Do you only place implants in the dark? That's my next question. 

Randolph: No, no.

Howard: By the way, do you know why they spell dark with the letter 'K' and not the letter 'C'?

Randolph: No.

Howard: Because you can't 'C' in the dark.

Randolph: Oh, I like that.

Howard: You like that? Is that a dad joke or is that a grandpa joe? That's beyond a dad joke? Okay, again, I'm trying to get you in trouble. I never want to talk about anything everyone agrees on. I want to talk about what everyone disagrees on, and this next one's a very emotional deal because I'm talking to a dentist and everybody listening to you right now is a dentist. Imagine that everybody listening is a Christian and then I'm going to say something like, "No, you should be a Hindu or a Buddhist or Confucianist. So, I got buddies in town, in Phoenix that are rhinologist. They don't like you guys doing these sinus lifts. They don't like it. They're like, "Dude, you had a (unclear 01:07:13) and a second (unclear 01:07:16) and a second molar. You had two rock sticking out, file down the (unclear 01:07:19) and do a bridge," because they're saying that there's Americans coming into their practice often that thought they had allergies for twenty years. Turns out it's a slowly leaking, failing root canal and they go up there and that whole sinus is covered with white candidiasis and fungi and this person has had a checkup at the dentist every six months for twenty years, and they extract that tooth and the lady's like, "Are you kidding me? That was all from a tooth?" And they're seeing the same thing with sinus lifts. They're saying they have people come in there and there's some implants sticking into the sinus, the whole thing's going crazy. In fact, Ryan, we've got to email Jason (unclear 01:08:03) to get that buddy- I've been on him to make a (unclear 01:08:06) to make us an online CE course. So, here's the deal. Dentists worship at the altar of enamel and there, they think tooth is sacred and they don't want to file down any enamel, but shit, they'll throw a hand grenade in the sinus and pack it with  dead cow bones and paper clips and hormones and all this stuff like that. And the ENT's are the opposite. Their god is sinus. They're saying, "Dude, stay out of my sinus and drill down those damn teeth." So you have no respect for the sinus and the ENT's have no respect for the enamel. Which one's right? Also wasn't that a big reason All-on-Four got so popular because you could stick two implants behind the sinuses, two in the front, and one of the popular things about the All-on-Four is you don't need any sinus lifts.

Randolph: Yes, so Howard, one of the most predictable areas to grow bone is maxillary sinus. It's very, very predictable. Why you see problems and I've probably read the ENT literature more than the dental literature, because my area of interest is the sinus. I do a ton on pharmacology. I do a ton on pathology. If you look at the textbook, there's probably thirty pages on maxillary sinus pathology. The problem is — and we spend almost the day on it at the institute — that a lot of dentists violate the maxillary sinus without determining if there is a pathology in it. I've done probably three studies with residents at the University of Temple perio department, and about 40% of patients who are asymptomatic have pathology in their sinus. My studies almost eighteen years. Now about 39% have some type of pathology. So there is a disregard for determining if there is pathology.

Secondly, you must determine if the ostium, which is the opening, which everything flows out of the maxillary sinus, is (unclear 01:10:28), meaning is it open or not. People always asked me, "How far can you stick an implant into the sinus without it causing a problem?" You can stick an implant ten millimeters in the sinus (inaudible 01:10:42) most likely have a problem. However, if you have pathology there, you bump up that membrane a half a millimeter and you're going to change that whole physiology of the sinus and the problem is, and why the ENT's get upset is, the paranasal sinus is the ethmoid. The frontal sinus in the maxillary sinus are all interconnected into what we call the ostiomeatal complex. So if you just push in implant a half millimeter into the sinus and you cause a maxillary rhinosinusitis, that secondarily affects the ethmoid and or the frontal sinus. So that's why they're uptight about what is happening.

Now, on a second point, you talked about a tooth that was causing problems in the sinus. What is interesting in (inaudible 01:11:35) is fifteen years ago, it was always thought that odontogenic origin of rhinosinusitis was about 10%. The latest studies are showing about 40% of chronic rhinosinusitis as an odontogenic origin. So what does that mean for the young dentist coming out? When you see a patient, you get a CT scan and you have to learn what his sinus pathology and what's not and be able to evaluate if a tooth is causing that infection. The maxillary molar, Howard, you're looking at over 40% of the mesial, buccal or the lingual cusp is in the sinus, in the first molar region. So, that's pretty significant to cause some type of sinus pathology.

Howard: I told you a really bad dad joke that there's no 'C' in the dark. I want you to put your dad hat. She graduated from dental school last May, she's working for a DSO and she's looking at this molar. It's a failing root canal. How does your amazing mind work about sending that to a endodontist and do a retreat or just treat that damn thing with forceps and do an implant? What are you thinking when you're grasping with that issue? 

Randolph: Now I look at the costs involved and the long term prognosis. We always look at the tooth. How is the five-year prognosis? If the looks of that tooth means that in five years that tooth is most likely not going to be there, we take that out because it is definitely more predictable to put an implant in a freshly healed site with no pathology. Doing an apico, the studies are all over the place. The funny thing is, Howard, you wouldn't believe how many endodontists we're getting now. We had three endodontists at our complication course. 

Howard: Well, you know why I think all the endodontists should do it? You know why I seriously do?

Randolph: Why?

Howard: First of all, these dentists think they can't sell an implant case. The average price of a new car in America is thirty-three thousand five hundred according to Kelley Blue Book. The average American will buy twelve new cars in their lifetime. So, if the average new car is thirty-three thousand five hundred, what percent of the dentists in America- There's a hundred and twenty-five thousand general dentists in America. Last year, what percent did not sell one single case that was worth thirty-three thousand five hundred. What percent?

Randolph: Oh, I have no idea.

Howard: 95%. And when anybody tells me there's no money in Toledo- That's why (unclear 01:14:32) dresses up like a girl. There's just no money there. And it's like, "Really? Well, the average person in Toledo will buy thirteen cars in their lifetime for thirty-three thousand five hundred, and you never sold one $33,500 case in your whole life?" We were talking about the endodontists in your program. The reason the average American buys thirteen cars their lifetime- Because you know the average woman lives to be just about eighty, average male, seventy-four. Men die six years earlier than women because we're married and want to die, so you buy your first car at sixteen, you're buying them till you're eighty. They're financed at five years. You're never going to sell an implant case if you go in there and say, "Give me $33,500." You've got to go in there and say, "Hey, my God, Randolph, you've got great credit. You've been approved. Your payment will be-" and thirty-three thousand five hundred without interest divided by sixty months, you're looking at $550 a month. That's how all the big boys sell their stuff.

So I go back to those endodontists. I say, "Dude, when you buy a car for five years, the reason that banks will finance the five years is because the damn car last five years," and I sent you a failed root canal and you took $1,500 from grandma and six months later we pulled it. Now you're going to give her fifteen hundred back?" "Well, I did the best I could?" Bullshit. It's the only way you can feed your family. So you get eight people a day and you know that tooth, that retreat's not going to work. You know that tooth's dry and brittle, you know she's eighty years old, but you do it anyway because if your only tool is a hammer, everything looks like a nail. So I tell them this. I say you either warranty the damn retreat for five years or you learn how to place implants and I know that you looked at this because the only thing every major religion has in common- My oldest sister's a cloistered Carmelite Monk for thirty-five years. The other one's a Michael Harner (unclear 01:16:32), but my oldest sister speaks multiple languages, has read every major book from Hinduism, Buddhism, Confucius, Christianity, Islam, Judaism… She said there's not a person, place or thing that's in all these major religion except for one thing — the golden rule. Clear as a bell, treat other people as you want to be treated. All the rest is commentary. All the rest is noise. Just treat other people like you want to be treated. Well, that endodontist is looking at that failed root canal and he thinks, "I could do a retreat or an apico or whatever, or I can pull it and do an implant. They're both fifteen hundred bucks. I think I'm going to go there." I trust that. What I don't trust is an endodontist who can't place the implant and doesn't warranty his work. 

So either start placing titanium or start getting five-year warranties because I think it really hurts the business. Americans wouldn't buy thirteen new cars in our lifetime if 20% of them were thrown away after a year. They wouldn't trust it. The only reason you buy a new refrigerator, a new dishwasher, a new car, it's because you really think- You can take it to the bank, it's going to last five years. And that's what I do to my associates. Someone snaps her tooth off at the gum line so they'll do a root canal build up and post-build up crown and charge out a root canal built up crown. "Howard, you know in six months or a year she's going to walk in and hand it to you." Well, we warrant everything five years buddy, so I'm going to credit all that towards the implant and the crown or the three unit bridge because it didn't last five years, end of story. And if you start making your associates start treatment planning to everything lasting five years, they stopped being little "hero-dontist" because it's easy to be a "hero-dontist" with someone else's money. Be a "hero-dontist" with your own damn money.

By the way, I didn't finish with that sinus still. I want to finish that sinus lift deal where you said you read more in ENT. Some people are shamed on Dentaltown when they do a three unit bridge. I mean they're shamed like, "You hack. Why did you file down those teeth? They were virgin teeth." When people start saying teeth are virgin, first of all, teeth don't have sex. I've been around fifty-five years. I've never caught a molar humping a bicuspid. So when you're calling a tooth a virgin, at what point are you an emotional wack job? But I just want to say this. Again, she's sitting there in Salina, Kansas and a bridge or an implant and crown- Is she a hack for doing a three unit bridge or is that still a viable treatment plan? 

Randolph: Howard, I truly believe that the dentist should give all the treatment plans to the patient, the advantages and disadvantages. You were talking about the endodontist. They do the apicos. Someone should tell that patient another option should be an implant, and you owe it to the patient to give all the options. So a three unit bridge. Is that below the standard of care? No, not at all. You have to evaluate. Say if you're missing the upper left first molar and you have very little bone. Is it worth it to put the patient through a sinus graft and an implant or just a three unit bridge? So there's advantages and disadvantages to every situation, and I believe that for the young dentist, if you want to be a good, productive dentist, you give them all those options, and then let the patients select from those advantages and disadvantages what the best course of treatment would be. 

Howard: Okay, and I promise, I swear to God, I'm wrapping up. I know we're an hour and a half- Same question with mini implants. Let me tell you how crazy Dentaltown is. Under implants, we had to separate implantology from mini implants because every time someone would place a mini implant deal, all these religious freaks would get on there and say, "Oh my God, mini implants! Three M!" And that's another question. Why did Three M buy M.Tech in 2008 and why did they stop selling implants? Do you know why Three M did?

Randolph: I have no idea other than maybe… I don't know. 

Howard: I don't know either. It's a closely guarded secret, but hell, even Three M could sell them mini implants. On Dentaltown, we play three strikes, you're out. By the way, if you, if you see something on Dentaltown and you don't like it, it makes you feel bad, hit the "report abuse" button. We've got a dozen dentists volunteers and I know some of you are all butt hurt that some of these people have been kicked out, but you know what, I get enough stress from insurance companies, staff, patients, Ryan, all this stuff like that. Ryan, why did you even take this job? All I do is abuse you during the whole show, but Dentaltown shouldn't be a place where you get abused and then they say freedom of speech. Freedom of speech is a constitutional right between you and your government. Dentaltown is my house. It's my private property. You have the freedom of speech, but you walk in my house, I'm going to blow your head off, and if you go to my house on Dentaltown and you start making people feel bad, I'm going to warn you once, I'm going to warn you twice and the third time, you're going to be banned.

But anyway, we had to separate the mini implants because there's all these purists that think mini implants are below the standard of care. So what's your thought on a mini implant? 

Randolph: As you know from going through the institute many years ago, we do still teach mini implants as a temporary. Such as, you're doing three or five implants on the lower and you use a (unclear 01:22:25) to stabilize a denture but not as a long term treatment option. Carl always used to say, "If you start to do implants, you need to move your office every couple years or it'll catch up to you." I think the morbidity of mini implants is just so high. It's not worth it and there's too much stress in a private practice to deal with that. So, I don't advocate them for final prosthesis definitely. 

Howard: Okay, so your website that you've all this on, do you recommend them going to, or do you want them to go to your Which one?

Randolph: has everything.

Howard: And then what is the

Randolph: That is just private practice. 

Howard: I wish all the implants would get shorter and fatter because I'm for anything that's short and fat. I mean, I'm five-seven, two-twenty. I want to be the poster child for a short, fat implants. That's another thing. When you and I were little, it was the longest implant we could get. It was doing everything. "Can we get fourteen or can we get a sixteen millimeter long or oh my God, did anyone get an eighteen millimeter long?" Now the trend is these implants are getting shorter and fatter. I mean, I always assumed shorter and fatter was a good thing. Is it? 

Randolph: Yeah, actually, if you go back to Carl's Master's thesis in 1988, he did three-dimensional stress analysis on the biomechanical force being put on an implant, and what it basically showed is the force is generated around the neck of the implant. Very little goes to the apical area of the implant. So why do you need a longer implant? For stabilization? But if you have good quality of bone, you certainly don't need a real long implant anymore. The statistics are definitely pro-shorter implant.

Howard: Pro-shorter implant, but also wider, fatter, right? 

Randolph: Yes, wider. If you go from a four millimeter to (inaudible 01:24:41) it increases the surface area by 30%. If you take a four millimeter implant, just add two or three millimeters to the apex, it increases only by 10%. So the surface area increases dramatically. 

Howard: You know what would be the best marketing for your book even though you don't need it at all? We pushed it out today. We posted it on Dentaltown, Facebook, Twitter, Google Plus Instagram, Pinterest, and LinkedIn, but I wish, just to give some massive credibility at Dentaltown, if you wrote us an article for Dentaltown magazine. It's mailed to a hundred and twenty-five thousand general dentists every month, and if you create an online CE course, the millennials- I'll tell you what, if you look at these meeting attendants, they're all drifting downwards and they keep asking, "Why do millennials not go to all these brick and mortar meetings?" Dude, we put up four hundred and fifteen online courses on Dentaltown. They're coming up on a million views. The millennials, they open up the online CE course on Dentaltown which costs probably less than the Uber ride from the airport to the dental convention, and then they have Apple TV, so they throw up the course on Apple TV, so now they're sitting in their favorite chair, at home, I assume drinking wine and eating popcorn, watching these lectures on their big screen. Oh man, it'd be so awesome to get you to do an online CE course. Ryan, will you send him both him and Howard Goldstein (unclear 01:26:17)? I'm Howard Farran, so I'm, but the guy in charge of the online CE is Howard Goldstein, so he's He's in Bethlehem, Pennsylvania. I think he moved there because he thought that's where Jesus was born, but I told him I'm pretty sure it was a different Bethlehem, but anyway would you ever consider doing an article?

Randolph: I'd love to. I would love to.

Howard: Oh man. I would love it too, but my gosh, you promised me an hour of your life and I stole an hour and a half. I want to tell you, man, I could talk to you for forty days and forty nights. Loved your book, loved you. I've seen you lecture so many times over the years. Just thank you so much for coming on the show today and talking to my homies for an hour and forty minutes.

Randolph: Great. Well, thank you, Howard.

Howard: The pleasure is all mine. Thank you, Ryan.

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