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AUDIO - Nicolas Elian - HSP #85
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VIDEO - Nicolas Elian - HSP #85
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Why recent grads have no implant training, what they can do about it, and how VIZSTARA fits into that equation.
Dr. Elian is a former assistant professor and head of the Division of Implant Dentistry at New York University College of Dentistry (NYUCD) Department of Periodontology and Implant Dentistry. Renowned for his expertise in the evaluation and retreatment of implants, Dr. Elian completed his DDS degree and postgraduate studies in prosthodontics and implant dentistry at NYUCD.
Dr. Elian was director of the Fellowship Program in Implant Dentistry and the director of Experimental Research at NYUCD. He consults on product development for industry manufacturers and is an inventor and expert in both cell culture and tissue engineering. An international instructor, Dr. Elian is a visiting professor at the University of Chietti, Italy, and Tong Ji University, China, as well as Honorary Professor at El Instituto de Investigaciones Craneo Dento Maxilo Facial de la Facultad de Ciencias de la Salud in Argentina. He was also an adjunct assistant professor in the Department of Periodontics at the University of Pennsylvania School of Dental Medicine. Dr. Elian serves on the editorial boards of many peer-reviewed journals and has trained an extraordinary number of specialists and general dentists in the science and surgery of implants.
VIZSTARA 300 Sylvan Ave. Englewood Cliffs, NJ 07632
TEL. 201-816-4000 FAX. 201-816-1114, vzdental@vizstara.com
Howard: Live in New York City. I am at the MegaGen Convention and it is an honor to be with Nicolas Elian at the Vizstara Center.
Nicolas: Vizstara.
Howard: You've been doing implant training for a long time. First of all, tell us about your background with Vizstara and how you got into implant training.
Nicolas: First, pleasure to meet you, Howard, and your lecture was truly incredible. I really enjoyed it.
Howard: Thank you.
Nicolas: Vizstara... My wife is a pediatric dentist and an orthodontist. I am a prosthodontist and implant surgeon. We both have been in academic for many years, and we saw what the universities are doing, and we felt very strongly that there is a need of a private type of education as opposed what the university does, short-term courses. Many residencies, mentorship programs, and we've decided to build a center based on that thinking.
Howard: Tell your wife that I love her to death because of the nine specialties. Seven of them are clinical, two of them non-clinical public health and oral radiology reading, but of the seven clinical specialties, if I had to be a pediatric dentist, I will climb to the top of the building and just jump off. I love ...
Nicolas: You have to be a saint.
Howard: Oh, my god. I love the root canals, I love placing implant, I love doing everything, but a 3-year-old screaming kid, I quit.
Nicolas: It's not easy.
Howard: I would go work at McDonald's [inaudible 00:01:36], so tell your wife thank you for taking all the children. What did you think the public schools were missing where a private solution would help?
Nicolas: Normally to advance your skill set, some people think, "I'll go back to school and I'll do a specialty." Today, in the US, most specialties are three years, full time. Of course, I know you mentioned it yesterday, they will need another maybe half a million dollar of debt to make it happen. Our environment does not create a specialist but we do deliver a super dentist. Dentist comes to us for short periods of time. They learn surgical skills, prosthetic skills, endodontics, orthodontics across the gamut. Of course, some practice management. We are going to need your help.
Howard: You're teaching at Vizstara. Where is that at? Is it New Jersey or New York?
Nicolas: It is in Englewood Cliffs in New Jersey.
Howard: That's close to New York.
Nicolas: It's about 10 minutes from ... Once you cross the bridge. [crosstalk 00:02:38] the bridge.
Howard: That new tunnel Chris Christie dug from New Jersey?
Nicolas: Yes.
Howard: Isn't there a new tunnel that he dug, that he dig that himself? Local joke. You're a prosthodontist and implantologist?
Nicolas: Yes.
Howard: What percent of the general dentist in America would you say place implants versus do not? Wouldn't you say that 9 out of 10 dentists have never placed one implant in their life?
Nicolas: That sounds about right because my understanding and the statistics that I see, there are only 20,000 GPs in the US probably placing implants at different percentages. The problem with that, education in dental schools related to implant surgery, almost nonexisting in undergraduate programs. Therefore, every young dentist that is graduating dental school today and years to come, until there is a particular training that is implemented in the curriculum, they will have to look at centers like ours to come in and learn and train.
Howard: These podcast are listened to dentist from every single country on earth so, to all the non-US dentists out there listening, I just got to explain to you that, I also have a Orthotown Magazine and website, and it goes to all 10,500 orthodontists but there's only 17,000 orthodontists in the world. America is very divided up by these seven specialties that you don't really see in Brazil and most of the world. When we go to dental school, they're not going to teach us something that the specialist want for themselves. I got zero ortho training so the specialty, they want you to be a general dentist and just do fillings and crowns and refer everything out. In America, America is really not based on truth, liberty, justice the American way. America is based on money is the answer, what's the question?
What I wouldn't talk to these people is that if 9 out of 10 have never placed an implant, before I tell them instructions, I had to drive from New York to Miami, and before ... I want you to address, why should a general dentist listening to this podcast on her way to work, why should she learn how to place an implant?
Nicolas: Sure. If I can add to your points regarding the difference between the US and international markets, as you all know, the US is a specialty-centric market. The rest of the world is ... The GP is really the captain of everything happens in that office. In that US, that model is changing. I'm a prosthodontist and I've trained in surgery. I have been training restorative dentists for the last 20 years learning implant surgery. Periodontist today, the American Academy of Periodontology requires that periodontists are familiar in temporization so they're learning restorative and building restorative skills. The Endodontics Academy made it a requirement that endodontist in training must learn implant surgery. The boundaries of the specialties are very different now. They are no longer as defined as we think they are. For the restorative dentist now, it is a must because introducing implant dentistry in their practices, it is income; it is money because once they introduce that surgical skill into their practices, we see it in our mentorship programs. They increase their revenues by 15% to 20% year one.
Howard: I want to also remind everyone that there's two Americas. Half of America lives in 117 towns over 100,000, and the other half lives in 19,000 in 22 towns under 100,000, and a lot of these dental schools are paid by state tax money and all these rural people are paying for these public schools and then they educate a dentist to go back to a very small town of the [inaudible 00:06:42], Arizona, and you don't have any specialist in these small towns. When specialist say, "Well, if you need to do that, you should send them to one of us. Hey, dude, you're only in half of America, and the other half paid for your school." When you walk out with student loans, your tuition and student loans, you only picked up about 30 at your tab. The tax payer picked up the other two-thirds and I think it's an insult to send dentist back to rule America, and they don't know how to do any of these stuff in the clinical specialties. Because I know humans and when you're in a small town and the big city is an hour away, and you say, "Well, I can't do a molar root canal, but you need to drive an hour into the big city.” You know that old man is going to say, "Ahh forget it. Pull it."
The fact that the economic [inaudible 00:07:28] is an hour drive, he just elected to have his body part pulled out and thrown away because you can't do molar endo. I'm telling you that healthcare has got to be accessible, affordable, easy, and with these dentists in rural America learn how to place an implant, they say, "Dude, I can do it right here. It's not that big of a deal. I can put that implant in right here." The care goes up. Quality ... There is two Americas: There's urban and rural. I wish all these rural dentists would learn more endo implantology whatever.
Nicolas: I think it is happening. We may not be seeing it at the scale that we would like. We see the demand on education and how often people are looking to attend these type of courses, how it ... The challenge in implant dentistry which is slightly different than endodontics. When the endodontist thought it is a danger for them that the general dentist does endo, they've realized over time that the more general dentist did endo, their growth went even higher. I believe the model is the same in implant dentistry. As a specialist and enjoy education and being passionate about it. I find that the more I train dentists, the more referral I get, so it is really about expanding the pie. It is not about who's taking a piece from someone else.
Howard: Exactly. Rising tide lifts all [inaudible 00:08:56]. I don't even trust an endodontist who can place implant because if you send a failed root canal to an endodontist, and all he can do to make a thousand dollars is to retreat it, he's going to retreat even if he thinks it's broke, it's fractured, it's hopeless, but I'll try because humans is going to rationalize anything. Those endodontists in Phoenix that I referred to, they’ll say, "You know what? I can make 1,500 either way. I can do a retreat, I can pull and do an implant. I can do it both ways. I'm going to pull this tooth. I think the first guy who did it found all the canals. I think that he tried well; it just didn't work.” I think all endodon ... I think and very surely, I think endodontist who can't pull and make money pulling and place an implant are going to be under serious downward pressures.
Nicolas: During my lecture earlier on, I talked about treatment planning and one of the elements of treatment planning that we talked about is to reduce morbidity and treatment time. Think about this. I'm a patient, I'm at the endodontist, I'm already anesthetized, and he or she finds out that this tooth is hopeless now. What they’re going to do? They're going to tell me, “Just go see someone else to do it? Wouldn't it be a greater opportunity for them to actually be able to extract and place an implant for me?”
Howard: Let's talk about that. Implants have changed a lot. You pulled that tooth right there on the spot. Do you like extracting and placing an implant at the same time?
Nicolas: In today's implant dentistry, if we're not doing that, I think we are actually making a huge mistake because placing an implant immediately, one, eliminates two or three surgeries following extraction, and of course, with new implant design like the … and you read it from MegaGen, not only we can place the implant immediately, we can also immediately temporize it so actually, patients leave functioning.
Howard: You would pull the tooth and you would place the implant, and you would temporize this, so they would leave with their tooth?
Nicolas: Exactly.
Howard: Would that tooth be for more ... For aesthetics, cosmetics, would they actually be chewing on that tooth?
Nicolas: I think in the last day and a half, we’ve debated that topic quite a bit. Some of us believe that it should be out of occlusion, but my comments in that regard that once the patient is chewing and functioning, even if clinically it is out of occlusion, that implant is subject to load. Our thinking is really changing as we speak.
Howard: A lot of people think the half-life of dental technology is only three years. Everything is here. Back to this person, what I want you to focus on is the people listening to this, 9 out of 10 have never placed an implant. They decided they're on the first floor, and they’re going to go to the second floor. What would be the first couple of steps? Pick an easy case, a scenario. What's the low [inaudible 00:12:02], what would be the implant that Stevie Wonder could do or ...
Nicolas: Sure. In most practices, Howard, there are probably multiple units of bridges that eventually over time fail. If we look at that unit bridge that failed and that edentulous area, the pontic, that's a healed ridge. Generally speaking, there is sufficient volume of hard and soft tissue. This is the first area that somebody that has never done surgery that should get introduced to. At our center at Vizstara, we have a clinical mentorship program. We call it implant mentorship level one. Dentist come to the center, they learn how to place implants on these type of cases. Once they graduate from that mentorship, they qualify for the International Congress of Oral Implantology Fellowship status. During that course, they are placing 20 implants on their own patients.
Howard: I got my diplomat in the International Congress of Implantology, and you know what I like the most about it was meeting life-long friends. It was the friends you met. I always look back at all of the CEA I took. When I took my first course in [inaudible 00:13:19], the most favorite thing about it was meeting Steve Rasner. You know what I mean? I have a friend from each one. Vizstara, it's V-I-Z-S-T-A-R-A, and the V-I-Z, that was your vision of the future?
Nicolas: The vision of the future.
Howard: It's in .. Did you say it was Englewood, New Jersey?
Nicolas: Englewood Cliffs in New Jersey.
Howard: Englewood Cliffs in New Jersey so if you go to V-I-Z-S-T-A-R-A, now, tell us again what didactics you teach. Implants, endo ...
Nicolas: Implants, endo, orthodontics, restorative dentistry.
Howard: Wow, so four?
Nicolas: Yes.
Howard: You said practice management?
Nicolas: We're always looking for help in practice management, so hopefully we’d have you at Vizstara in the near future guiding some of the dentists who graduated from dental school in their career.
Howard: That sounds amazing. This person who's listening to the podcast driving, talk about the implant didactic, is that a weekend course, a three-day course, is it three courses?
Nicolas: There are one-day courses and two-day courses, but we feel in implant dentistry, the introduction to basic implant dentistry is a four-day course. During that course, I'm doing actually live surgeries. They're observing over the shoulder.
Howard: Is this Monday to Thursday or ...
Nicolas: That's the course that we have from Wednesday to Saturday.
Howard: Wednesday, Thursday, Friday, Saturday. It'd be a four-day course, your intro level to implants.
Nicolas: Yes. What we find in that course, the attendees once they've observed over the shoulder and learned the basic science and clinical science of implant dentistry, some of them, they will elect a mentorship program. Once they make that decision, level one mentorship, it is a 20-session because we want them to place 20 ...
Howard: Twenty sessions?
Nicolas: Twenty sessions. Twenty full-day sessions.
Howard: Twenty-one-day classes? They would come back to Englewood Cliffs, New Jersey, 20 times over the course of what? A year? [crosstalk 00:15:28].
Nicolas: Usually, it's a year because we’ll give them also at the end usually two sessions as a makeup if somebody didn't finish the requirement that were asking for.
Howard: Wow. That's an intense curriculum.
Nicolas: Yes.
Howard: Let me get this right. It would start as a four-day ... Wednesday, Thursday, Friday, Saturday, and then 20 more one-day class ... Twenty days or 21-day at a time?
Nicolas: Twenty-one day at a time, alternating. As an example, we have a mentorship that takes place on a Wednesday so alternating Wednesdays. They come to us twice a month, and during that one full day, they’re treatment planning, they are learning how to read cone beam CT, they are learning diagnostics, they're learning how to do implant surgeries step by step on their own patient with one-to-one faculty ratio which is unheard of even in the best postgraduate programs.
Howard: After the four-day start and the 20-day followup, what do you think that person surgical ... What could they be doing in their office?
Nicolas: I think any healed ridge in the office is they ...
Howard: Any healed ridge?
Nicolas: Any healed ridge, they're able to treat with confidence and with high predictability. Here's what we do that is unique once they complete that course. For one year, we ask them that they should send us their CTs and their photographs to work with them on their treatment plan to make sure that actually what we have done is accurate and is allowing them to actually practice and do implant surgery in their practices.
Howard: My whole mission with Dentaltown is using the Internet, and now the smart phone to connect dentists so that no dentist has to practice solo again. I thought it was very painful when I would come home from work, and I would be alone with my four little baby boys, and I'd be stressing out now about I did a root canal and it swelled up, and should I pull it or put them on antibiotics. I just wanted to talk to someone. When my boy, Eric, was nine years old … He's born in '89, so in ’98 he walks into my office and then he says, "Hey, dad, can I borrow your credit card?" Out of morbid curiosity, I said, "Of course." You want to see what your nine-year-old is going to do to your credit card. He logs on to this stupid AOL dial up and all these crazy crap that we had to get for his homework, and after about 15 minutes, this AOL dial up, he gets on this website and he's talking to other kids about skateboard wheels and then puts in my credit card for 100 bucks of these wheels, and I'm just looking at it. "Oh, my God. That's a ..."
I want to be talking about root canals, and it was just the greatest thing. I think what these dentists need, they're all alone. Their whole circle of friends, they don't place the implant, no one placed an implant. Courses like these are game changers because you're going to go there. You're going to have a mentor, you're going to have a friend, you're going to meet classmates, and these are decisions that you make, and then a year later, you might be placing 5 or 10 implants a month, right?
Nicolas: Actually, that's quite interesting, Howard, for somebody that just learned implant dentistry and took the course. Recently, we started to offer them an opportunity in the early stages that you may not be ready to invest 15,000 or 20,000 dollars buying an implant system in your practice. Of course, the cost of cone beam CT, that is very high. What we offer them is an opportunity to continue to come to the center. Now, they are treating their own patients. Also remember, these are people that we have trained, we know their caliber and their level, so they're already vetted and accepted to be at the center. They bring their patients; we have huge inventory of implants, so they don't have to worry if they have the right size or the right implant. If they need bone grafting, we have large inventory of bone grafts, membranes as well, and in the event that there is a challenging case, they have us as their backup ...
Howard: You're saying the doctor could bring a patient and do it at your center?
Nicolas: Yes.
Howard: What about the licensing? What if I'm Arizona? I have an Arizona license; I don't have a New Jersey license.
Nicolas: We have ADA CERP accreditation for our courses. Anyone that is enrolled in the course can actually treat their patients doing the course at Vizstara.
Howard: Is that in ... New Jersey can do that?
Nicolas: In the city of New Jersey, you can do that.
Howard: Wow. That's very rare. Most states will not let …
Nicolas: Allow that. Yes.
Howard: Wow. I did not know. Has that been that way a long time or ...
Nicolas: I've personally only learned about it when I applied for the ADA CERP and we've learned that actually many dentists from the US ...
Howard: Wow. Now, in Arizona, if you're doing it at a charity house ... There's a couple of charity places in Arizona where just dental [inaudible 00:20:29] St. Mercy or ... A couple of [inaudible 00:20:31] and if you have the course there and the dentistry is on ... Once for a homeless vets and once … [inaudible 00:20:39]. That's interesting. Again, this dentist all alone, he's looking at the market; it's very confusing implants. There are implant companies like Nobel Biocare. They are very high cost probably what? Over 500, probably 40, 50 companies all the way to a very low cost down to a hundred. Do you get what you paid for or is it implant and implant and implant; Is titanium titanium? What should this dentist would be thinking about? What should the dentist be thinking about when they look at 50 different implant systems?
Nicolas: The answer is yes and no. Implants may look very similar but also at the same time, there are huge differences. It all boils down to the quality assurance that a company has. Of course, you want to work with companies that have good reputation, that very consistent in their quality production. Also very importantly, I tell everybody to focus on who are the people behind a particular company? In the case of MegaGen and IDS, Dr. Park and Carey Lyons and Steve Pfefer, they have been in the industry for a very long time, and yes, they're selling a brand, the MegaGen and AnyRidge implants, but also I think they're selling their names and their reputation. They are a brand as well, so they're very careful with that and they will not be associated with anything that is not of high quality.
Howard: I'm going to give you three words and I want you to talk about them. On Dentaltown, I always like to look at the search data. We have 50 different forms. Root canals, fillings, crowns, all that stuff, but on implantology, people are always searching screw or cement. They're always searching immediate load or not, and platform ... What is it?
Nicolas: Platform switching.
Howard: Platform switching. I'm going to start again. Tell me, do you agree with this premise: When impressions go to the lab, 95 out of 100 impressions are just for one crown. Would you agree that when implants are placed 95 out of 100 are just one implant going in for missing one tooth and only 5% are big cases? Would you agree with that?
Nicolas: That's definitely what we see in our center. The majority of implants that we are placing are single tooth implant.
Howard: For that single tooth implant, the dentist is always asking, would you just cement that or would you do the screw-retained? What's your thoughts on that?
Nicolas: As you have probably already seen the issues with peri-implantitis and the big question of cement not being cleaned from the sulcus. That is always a concern that someone may not be able to clean the sulcus properly. If the implant is in the right position, I think just a question of preference for the restorative dentist. Some of them are very comfortable cementing and cleaning the cement out. We find that there is a larger number nowadays that is leaning more towards screw-retained. At least in our environment, that's what we are seeing.
Howard: What do you do personally? If you did 100, if you put 100 single-tooth implants in, what percent would you screw down versus cement?
Nicolas: In our training, Howard, we work very hard on not only placing the implant but creating an environment surrounding the implant. That is part of our treatment plan and in the courses, we emphasize that. Doctors are not only learning how to place implants, they're learning how to provide a better treatment plan. In that regard, we’ll place our implants probably 95% in the most ideal position, that's the center of the center fossa of a posterior tooth, center of buccolingual, center of mesiodistal. In that particular scenario, we find that screw-retained is more cost effective in our environment, faster, simpler, and less visits.
Howard: When would you do an immediate load and when would you not, and have them come back three months later?
Nicolas: Immediate loading is such an interesting concept and life-changing experience, I think, for both the dentist and the patient. As a protocol in single teeth, anything from the second bicuspid moving forward anteriorly, it is immediate implant placement, immediate temporization.
Howard: For the front 10 teeth, upper and lower?
Nicolas: Lower.
Howard: The front 20 teeth, second bi to second bi would always be 99% of the time would …
Nicolas: 99% of the time.
Howard: Would be an immediate load with the provision.
Nicolas: With the provision.
Howard: Wow. That's amazing.
Nicolas: There are occasion that we find that a completely blown out sockets that we can do it, but that is very rare. We don't see this type of cases.
Howard: Will you explain again platform switching? It seems to be a concept to a lot of people have difficulty with. They are always trying to ... They’d never ... and even when people explain it, they still don't get it. Will you try to explain platform switching, and is it even important?
Nicolas: Yes.
Howard: Is this something they need to know about?
Nicolas: I think it is important and I think it's an important concept that we simplify it and make it clear. The reason for platform switching is to provide better aesthetics. In that, we mean more soft tissue around the head of the implant or at the junction between the implant and the crown. What it is is very simple. The [inaudible 00:26:33] is a smaller diameter than the body of the implant itself and that allows or prevents crestal bone resorption and a greater volume of soft tissue. It is a concept that is here; it will stay. Truthfully, I cannot think of an implant that is not platform switched on the market today.
Howard: I’m going to ask you what are your most common implant questions at your institute.
Nicolas: We've been looking at the trends and soft tissue changes. While we place the implant and we can get great results, what we find that over time that the volume of soft tissue around an implant is usually less than what it is around a natural tooth. We are finding that we really have to enhance more soft tissue on the buccal. This is an area that we keep asking ourselves, do we need it, is it really necessary, do the patients benefit from it, and how can we show its value? I think we're making headways because the education that we're doing, I believe, dentist, practicing dentist, they do have the relationship with their patients. They're making a very good case for it, and I think we will see more and more soft tissue graftings around implants.
Howard: Do you want to switch gears to ... You also teach endo and ortho.
Nicolas: Yes.
Howard: Let's jump into endo. In your career, do you think 3D, going from 2D radiographs to 3D has changed implantology with surgical guides and [diagnostic 00:28:21] implant. Do you think 3D CBCT is changing endo because ... Is it safe to say that the number one cause of a failed root canal is a missed canal and this could be eliminated with CBCT. Do you believe that statement?
Nicolas: Without a doubt, I think we're seeing so much more of it. The challenge is can every dentist have a cone beam CT in their office? That's one. In regards to the endo, I just want to make sure that I'm not misrepresenting this. I personally cannot teach endo, so we have somebody ...
Howard: You can't teach endo?
Nicolas: Not myself.
Howard: Why?
Nicolas: Because I haven't done endo for the last 20 years.
Howard: That’s rare.
Nicolas: We have an incredible endodontist and incredibly talented clinically and as a teacher, Michael Feldman, so the endo courses that we do, he usually runs these courses, and he puts a lot of emphasis on diagnostics using cone beam CT.
Howard: Does he have any favorites? Do you have any favorites for 3D X-rays for implantology? Does he have and it’s his favorites for root canals the same as your favorites in the implantology?
Nicolas: Actually, we have two different units. He has a Kodak in his office.
Howard: Carestream.
Nicolas: Carestream, and we have Galileos in our office. I think in terms of quality and this probably similar to what type of implant do we select, the majority of the units that I have seen and I have read the scans from, they're of high quality. Vatech is doing a great job. I have looked at some of their imaging.
Howard: For CBCT, Valtech?
Nicolas: Vatech.
Howard: How do you spell that?
Nicolas: V-A-T-E-C-H.
Howard: They are out of?
Nicolas: They're out of New Jersey actually, I think.
Howard: They're out of New Jersey?
Nicolas: Yes.
Howard: Really? Interesting.
Nicolas: They have very interesting units.
Howard: CBCT?
Nicolas: Yes, and it eliminates scatter better than some other units. At the end of the day, there is a lot of similarities, the question of comfort, learning the software, and of course, cost.
Howard: If you have Galileos ... Let me just go back to the question. For a single implant placement, for this ... Let's bring out here 90% of them have never placed an implant. They're going to place their first one, when they place their first hundred ... Would you .. Just to say, you only got two teeth guiding you, and you can see the buccolingual. They know how bridges draw, so they just have two teeth. Would you recommend a surgical guide for their first 100 implants or not really?
Nicolas: Howard, in all my years of education, this question has come up on many committees when I ran the division of implant dentistry at NYU. We've debated this at length. While a surgical guide is very important and very useful, for the novice, I think it is a limitation because you're minimizing their surgical skills, you're making them depend on a device, so you're not allowing them the opportunity to build surgical skills. What do we take away from them when we give them a guide? We take visibility and we take tactiles.
Therefore, we're not building any skills for them. In our curriculum and what we do, as a matter of fact, all the beginners don't use cone beam CT because they're placing one single implant. There is a medial tooth, there is a distal tooth, they see the buccal very well, so we make sure that it is in the center of the mesiodistal and buccolingual. Here's what I can tell you. In that particular case, guided or guideless does not make a difference but what makes a difference if it is thinkless because some people just sit there and think it is just placing a screw inside the bone, and that's unfortunately when we see problems.
Howard: That is very well put. Also when I ask you, when you're looking ... You're placing an implant and you're doing your ... You’ve laid your flap, you're about to go, do you personally like to look in from the side or do you like to pull the patient's head right in your lap and look straight down ... What do you do? Are you standing up or sitting down?
Nicolas: I sit down all the time.
Howard: You sit down.
Nicolas: I sit down all the time, but this also quite interesting. Yeah.
Howard: I've never pulled a tooth or neither placed implants sitting down. I do all my fillings and crowns and root canals sitting down, but I have to stand in surgery. I don't know why.
Nicolas: Now, I feel terrible because everything I do is sitting down.
Howard: That's interesting. You're sitting down ...
Nicolas: I'm sitting down.
Howard: Where is the patient's head?
Nicolas: This is quite interesting. Actually, I'm going to find out a way how we are going to provide you this material because in our course, we eventually decided that certain teeth ... Let's say tooth number 5, right? Tooth number 5, it's maxillary right central incisors for the international viewers. We've decided, okay. When we are training dentists, where is the patient and where do you sit? We have diagrams in our manuals that I'm going to send them to you that you decide where you want to put them on your website because it tells every dentist for each site where the patient's head is. For instance, tooth number 5, the patient turns their head to their left. The doctor is in a 9 o'clock position; they have complete visibility. They see the buccal, they see the central fossa, and they place the most accurate implant that they can be. That's, as I said, guideless but the most important part it is not thinkless.
Howard: I think it's interesting that whenever you get into full mouth rehab, and you're going to ... All the teeth are going to be prepped, every lab man can tell you if that a dentist who is sitting, a right or left-handed.
Nicolas: Left hand.
Howard: Because they're always there one way or the other. They can all tell. Back to endo, what percent of the 120,000 general dentist in America would you say do not do the molar endo? How many of them just say, "I don't do molar endo."
Nicolas: Howard, I must admit I am not familiar or knowledgeable of that statistics.
Howard: What I'm reading is half. I'm reading 9 out of 10 have never placed one implant and half will not do molar endo and that's just every time I see the number. This person's either ... Do you see when he do this ... Every day that you'll get more views on Dentaltown, YouTube, iTunes, so probably three or four months from now, a thousand people will have watched this on Dentaltown, probably 300 on YouTube, and probably 2,000 to 2,500 on YouTube so about two thirds are just listening. This person who's listening to you right now, they're driving an hour of commute to work, they don't do molar endo; they hate it. They say, "Dude, I'd rather get a paper out than do a molar endo." What is this person missing? Why does he hate molar endo and do you think you could turn him into freshening up the love affair of molar endo? Because the reason I like molar endos, number one, they come in there and pay. I'm not trying to sell you a smile lift or veneers, and I don't even like selling cosmetic dentistry.
I think when you go up to a woman and say, "You should get veneers." She's probably going to look at me and say, "Yeah. You should lose 50 pounds, get a tan, and wear a wig." I don't like to tell people ... I wouldn't like to ... Every time I go somewhere, someone's telling me I should get a wig or whatever, but they come in with a toothache, that's an easy sell. They're in pain, and a root canal is a thousand bucks and insurance pays 80%; I love them. It really blows my mind that half of my colleagues hate them. Who doesn't want ... I felt like a hero because you came in like, "God, I can't even sleep last night," and then you leave like, "Thanks, Howard." They're out of pain. It's a hero, it's a thousand bucks, the insurance pays 80%. Talk to this person, do you think your center, Vizstara, could get them fired up in molar endo?
Nicolas: Without a doubt, Howard. While we're very passionate about education, we’re also very passionate about making dentistry better. I think in any discipline or any areas such as the molar endo, when people don't get involved in it because truthfully, they have not had the proper education. Our model is based on what we call hands on, practice-based clinical training. Yes, I can sit in a lecture room and listen to someone talk about molar endo for half a day or a full day. That does not necessarily translate into me going to my office and doing molar endo.
In our model, it's not only that we make sure that dentists are knowledgeable in the didactic component. Immediately after that, they’re in the operatory and they're performing endo, molar endos, under supervision with incredible faculty of the highest skill and talent and commitment to education. I have no doubt that we can fire them up. They go back to their practices and the next day, they're doing endo in their own offices.
Howard: Do you like any of the automatic rotary NiTi systems?
Nicolas: Of course, I don't believe that today we should be doing much endo without having rotary component in the practice but hopefully, we’ll get you to Vizstara to visit and we’ll have an interview with Michael Feldman, and he will talk about the different systems.
Howard: [crosstalk 00:38:34]. Have him call me. I'd like to do a Skype podcast. Most of my podcasts, I do via Skype because we're not in the same city. Have him send me an email at howard@dentaltown.com, and I would love to do a Skype system because a lot of these dentists, they see all these different file systems. Again, I try to give them a stairway kind of like if you’re going to leave New York and go to New Jersey, they need to first know, "Okay. When I pull out of the Grand Hyatt, do I go left or right?" What course would you recommend? You say you're a center, what file system? I would like more of that. The other one you taught ... You teach implants, endo, and ortho?
Nicolas: Yes.
Howard: Who teaches your ortho?
Nicolas: In ortho, we have two orthodontists on our team, Dr. Martha Miqueo and Dr. Frank Celenza. They're both incredible orthodontists. They both have been in education and in private practice for many, many years. Again, also in ortho, we use the exact same model. We are hands on, practice-based clinical training. Yes, there's a didactic component that the dentist needs to be familiar with and immediately after that, it is getting them into the operatory, seeing patients, and actually doing it themselves.
Howard: Another interesting thing about the specialties is like if 95% of implants are one at a time, if 95% of crowns are one at a time. In ortho, 80% of orthos class 1 molar, class 1 canine, 15% are class 2, 5% are crazy class 3. The one advantage of a general dentist is you can cherry pick the easy ones. You could do these cases. There's big difference between replacing one single missing tooth of the implant versus some lady come in with a full set of denture with no retention, no ridge, no jaws, and says, "Can you make this work?" That's a ... By the way, on that case, to the advanced listener, grandma comes in. She says, "Doc, full dentures. I can't eat. I can't chew. You take them out." She's almost ... She's very flat ridged. She's had these dentures since she was 20, and now she is 65. What would you do for this case?
Nicolas: Obviously that puts this patient in the advanced category or possibly a higher case depending on the bone volume and soft tissue volume. In our environment while that case might be an advanced case, we have the skill set and the tools to teach how to build bone if you don't have that right volume whether height, width, the quality. We place implants if the desire is something that is fixed, but also I am also a great advocate actually over dentures. There is always a spot in the mouth where you can get one or two implants and if it's a mandibular denture, you can place a locator or another type of attachment and give them their security.
Howard: One thing that you always hear people are talking about ... Sometimes when people ... It's weird. It's like there's this big religion in dentistry to preserve bone and save bone and grow bone and bone graft, but a lot of times, you see this people in order to get a bar or just mowing the bone down. There's some implants where you just have the implant in a little ball and the denture snaps on. In other implants, you need to connect with them all with a bar but that takes a lot of room.
Nicolas: Yes.
Howard: Will you talk about treatment planning or if someone came in with a full denture, what percent of the time would you do an implant bar over denture versus just implants with balls and snapping down.
Nicolas: I think in terms of the quality of the denture. If it's an over denture, I think you'll get very similar retention if not better with two implants and a locator attachment and patients will do very well.
Howard: What locator?
Nicolas: Locator. There's an attachment that is called locator or ring. There are few [inaudible 00:42:59]. There are a few different attachments on the market that can do a very, very good job. That's very interesting because now, the patient can actually remove their denture and also clean it, clean the implants. In terms of hygiene and long-term maintenance, it is a great model. I don't believe that you need to have a bar to have an over denture. It is not necessary.
Howard: Was that a concept that Carl Misch pushed a lot because he just like the physics that if you had four implants whenever you connect them together, the geometry, the physics, the forces are better.
Nicolas: Sure. Yes, if you already have for implants and we've heard the last couple of days at the symposium, the concept of all on four and the immediate loading and temporization. If you already have for implants, the chances are you can have something fixed. I think if we have five, we’ll make it better. Here is the issue in regards to your question leveling the bone. I do have a concern because if we are leveling it to an extreme in 4 millimeters or 5 millimeters, I think we're creating situations that are much more challenging for our patients to maintain. Even for ourselves, I think if you look at some of the cases that are treated with that modality while you're leveling the bone, and you're using about 5 millimeters, your hygienist is going to have a challenging time cleaning that case.
Howard: Some of these dentists ... What's your way on this [inaudible 00:44:32]? Some of these dentists say, "Okay. Obviously if you take out your dentures and there’s [inaudible 00:44:38]."
Is that [Dr. Art 00:44:39]? How are you doing?
A lot of people say if I take out my denture and I have four balls, the patient can clean around it and brush. If it's connected with a bar, it's harder to brush and clean around the gums that are inflamed. A lot of them say, "Okay, the gums are inflamed. There’s peri-implantitis, but it's not a game changer. I'm not going to lose my implants from chronic peri-implantitis." Do you agree with that statement or do you not agree with that statement. In fact, Gordon Christensen, he believes a lot of peri-implantitis, it’s just a reaction to the metal. Some people will wear a ring and they'll get a green tattooing around it?
Nicolas: Yes.
Howard: Some people wear that base metal ring and not. Gordon thinks a lot of the peri-implantitis. Actually, it's just a metal allergy.
Nicolas: Howard, I was hoping that you'll ask me what is the cause of peri-implantitis?
Howard: What is the cause of peri-implantitis? That was my next question, and then I'm going to ask [inaudible 00:45:35] for the same one after you.
Nicolas: I tell everybody. I think peri-implantitis is duly in your treatment plan. You've already missed something in your treatment plan and you did not account for. Take the bar as an example. In the decision-making that we have four implants and we should have a bar, usually you start, you have very limited space. Your bar is very close to the soft tissue, you cannot clean it as a dentist, your hygienist cannot clean it, you cannot expect your patient to clean it. Is it peri-implantitis? Maybe not, but here is the concern that I have. It is an inflammatory process that is in somebody's mouth. Does it affect heart disease? Does it affect diabetes? I think our responsibility as dentist to provide a healthy environment. How do we provide them with that? A treatment modality that actually, they can maintain at home.
Howard: Well-put. I would like your two orthodontists to call me in Skype for podcast too.
Nicolas: I'm going to make sure that Michael Feldman, Martha Miqueo and Frank Celenza, they'll reach out to you and ...
Howard: You teach implants, ortho, endo, anything else?
Nicolas: Restorative dentistry.
Howard: Restorative dentistry?
Nicolas: Yes.
Howard: Does your wife come in there and teach pediatric dentistry?
Nicolas: She is an orthodontist and pediatric dentist.
Howard: Which one does she like more?
Nicolas: I think she likes ortho more but obviously she is very passionate about what ...
Howard: She likes pediatric dentistry.
Nicolas: That combination between ortho and pedo can do.
Howard: What does she recommend for pediatric dentistry, the dentist being on nitrous or taking an Ativan before the appointment?
Nicolas: I'm going to let you ask her that question when you interview her.
Howard: I want to interview her too. My last question is you’re lecturing at the MegaGen symposium, 11th Annual MegaGen Symposium, what were you lecturing about? What was your lecture about?
Nicolas: My topic was controversial concepts and therapies in implant dentistry.
Howard: Would you have time to run through some of that?
Nicolas: Sure. You've asked me earlier about immediate implant placement and immediate load. While for the way you've just described it, what we have in the US, we have the city dentistry and the rule dentistry. Unfortunately, even in the city environment, some people think this is a concept that shouldn't be done. We've been doing it for a very long time. I shared some of our experience at the meeting. My very first immediate implant placement and immediate loading was done as a dental student in 1993. I tell everybody I was a non-obedient graduate student. I questioned the science; I questioned our clinical skills if we can do better. It is an area that I have done a lot of work over the years and learned the limitations and the potential opportunities. We don't have patients that walk out of our office just taking teeth out.
Howard: It's funny because I'm older than you and then '87, everybody would … On a root canal, there’s two appointments. The first one they’d find the oral canal and get it all cleaned out and then temporize and then I'd say, "Well, why do you temporize it?" They say, "Well, to make sure it's okay." Then I have them back in two weeks to fill in. I said, "Okay. Well, what percent of the time when they come back in two weeks do not fill in?" They go, "I always fill it." “You wait two weeks to check something and it always checks out okay? Why don't we just fill that baby now and get rid of that second appointment?”
Nicolas: [crosstalk 00:49:26].
Howard: People will just literally tell you're crazy, and I also want to tell you something else. When I got out of school in '87, the very few people placing implants, there was about a third subperiosteals, about a third ramus bars, and a third root forms. They were all considered quacks where I went to dental school in Kansas City, where I practiced in a ... I remember walking into meetings and there was the good oral surgeons who did exodontia and there were the weirdoes over there sticking metal in the people's jars. They were all viewed as quacks. Some of them around the United States literally had their licenses taken away because they do a big case, and they were doing lots of them but the first time a big case failed, they took their license away. That was common in the '80s. There are ... It's amazing how things changed and amazing how much it will change. Hey, I just want to tell you you're a busy man. It was an honor and a privilege that you gave me an hour of your time.
Nicolas: Howard, a pleasure meeting you and thank you for the opportunity. It's been pleasure getting to know you.
Howard: I would drive by your center and see it myself.
Nicolas: I would love to bring you over.
Howard: How long of a drive is it from New York City?
Nicolas: Fifteen minutes.
Howard: Fifteen?
Nicolas: Yes.
Howard: Is that where your clinical practice is?
Nicolas: Yes.
Howard: Will you be there on Monday?
Nicolas: We don't practice on Monday, but I'll be …
Howard: Will you be there Tuesday?
Nicolas: No. I'll pick you up on Monday and I'll bring you to the center.
Howard: I want to see it. I cannot wait to see it.
Nicolas: We are going to make plans. I'm going to pick you up and bring you over.
Howard: Okay. It’s a date.
Nicolas: Maybe we’ll get you some Lebanese food in our area.
Howard: Obviously, I like all food. I've never found any food I didn't like. Food is my favorite vice, but thank you again. Have a good time.
Nicolas: Howard, thank you. It's been great. Thank you.
Howard: All right. Bye-bye.