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VIDEO - HSP #283 - Jack Lipkin
Mission Statement: Kennedy Professional Educational Seminars is committed to providing high quality, clinically oriented continuing dental education in outstanding holiday settings.
Dr. Jack Lipkin, BSC, DMD:
Dr. Lipkin obtained his Bachelor of Science from the University of Manitoba in 1970, and his D.M.D. from the University of Manitoba in 1974. In 1979, Dr. Lipkin received his certificate of Fixed Prosthodontics from the State University of New York at Buffalo, New York. He is a full time private practitioner and has practiced as a prosthodontist since 1979.
Dr. Lipkin is an assistant professor in the Department of Dental Diagnostic and Surgical Sciences, Faculty of Dentistry University of Manitoba. Dr. Lipkin is Vice President of the American Academy of Fixed Prosthodontics. He is a member of the Association of Prosthodontists of Canada, the Canadian Dental Association, the International College of Prosthodontists, the Academy of Osseointegration and is a fellow of the Pierre Fauchard Academy and the International College of Dentists.
Kennedy Professional Educational Seminars Inc., was started in 1993 by Dr. Marshall Hoffer and Dr. Jack Lipkin, as a natural continuation of their involvement in dental continuing education. The origins of Kennedy Professional Educational Seminars, Inc. arose from the Winnipeg Prosthodontic Study Club, an active dental study club started in 1981, which sponsored lectures by many top dental clinicians and academics.
The concept of combining high quality programs presented in conjunction with exciting holiday venues led to the formation of Kennedy Professional Educational Seminars, Inc. Our goal is to provide a selection of clinically relevant continuing education programs, hosted in a variety of holiday oriented locations. These programs are scheduled through the year so that a suitable subject and location should be available to most practicing dentists.
Howard: I am in Winnipeg Manitoba, Canada. With a very big role model icon of mine Dr. Jack Lipkin, a prosthodontist. When did you become a prosthodontist?
Howard: You've been a prosthodontist for how many years?
Jack: 36 years.
Howard: 36 years? I am ... I really want to do this interview because of all the nine specialties, prosthodontist is kind of the most rare one. I mean there's only about a thousand. How many are there?
Jack: At one point we did a survey across Canada, which was quite a few years ago there was like a 130. Now there's more but I would imagine 2-250, that's it. Most of them are in schools.
Howard: Yeah, so first of all just in case one doesn't know, what is a prosthodontist, and what made you become one?
Jack: Well prosthodontist is a specialist that is involve with providing prosthesis for dentitions. It might be fixed, removable, part of our definition is we were the original cosmetic dentist, and major full mouth rehabilitation, anything related to occlusion, TMJ, that's our specialty. Providing prosthesis to replace missing dentinal parts, dentitions and oral facial structures.
Howard: You ... I mean in your own, right you really are a legend on this, and you also have a website where you for twenty years you've been teaching dentist all over the world. You obviously mix continue education with fun, high end travel which I assume your wife had something to do with that. Wanting to go on these cruises.
Jack: Yeah she works hard out.
Howard: She told me she just got back from Galapagos Island, she was ... What is the website for ...
Jack: Kennedy, it's www.kennedyseminars.com.
Jack: The official name of our company is Kennedy Professional Educational Seminars. We've shorten it to Kennedy Dental Seminars, or Kennedy Seminars. We've been doing this for 20 years.
Howard: The Americans are thinking Kennedy comes from John F Kennedy. That's not so the case.
Jack: It doesn't. It actually, originated from the street of Winnipeg where it's a long story, but we were tempting to put up a dental specialty building on Kennedy street. In order to get things moving, we had to create a corporation, so they call it Kennedy Professional Center. We have this corporation and then things progressed, and long story short we couldn't get enough interest from other specialist in the city to move into this building and become part owners. It wasn't just moving in, but actually everyone having an equal ownership and building at.
The developer were so excited, he built it himself anyway, because it was just ... All the conditions were right, and we after I did this with the good buddy of mine, he's an endodontics, Wayne Acheson. After the project didn't go anywhere, the lawyers called me and said, "We have this corporation called Kennedy Center. What do you want to do with it?" It was like $500 to create this corporation. I said, "Well I don't want to throw away 500 bucks, so let's keep it." Then we built this building and even though it's on River avenue, it's Kennedy professional Center. Then everything after that have the name Kennedy attached to it.
An interesting story is when we wanted to patent the name, or trademark the name, or I'll patent actually. Initially we apply through the US Patent office, and I got a call from the patent office as they were reviewing my application. They wanted to know if it was attached to the famous Kennedy name in the United States because they were not going to have any part of that. I explain them the story, and we have little chuckle and we got the name trademark. There is this name connection, but not really connected to the Kennedy name.
Howard: Kennedy is my mother's favorite president, only because he was the only [calvic 04:39] president. That's my mom's only equality ...
Jack: Actually Canadians were quite in love with him too.
Howard: They were? Why is that?
Jack: He projected a new era, he's young, and vigorous and smart and he was going to lead the Western world into a new and better place to live. That was our feeling when he got elected, and tragically his life ended a way too early.
Howard: Was the new, and young, and vigorous, and smart. What do you like to teach in your courses?
Jack: Well it ... Many, many years ago it was the whole range of prosthodontics. From TMJ to restoring the endodontically treated tooth, crown or bridge, etc. Then implants came into being, so gradually my lectures change to involve more implants. I've been doing, I've been restoring implants since 1985. Gradually as implant restorations became more popular, and the science became better. My lecture started to switch more towards implant, restorations, and probably in the last half a dozen years. It's virtually almost all implant dentistry.
Although I like to get back to some of the other things, occlusion. Restoring the endodontically treated tooth, dentures, removable, very, very important parts of dentistry. Because not everybody can have implants nor afford implants.
Howard: My whole motto with capturing the internet now, the smartphone is with Dentaltown, "No dentist ever has to practice solo again." These young dentist are walking into these dental conventions, and they're at the largest dental convention in the world is the FTI in Cologne, Germany every other year. Last year at Cologne, Germany. There were 275 different implant companies. You're a prosthodontist, you done this forever. If a dentist was going to buy an implant system is titanium, titanium is it easier for you to restore some systems more than others. Do you have your favorites or are you agnostic and don't care?
Jack: No it's easier to restore some systems versus others. Surgeons then have their favorites, however to ever [inaudible 00:07:05] dentist, what I want to tell them is that you are the quarterback of this treatment, and if you're dealing with a surgeon you got to play the quarterback role. Some surgeons have their particular favorites and that's fine. As a restorative dentist, you've got to be able to restore the case as you see fit and the surgeon really is in a way of subcontractor. Although it's a crucially important step.
The quarterback, and the final nail gets place at the hands of a restorative dentist. What I'm saying is that, you have to work with the surgeon that's working with a system that you can work with. If the surgeon is not, and you're not comfortable then you can either learn that in your system, or find another surgeon. At some cases, many dentist are placing their own.
Howard: A lot ... I try to ask so many questions they're asking. I'm sure some guys is yelling in his car right now. Just tell me your favorite system. Quit pussyfooting around ...
Jack: I'm happy at all. I started off, I mean in 1985 we attended a Nobel meeting in Toronto, professor Brånemark of [Late 08:32] was there. The whole ...
Howard: That was his company.
Jack: That was his company. The whole Swedish surgical team was there, and the whole Toronto team that had corroborated the Swedish research. It was an incredible two day meeting, there were dentist from all over the world there.
Howard: The [clamps of infusion 08:52] how did it go from a Brånemark implant to a Nobel Biocare.
Jack: Well the ... Well initially it was called the Brånemark Implant because he had developed it, and I think they wanted to put a more kind of generic name on it, and unattached his name to the implant that might have actually been his doing, I'm not sure. He was a very humble and modest man, a brilliant man. I don't really know. He might have wanted his name taken off of the implant, I don't know. It became a more generic type of name. I took the course there, and then at the same time, Core-Vent Implants were becoming very popular.
Howard: Core-Vent that was ...
Jack: Dr. Gerry Niznick.
Howard: Gerry Niznick, who later sold it to Dentsply.
Jack: It's had many iterations. He sold to Dentsply, Dentsply then paid him to take it back as my understanding. Then it got sold, and repurchased, and it's had many ...
Howard: Then Gerry Niznick went on to Implant Direct ...
Jack: Implant Direct.
Howard: Then sold that to Sybron Kerr owned by Danaher. Now the rumor is he's back.
Jack: Well, I don't think Gerry has ever left. Truly. I think his heart ...
Howard: What do you think he's going to show up next?
Jack: You know what? Well I'll get to that story soon. We've been ... We started using Zimmer implants. Gerry has a Winnipeg connection. He's actually went to school, at the University of Manitoba.
Howard: Gerry Niznick did?
Jack: Yes he did.
Howard: This is his country place?
Jack: This is his country. I graduated from the University of Manitoba Dental School.
Howard: He's Canadian?
Jack: He's Canadian.
Howard: Born in Canada?
Jack: Born in Canada.
Howard: I did not know that, I thought he's born in LA.
Jack: Yeah, took his prosthodontics, I believe from Indiana not quite sure. I think Indiana. If I'm wrong then I stand to be corrected. I became a prosthodontist and went to Los Angeles and started working there. He is a brilliant man, and ...
Jack: Extremely. The Nobel Biocare Implant was out, he looked at it, and with all due respect to the Nobel people and they will tell you this ethos, they will agree with this, that at that time it was a surgically driven system. The prosthetics was like, "Okay you guys go over there and play with your teeth, because we're the big boys are doing the surgery here." It was a surgically driven system, and they will all agree with that back in early '80s, mid-'80s. Dr. Niznick being a prosthodontist said, "What can I do to make this more friendly for the average restorative dentist/prosthodontist." He did ...
Howard: That was Implants Direct?
Jack: No that was Core-Vent.
Howard: Okay, that was Core-Vent.
Jack: 1983, '84, '85. Then I went and took a course from Gerry Niznick in Los Angeles in, '85. We started using that system, as it turned out the internal connection was a much better engineering design, then the external hex which I don't think exist anymore except in the old style implants. They actually engineer something that was better, easier to restore. We started using it at Marshall Hoffer my partner here in the office and I started using it.
Howard: Why was the internal hex better than external hex?
Jack: You know what? I'm not an engineer but it ... There was much less screw loosening. The ... Again not being an engineer I can just give you my version is that, that for many years, when the external hex is being used, they were lots of studies on the number of screws and implants that would lose, they would come up with these certain percentages. The Zimmer Implants, it was rare, rare for a screw to loosen. I think it was related to the Morse taper of the connection. We started using Zimmer implants, and had a phenomenal success rate with them, over three decades.
Now lately, Zimmer, Zimmer dental implants was bought by Zimmer Orthopedic. Zimmer Orthopedic I think was less interested in that little arm of their company as a business. The orthopedic was just ... That was their main business. Just in the last maybe half a year, they've either merge with 3i Biomet or sold out to 3i Biomet. The ... I'm not really sure where it's at. Everything is called 3i now, and so I think the Zimmer implant I think is still around, but it's 3i is now the company that hasn't.
In Canada 3i has its own customer based, and its own culture Zimmer had its customer base. I think now, they merge the other.
Howard: Another common question we get on Dentaltown is, they're confused about platform switching. Could you say a few notes about that?
Jack: I think it's much to do about not much. I mean the whole key is making a proper diagnosis which takes some time communicating with your surgeon, having a proper Cone Beam CT taken with a radiographic stint, or alternatively using anyone of the systems that are out there, being able to place implants right on your CT and getting the size and the angle, etc, etc. Then planning an implant that's going to go into that space, and then you've got what you've got. To me that was ... It was a huge deal, and I just didn't really, I never got involved that I didn't really need to. When I ... Whether I was doing a single unit or a full mouth of implants.
I knew exactly what I wanted to get where I wanted it through proper radiographs, through proper clinical exams, my clinical exams, the surgical clinical exams which is crucial. I would meet with the surgeon go over the scans, mounted cast with radiographic guides and we would just plan it out and we knew what we were doing. We knew what we wanted to get. That's ...
Howard: Do you have any favorites on CBCTs or surgical guides or implants or?
Jack: Well my answer to your question about the implants is that I've been using Zimmer for 30 years. I use Nobel in particular cases.
Howard: Zimmer is your ...
Jack: Zimmer is my main stay off, I don't really know what's happening with the company. I'm very comfortable with Nobel. I've restored a few Straumann which I love doing, so I was very happy with that. I have a lot of friends are doing Implant Direct who are extremely happy. Those would be the classic four that I would ...
Jack: Zimmer, Nobel, Straumman, Implant Direct would ...
Howard: You ever ...
Jack: I have not restored any others.
Howard: Gerry Niznick the Manitoba process. Do you think he's going to be back in the implants?
Jack: Well he's got his heart and soul in it, I think it's entirely possible.
Howard: He spent his whole life in dental implants I can't imagine him ever saying, "I'm done."
Jack: Exactly. Brilliant marketer, and brilliant, brilliant marketer.
Howard: You're talking to thousands of general dentist. That's mostly anytime anyone I e-mail me whatever is usually a general dentist, and they're usually very young, they're usually within five years out of school. You've been doing prosthodontist for 37 years?
Howard: 36 years. Most of these kids have been out of dental school less than five years. What words or fatherly advice would you give them of. What are common low hanging fruits prosthodontics advice you could give them to keep them out of trouble?
Jack: I think the key is examination and diagnosis. I think it gets treated halfheartedly, it's lip shot and when I give lectures of dental school here. It's the first thing I say is that you need to do a proper exam and diagnosis. Take cast, mount them, proper set of x-rays a full exam.
Howard: You're talking about fore a complex case or what are you talking about?
Jack: I'm talking about most cases. Because the problem is, is that if you're asking me to give advice to someone who's been out for five years. What I'm going to say is that, it's amazing how many times someone will see a tooth that needs a crown, and stunningly not really look everywhere else and get focus on that one particular tooth. Then suddenly before you know it, it's prep. There's a problem, there's other problem at the opposing arch. Perhaps the tooth is super erupted, not enough was remove. I see this all the time.
I see mistakes constantly being made by young practitioners because the examination took ten seconds and they jumped in, and started working. Then suddenly the impression is made, it get sent to the lab and there's a problem of whatever description. I think if in your first five years. I think of someone needs are restorative work of almost any kind. Single crown to whatever, I think impression should be made, mounted, proper exam, perio exam, which is crucial. The first I tell the students when I lecture them.
The first instrument you should pick up is a perio probe. Then obviously proper charting. When you look at those mounted cast, and it changes your whole perspective. Sometimes it's straight forward and then you've got a set of mounted cast, and you've got the opposing cast, away you go. Quite often it isn't, because it gives you a whole different perspectives. That would be my first strong suggestion to new graduates. I tell the students that I lecture to, you need to look, you need to think, you need to assess what's going on.
You need to ask, and ask means ask your patient, ask your staff, ask the dentist, that the patient came from prior to seeing you. Ask can mean anything, but get information and then action is the last of the five. This is what I tell the third year class. When I lecture to them, is that you're actually doing something five steps down the road. Look, think about what you're looking at, assess the situation, ask and then act. Act might be whatever. That may also mean not treat them, saying no, is an option. The patient saying no to treatment is one of their options.
Unless there are ... People have a right to make bad decisions for themselves, you don't want to hear that, and you don't want to see that. But they do, and so saying no to a treatment plan is an option that patient has, and as for your lecture yesterday, many people exercise that. A dentist saying I can't help you, is also another option. Setting that aside, those are the five steps that when I lecture to students, that's what I tell them. Another piece of advice would be, don't be the first person on the block to buy the latest and greatest and all that. I think that's a mistake.
A lot of companies are out there pushing products that haven't been tested properly. You just don't want to be the first person out there, grabbing onto something. I believe you mention that in a lecture as well, I've heard you lecture before. You mention that in Calgary. I think it's great advice.
Howard: You had a very successful prosthodontic office for 36 years. Talk about your high end technology, do you own a CAD/CAM, do you own an optical scanning for impressions?
Jack: No, no, no we have a dental lab down on the main floor. We have a i-CAT machine here.
Howard: The i-CAT a CBCT, owned by Danaher. What I'm getting at is my prosthodontist friends, I generally don't meet prosthodontist with CAD/CAM CEREC machines.
Jack: I don't have one.
Howard: You're looking at students that have $350,000 student loans, and due to marketing impressions, they feel like they have to have one. I'm sitting there saying, "Okay, here's a really successful prosthodontist for 36 years. He doesn't have one." Tell them how you are able to be a prosthodontist for 36 years without $350,000 CEREC machine. Is this ... Do you call this the miracle of Manitoba?
Jack: No, it's not a miracle of Manitoba. I have a referral based practice. People get referred here, and for examinations, diagnosis, treatment planning. I treat what comes in the door. Dentist are not going to refer patients to me that need a couple of veneers and nor should they. I typically get patients that get referred, that have complex dental issues, and it doesn't mean their entire mouth. It could be a mouthful of teeth, where they've been unable to chew on one tooth for a year, and no one can figure out which tooth it is. It doesn't have to be a full mount of teeth.
I do the traditional tooth preparation making a temporary fabricating and temporary taking a polyvinyl impression. Having the typical dental laboratory technician. Wax it up, we do a lot of PFM, Porcelain-fused-to-metal. I use gold, and I'm doing some all ceramic crowns. That's the nature of my practice, and if you're in that kind of debt, and you ... To me someone who's graduated in the last five years, they need to get their skills up. They need to get their skills up. To me that's where you start. You got to watch your debt load, debt is extremely injurious to anyone's financial health.
Some debt's important, but you need to get out of that ultimately. You need to get your skills up, just start the traditional way and if it works for your practice. Ultimately to buy a CERAC machine then maybe do it down the road.
Howard: Are you impress with the quality of crowns you're seeing at a CERAC, out of CAD/CAM machines in your backyard, in Manitoba? This is Dentistry Uncensored with Howard Farran. We don't sugar quote everything.
Jack: Well I can't speak about CERAC. Because I actually don't see them, I don't really see them. I don't have a machine, there is a few dentist that in town, that are doing it maybe more than a few. I've seen their work and it's very nice. From that standpoint, there are nice restorations, they're good restorations. Some of the CAD/CAM crowns that are made, I would not cement personally. I have colleagues really around North America that travel with our seminar company that are not terribly thrilled with some of the results they're getting. Of course it's a very, very controversial, it's at a very controversial stage right now.
From my own standpoint personally, I have not been happy with some of the quality that I have not seen. I know dentist will tell me, "Well if it's ... If the margins are open, a hundred microns or so that sort of okay. Using an appropriate cement, and perhaps it is. I have mix views on that right now. I'm sticking with the Trident Trio.
Howard: I want to ask you another question. My deal with Dentaltown is that these people are all loan, and trying to connect them. A lot of these young kids are confuse because they feel like they should pursue their education, learn about occlusion and there's very distinct cams. You have LVI, in Las Vegas talks about neuromuscular occlusion. Then there's this Dawson-Pankey with other types of occlusion. Its occlusion, occlusion, occlusion. These [inaudible 00:28:25] you have to pick a camp. I mean should they do gold neuromuscular, should they go Pankey-Dawson occlusion.
Then there's people out there that say, "You know what? The occlusion, all those camps are ... They're like religions. People just believe stuff with no evidence. Is occlusion voodoo, is occlusion religion or is science, is it more neuromuscular, is it more LD Pankey. If you're talking to your 30 year old granddaughter that just walk down dental school, and she said, "Grandpa I need to go to, I want to study occlusion." What will you tell her to study, or would you even tell her to study at? At this point you just want to leave the lecture, the [inaudible 00:29:03]
Jack: Exactly and I'm looking for the closest escape hatch here. Well occlusion is very important. I think some camps have turned it into religion. I stand very strong with some of the science that has been out. Teeth come together and they touch, you hope.
Howard: Not when they chew.
Jack: Right. That's right. Up until perhaps that last bowl of food is down to maybe tiny, little, thin little pieces. When I first got back from graduate school, both of us got back. My Marshall Hoffer myself. We were asked what occlusal scheme do you subscribe to? It was like, "Well we don't." Okay, we don't have an occlusal scheme that everything is going to fall into that pattern. If I have to ... Right now, it is and I'm going to create a lot of controversy about this.
Jack: Right now, it's ... My opinion base on the best literature that I can read that the neuromuscular approach in my opinion doesn't have the science behind it that I ... That would work for me. I know that there are people that are doing it, and that's fine and it's working. It might be working because man is a highly adaptive organism. I don't subscribe to that. If I had to pick something, I would pick the Dawson-Pankey and I think they give great courses down there. The thing is, is that you need to go down there and take a course, and take out of it what is going to work for you and what make sense.
You need to read, and all of the books on occlusion. You need to really, when you get back to your offices. You need to really thoroughly examine your patients, and this goes back to examination diagnosis and treatment planning. You need to start thinking about what it is that you need to do from an occlusal standpoint, and what and what is it about occlusion that really you don't need to worry about. Because as a prosthodontist, I look in people's mouth every day, and it is so highly variable and people are functioning fine, and there's no pathology, and they'll have a contact here and a contact there and another contact here.
They're 70 years old, they've got a healthy dentition with no pathology, and you look at that, and that doesn't fall into any occlusal scheme. Suddenly you're asked to put in a crown for that person. Of course you want to have some ideas about the type of occlusion you want on there, to me you want to load it along the long access of the root if possible. You don't have balancing interference's, depends on working, the [extersions 32:43] whether you want to include the tooth or not.
There's also basic concepts that you want to follow. The answer to your question is, I don't think you want to fall into a camp. I think you want to look at this, look at the rationale behind it. Read about the histology and pathophysiology of the periodontal ligament. Learn about force generators and force direction. Study about the TMJ and you each practitioner will end up, having their own scheme within a scheme for lack of a better work. They'll do what works for them, and as long as you're adhere to some of the basic principles. Long answer to a question.
Howard: Is it overly cynical for me to fill that some of this TMJ camps will get a device, a measuring thing have that deal. Because when they get done, with a diagnose and treatment plan. The only way they can fix you is crown all 28 of your teeth. That seems to be more about big money. My my very cynical saying that? have you felt that sometimes over the years?
Jack: No I agree with your cynicism. I think that, TMJ is a whole different topic, and when it comes to that, I really believe you need to really delve into the literature and look at the literature and look what it's telling you, and look at what it's not telling you. Try to understand that the jaw joint is probably the most complex joint in the human body. It's highly adaptive, under crazy circumstances. You can abuse the heck out of it. People that ... I've been asked to adjudicate cases, where patients got into a car accident and we're hit from behind by a car going 100 kilometers an hour, 60 miles an hour.
Whiplash the whole gamut, soft tissue injuries and then they develop TMJ. Quite frankly their problems are way beyond that, and they get into a hands and I've seen this, I have seen these cases come through. Various insurance companies that end up landing on my desk and they'll have a full complement of teeth and they're doing quite fine before the accident. Next thing you know someone is suggesting they crown 28 teeth in their mouth in order to treat their TMJ problem and it's just not reasonable rational and there's nothing to suggest that those crown is going to help that person in that type of situation. There are many off shoots of that as well.
My TMJ treatment are extremely conservative, extremely conservative. I sent a lot of patients out for physio therapy, physical therapy. Because a lot of it is soft tissue. People who [brex 36:13] or clinch obviously need a process night guard which I make, which in my view has to cover all of the teeth.
Howard: Top or bottom?
Jack: I make top because it's just much easier to develop the most ideal occlusal scheme that you can in my opinion in my hands. Although bottoms, bottom splints work equally as fine. The key is to cover all the teeth. Because I again, I've been called in to treat people who are wearing this little unilateral splints or splints that just cover a couple of teeth.
Jack: Yeah, or whatever they're called. Splint seat cover, there's many different iterations of it, that cover a couple of teeth. Two, three, four, five years later. Their occlusions are in absolute mess, and so the same group of new grads think about what it is that you're doing, and follow establish practices. Follow a establish practices before you get out onto some ledge because you went to a lecture and you heard something and it sounded cool. Follow establish practices, get your skills up, patient brex, well they need a splint.
Establish practice is to fabricate a splint, upper or lower. I make uppers, but whatever that cover all of the teeth with a proper balance occlusal scheme, etc of the patients wear it at night, or during the day or whatever the diagnosis is. Those are ... That's sort of the standard approach. The classic TMJ patient I think the word is being often overused for lack of a better word.
Howard: Okay, I want you to answer this question for. I know she has a [slot 00:38:30]. When can I just take for ... When is it okay to just take a sideless Triple Tray impression. When do I need to cross line and take full upper and lower impressions, and when does it cross the line where I have to get out a facebow transfer, and mount this cast on a semi-adjustable articulator.
Jack: Well there's literature out there that the Triple Tray works fine, and again there are practitioners that I've used it once because I wanted to try it out. Okay? There's lots of literature out there that support the fact that you can get very well fitting crowns. I think that, if I have to pick some criterion, you want to have a lot of occlusal stops on the teeth, in the quadrant, and the opposing quadrant that you're working on. That these things can get mounted properly. If you're working on a posterior molar, and it's the last tooth in the mouth.
Let's say a lower right second molar and then the next tooth is a first bicuspid, and then a cuspid. I think you're better off, taking, making, using a tray that will capture the whole mouth. I think you'll end up with consistently a better result. Although people are doing the Triple Trays there, and they're saying it's fine. When I hear that, I don't know what it's fine means. Quite honestly. That would be one of the criterion, if it's the ... If you're missing a lot of context, and it's a terminal tooth, I will take a full tray.
If you've got a full complement of teeth, and you're doing a single crown, or a couple of crowns, then I think the Triple Tray is fine. It's again it's new students when you speak to labs around and they will tell you. New students are having trouble taking impressions that show the margins. To me, it goes back to the beginning, for these new grads, 0 to 5. Get your skills up. Learn how to take a great excellent impression that captures all the detail that you want to capture. Then go ahead and use your Triple Tray, but the problem is, is that they're trying to pay the bills, they're getting busy, they're in my opinion rushing.
Trying to do the latest and the greatest, and they're not getting the basics done. They get onto school, how many crowns have they done? Two? Three? One? Some schools? That's a whole different story. The next thing you know, they do one crown, or two crowns in the school under supervision now, they're out there and they want to do a whole bunch of crowns, and they hear this Triple Tray, and then I talk the labs all over the country, and it's like they're getting impressions that are not readable. You need to go back and say, "Okay where is the issue?"
It's not the Triple Tray, that's not the issue. The issue having a proper preparation, learning how to pack retraction cord, learning how to take a good impression. That's ... You have to get back to the bottom.
Howard: What is your favorite impression. Are you a polyether man?
Jack: No, I use polyvinyl, I use extrude ...
Howard: Who makes extrude and imprint?
Jack: Yeah and imprint. Extrude is Kerr.
Howard: Extrude is Kerr.
Howard: And Imprint?
Jack: Yeah I'm not sure. Yeah. Getting back, that's that. Now if you're doing multiple crowns. You want to have a full tray. To me, they should be mounted on a semi-adjustable articulator. Where you want to get into a face bow is where you ... You could make an argument for doing a face bow for any posterior crown. Because the face bow just translate the ark of closure, that's what it gives you. You could make an argument, and I wouldn't do a face bow for single crowns. You can get inexpensive Hanau articulators that have a little jig that you screw on the bottom mounting plate, that you put the upper cast on that simulates the position of a face.
It's obviously not the same, but it's very, very close which I use all the time. You can do that, and it's maybe two extra minutes in the lab. You mount your upper cast first, on a jig lining it all up. It's all been engineered to simulate a face bow. Then you ... You're not obviously doing the Triple Tray here. You're now doing two separate impressions. Then you mount it, and then you've got something even closer, than it would be if it were a hinge, obviously. Then the major full mouth, those are the types of things you would want to take face bow on.
Where you're ... If you're doing, if you're doing four crowns, let's say lower right. cuspid first by, second by first molar, there's no second molar. Okay? It doesn't seem like a lot, but your changing half the occlusion, really. It doesn't take much to get to a point, where you're really making a major change in the occlusal scheme. You need to look at that, and say, "This isn't just for crowns, but I am now getting involve in half of this patient's occlusal scheme, and depending on what's going on, on the other side. It might even be more than half." It doesn't take too many units of crown or bridge to affect some major changes.
Sometimes it can turnout negatively, that type of case you might want to take a facebow. It all depends on kind of where you're at personally. I don't use the Triple Tray. I take either ... I'll take a full tray, and I'll cut it on the opposite side to what I'm working through the cuspid and bicuspid. I'm going to capture 2/3 of the arch. Then I'll do an opposing the same. That's about the smallest tray that I will use.
Howard: What about [seamning 46:01] your PFMs?
Jack: Zinc phosphate. They did, and this study goes back, number of years that they did a study where they survey general dentist and specialist, prosthodontist. The vast majority of prosthodontist. The vast majority of prosthodontist at that time and the survey goes back a few years, we're using a zinc phosphate type of cement. It was just very interesting, and the general practitioners at the time were using resin modified glass ionomers, things like that. For my cases, I use zinc phosphate, I use resin modified glass ionomer for my all ceramic crowns.
Those are my two cements. The reason I use zinc phosphate it's ... I do a lot of PFMs, I do their bonnet, the crowns are [inaudible 00:47:01] gold. These are high noble alloy from Jensen. As often as I can, I will use a small metal color on the labial, and on a bevel edge, 45 degree bevel something like that. We have our own lab downstairs, so the ... Our gold technician downstairs is outstanding. These crown fits beautifully. Zinc phosphate cement has stood the time for a hundred years. It works, I don't have the need, I could use resin modified glass ionomer. I just, I'm fine but what I'm using is ...
Howard: Isn't it the least water soluble?
Howard: It also has a bacterial static component with the zinc.
Jack: It's the least, it's ...
Howard: It's always a red flag to me, when [inaudible 00:47:56] other cements are saying, "Yeah this cement is good, this cement is good, this cement is good." If it was a mandibular second molar, and you didn't know if you could have it dry all the way, and there might be recurring decay. You definitely want to go zinc phosphate. I was saying, "Well then why wouldn't that be your first choice on every crown." I mean if it's what you need when the going gets tough, why wouldn't you use it [crosstalk 00:48:19]
Jack: I mean you could imagine when it gets referred to the office. Okay? I deal with treating mandibular second molars and maxillary third molars, and some mandibular third molars where the teeth have decayed into the furcation. I mean this is what gets referred to me. When someone says, "Well I don't know if I can get a dry field." Well I say to myself, "Get a dry field." If someone says, "Well I don't know if still decay there." Make sure there's no decay there. I don't understand that thinking at all.
It takes time to do this, you're working on a third molar, or a second molar that's decayed down the distal to osseous, into the furcation. Take the time to fix it properly or refer it out. Refer to a prosthodontist in your area that will deal with that. The comment that, "Well I'm going to use this cement, because I don't think I can get it dry." I haven't had that issue. I cannot get an area dry. It might take me a little time. When I get a case like that, we live in a ... prosthodontist lived in a different world.
I might need an hour and a half just to get the decay out and make a temporary crown. It might take me that long, because of the access, because of patient issues, if that's what I'm doing. I know darn well, if there [properioal 00:50:10] surgery after that, and periodontist love it ... Our periodontist love it when they get a case where there's a temporary crown, because they like doing the [perial 50:22] sur- Taking the temporary crown off, doing the perial surgery, recementing the crown back on, sutchering around the temporary crown. They love getting cases like that.
If I can make their job easier, and ultimately mine. That's what I will do. It's not uncommon for me to be treating a tooth like that and taking that much time just to get a temporary on.
Howard: Tell me this, most of my periodontist for instance tell me, that if they practice in a five mile radius. It's like 10% of the general dentist refer like 80% of the crown lengthening, and there's ... You're talking to ... There's dentist out there, they do that all the time. You're talking to other dentist out there, they haven't done it once in the last one, two, three, four years. Haven't done it one time.
Jack: Or 20.
Howard: Or 20. Talk about that. Why do we see that? Why do you some people never do it. Some people do it all the time?
Jack: My question, my question is for the 80 or 90% of dentist that are not referring out crown lengthening. My question is, what are they doing? Are they doing it themselves?
Jack: They're ignoring it? Okay. Well to me, that's not proper practice.
Howard: Explain it, because it's huge in America. It's huge. I don't know if it's huge in Canada.
Jack: Well I assume that there's a lot of similarities.
Howard: What are you seeing why you do crown lengthening and what do you think they're not seeing if they're just not doing anything about it?
Jack: Well they ... if you have decay down to osseous tissue. I don't know how you can have put a crown over that tooth which invades the epithelial attachment, and not have chronic inflammation down there. I don't know how you can do that. When you're invading the biological attachment like that, you need to do a crown lengthening. I think what's in my opinion, you need to do a crown lengthening. Periodontist would obviously agree with that. Now, so I guess my question is are not according to your statistics, 90% of the dentist that aren't referring, if they're not doing the surgery themselves, which they're taught how to do in dental school, they can certainly do it and maybe they should consider doing it.
If they're ignoring it, that's not proper practice. If that's being ignore that often. That's not good for the patient, not appropriate treatment, not healthy for the area or the patient and it's not proper practice. That's what's happening. I would be ... If that's an accurate statistic. I think it's sad, that, that's going actually. Then there's various levels of it. In my practice, I will look at the situation and if I have got a problem, let's say for example decay, that leaves me with a very, very, very, very narrow sulcus, or shallow sulcus, and it is quite deep subgingivally.
I might say to myself, I can restore this, but it will be a much healthier area if we do the crown lengthening. I can tell you, that when I get these crown lengthening back from periodontist, it's a whole different tooth. It's a whole new deal, you've gone from something compromise to something that is just so clean and will be easier to maintain, easier to look after. Healthier tissues, it's a much better treatment. After 40 years of practicing dentistry, 36 prosthodontist I still look at these coming back from a periodontist, that off where the crown lengthening has been done, and I am saying, "Wow I'm glad we did that. Because this is just a clean great situation that's going to stay healthy for hopefully a long time."
Howard: In your 36 years ... 36 years ago, implant was kind of experimental. Wouldn't you say? I mean there were blades, and subs, and [Remus bars 55:18] and a lot of the early guys doing it, were kind of bad mouth by their peers as being crazy. It was a lot of bridges and removable partials. Now that implants are more mainstream. Is the 3 Unit Bridge going to go the way of the dinosaurs?
Jack: Well ti's certainly going that way in my practice. Because when you look at the statistics, and some of the best articles are to read are from Dr. Dr. Charlie Goodacre. When you look at it ...
Howard: Where is he at?
Jack: He was the dean of Loma Linda, he is retired, but he still in dentistry. A wonderful man.
Howard: Do you think, you can fix me with a podcast with me?
Jack: I think he would probably do that.
Howard: Well can you, do you e-mail him?
Jack: I could.
Howard: Yeah, e-mail him and CC me at email@example.com.
Jack: Okay, I will do that. Wonderful man.
Howard: Now they're in Redland California?
Jack: Yeah Loma Linda.
Howard: That's where I took my boards.
Howard: That's the oldest living zip code in the United States?
Jack: Was that right?
Howard: Did you read the book The Blue Zone?
Jack: No, no.
Howard: The Blue Zone is studying around the world, there's ten cities that have ten times the amount of people living to be a hundred and they all have the same thing in common there. Mostly vegan, they're religious, they're ... Very interesting. The only place in North America is Redlands. They're Seventh-Day Adventist. They eat a Old Testament biblical plant based diet. They also don't have many amenities like cars that's more walkable society. They were likely to walk to the grocery store every day and walk back with these food.
Jack: Guys are wonderful man, wonderful man. His articles are ... I think if you want to read collection of articles, his are the ones to read. The 3 Unit Bridge I think is going the way of the dinosaur. I think an implant place in the edentulous space is a far superior long term treatment. Again missing a lateral incisor last thing you want to do, in my opinion. Is a bridge from a cuspid to a central. An implant in the lateral incisor all things being equal okay because there are exceptions. An implant is a far better treatment.
I've gotten to a point where if someone young, comes in. A young, a teenager 16 to 19 or 20. They're not quite old enough to have an implant but they want that space filled. I will do in order to preserve the integrity of the cuspid in the central. I'll do a Rochette bridge, very conservative. Maryland style bridge with holes through the wings, Rochette bridge. You can get it off, you don't have to prep the teeth, assuming that the occlusion allows you to get something in there, like that. I will do that to tie them over until they're ready to have an implant. I absolutely will not prep those teeth.
This is my own particular philosophy and I'm not saying it works for everybody. But I will not prep those teeth. If they can't have an implant, I will get them by with a relatively inexpensive Marylander Rochette style bridge. I've had them on patient's mouth for most of them for over a decade. They do de-bond, and you can ... Because the holes on the wings are what's holding it in. You can go in with a quarter round bar, just go through each little hole and just pop it off, clean up the internal wings, roughen up the lingual aspects of the two teeth.
Freshen it up, etch bond, recement it back on. I would rather do that, and allow the patient to make a better choice for themselves down the road, than say, "You can't afford an implant, well I'll prep the teeth and do a 3 Unit bridge. I absolutely won't do that.
Howard: Final question, and then we're out of time. Final question, wonder this all the time. They do a single implant the most common missing tooth is a first molars, and the most common implant is a first molar. Would you cement that, or would you screw that?
Jack: For 20 ... The first 25 years of my implant career, I cemented them. I'm doing Morse screw retained now. I know, and once again he talk about this cult and this sort of ... There are people saying. "You've got to do cement, and other people say you got to screw retained. I do both. Although I did cement retained crowns for the vast majority of my implant career. I'm doing Morse screw retained now, and it depend ... The answer to your question is, it depends on what is going on in the adjacent teeth. It depends on what is happening on the opposing arch.
If you have got a brexxer or a clincher. I would absolutely do screw retain, so you can get it off because under those conditions, a lot of screws will loosen under those conditions. You're just easier ... It's easier for yourself to be able to unscrew it. I would do that, in those particular situations. It also depends on the angle that the implant has placed, and the path of insertion that's created by the screw X of angle. Because having good context is extremely important as we all know. We'll talk about the occlusion in the second.
If you're replacing your first molar and the implant is a little off. You need to look at that screw X of angle, and figure out if I do screw retained, and one of the by, is perhaps tilted a little bit. What kind of contact am I going to get with that. Certainly you can do an odontoplasty on distal or the by, depends on the degree of tilt etc. You got to be very, very careful. You can't just approach it from a blanket standpoint. Again this goes back to cast mounted examination, look, think, assess, all of those five tenets of in my opinion of clinical treatment.
You need to look at that. If it's everything is standing straight up, and everything is in beautiful alignment and you can get a good wide implant in there and or long implant in there, the surgeon places it right where you want it, and the screw X at angle is coming straight up then pick it, pick it. I like to develop occlusions better on cement retained crowns, implant occlusions on crowns that have been cement retained. It's ... I feel I get a better a occlusal result because I try to load it at the long access of the implant.
Well that's where the screw hole is. There's nothing to load except the covering you put over it. You're loading it somewhere else. I don't like to load these unmarginal ridges, I want to try as best as possible to get the load factor as close as possible to the long access of the implant. That's another factors whether you're going to use cement, or screw retain. You need to get your mount of cast, look if it's the lower molar, look at the opposing arch. Look at the palatal cast of the opposing tooth. You don't even need to do a wax up, although at some point you may have to and say, "Where is that going to land on my occlusal surface. And make a decision like that."
To me there's pros and cons to both, I think you need to assess it. I've done both, I'm happy with both, the context, proximate context, screw X at angle, occlusion, and load factors are all extremely important which we'll ultimately help you make a final decision.
Howard: How can these homies contact you, what's your website? Www.kennedyseminars?
Jack: Well Kennedy Seminars is our travel ...
Howard: You've been doing these seminars for 20 years, and it's mostly high end prosthodontic education and resort fun travel location.
Jack: It's outstanding education. It's not prosthodontic, it's everything. We've have had periodontist ended on a surgeon's prosthodontist. Pediatric dentist, all speak. We've ... To us, essentially it's a company we started in 1996, Marshall Hoffer and I. We started it essentially we advertise across Canada. He and I lectured. We put the ... We were going on a cruise ship for a week, in the Caribbean on the Regal Princess. I'll never forget it. Cruise ships at the time were so not use to doing this kind of thing, and we took a dozen carousels, 1200 slides, in a slide pack up, the huge binder of slides.
17 dentist across Canada signed up. We went on a cruise, had an outstanding time. Just fabulous time. We came back, we say to, the travel agent that we had connected with. "You should be doing this again." We said, "Okay." The next year we did two trips." We did a cruise and we went to Sandals, I think St. Lucia, 1997 and Marshall and I went. The travel agent said to us, "There's three ladies, Wendy, Judy, and Cathy at the agency." It's a huge international travel, our company Carlson Wagonlit.
I remember Wendy saying to us, "If you keep doing this, you're going to get a following." I laugh at her, because I thought it was a ridiculous. If she's watching this, she's going to chuckle because she was right. We went to 1997, had a fabulous time, and then we came back and said, "Well let's see where this goes." In '98, we ran a couple of tricks, and then we started adding a trip and then hiring people to lecture. Then we got our [ADA Surp 01:06:46] qualifications we apply for that and got that. We've been Surp qualified for 10 plus years.
Then the trip started to get fancier, more involved because our customers that were coming back over and over didn't want to go to the Caribbean. They wanted to go somewhere else. They wanted to go to Europe, they wanted to go to Asia, they wanted to go to South America. We then hired a website company and created a website, we hired a marketing company. Then the world became our oyster so to speak. We've been to 44 countries.
Howard: Holly molly. 44 countries in 20 years?
Jack: In 20 years, we've been to 44 countries. We've done multiple Mediterranean cruises, Black Sea, Baltic, Danube, the Rome, in France, we're doing the Douro in Portugal, in '17. We've been to China, Thailand, Bangkok, Vietnam. We've been to Australia, we've been to South America, Rio de Janeiro, Buenos Aires, we're doing the Antartica in 2017, doing Spain and Portugal in 2017. We still run a hot several hot holidays in February and March. We tie in with the Ontario midterm break, in mid-March.
Howard: Are these mostly Canadians going?
Jack: No we have a lot of Americans coming. Although we're ... I'll get to that in a minute.
Howard: Are those the lower class [sale boys? 01:08:33]
Jack: The dentist from Kentucky. We go to Turks and Caicos, which is beaches Sandals there for I think this is our fourth one this coming March. That's a hot holiday. We're doing Barbetos in February. We're running a hands on implant course in Barbetos. We're running a perial course with Dr. Howard Tennenbaum, Perio Oral Path course in March. Jack Griffin Jr. is lecturing in Tahiti for us.
Howard: Jack Griffin Jr? Love that guy.
Jack: Yeah, no he's super, super guy. He's lecturing for us in Tahiti this coming January. We're going to Poland and Israel.
Howard: I did a podcast for Jack Griffin Jr? Can you line that up?
Jack: I can line that up. I'm doing up ... We're going to Poland and Israel in September, and then in '17 we have a whole list. We actually ... We actually are now spending a fair good of time on this little side business. Because when you're taking a hundred people halfway around the world, you need to have your act together.
Howard: It's grown to now a hundred people to an event?
Jack: It's more, it can be more. Sometimes the venue restricts the number of people. For instance, when we went to South Africa, we chartered the blue train. The blue train is one of the five great train rides in the world. We chartered the whole train, and to the point where they actually put on a special run for us. We went from Cape Town to Johannesburg, and we had to go in a certain day. The train was not running that day. They put the train on for us. The train had 36 berths. Our trip was restricted to 36 couples. Sometimes the venue determines the number of people.
Howard: How long was the train running?
Jack: A day and a half, it was spectacular. Ended up in Johannesburg and we did lectures in Johannesburg.
Howard: I heard the train across Russia is pretty neat too?
Jack: Yeah I heard that too. We're not going there anytime soon. That's not in the cards for us to go there. Sometimes the venue determines, the ship in Antarctica is a smaller ship so they have limited cabins. It depends and then Turks and Caicos we've had 200 people. It just, it varies on the venue, the time, the type of trip, and these are high quality trips, we have usually besides myself and my wife, as host or Marshall and his wife Rochelle our host. Besides that we'll have 4, or 5 guys when we were in South Africa.
We had guys with us right from the get-go. They flew on the ... When we went in on the blue train from Cape Town to Johannesburg. They flew and met us in Johannesburg, and they were with us all the way through the Safaris. When we were in China, we flew to Chinese English speaking guides from Vancouver to China to be with us. These are top quality trips. In India, we had a driver, three guides, plus Debbie and I who are on that trip host. Everything is looked after, from ... It is [inaudible 01:12:26] as you seen in Canada.
Howard: Debbie is so adorable. She is adorable.
Jack: Thank you, she does a lot of work on these. These are ... We are opening up the American marketer. Most of our Americans are along the Eastern seaboard that travel with us. I think the California, Oregon, Arizona, dentist ... Maybe they vacation differently. I don't know. Because they're living in better weather all the time. Maybe they look at, I don't have an answer to that.
Howard: I think it's a statistical though. Three out of four Americans live east of Mississippi River. Two out of three live within 500 miles of Washington DC. No matter what ... If you're talking about eating candy bars, or drinking Dr. Pepper. It's all in the Northeast. I mean if you fly from New York to Phoenix. I mean the first hour out it's just all lights, DC and then it's just pure darkness. There are just no density out there. From the Mississippi it's not until you get back to California where 10% of Americans live. There's just not anybody ...
Jack: I think they might vacation differently. I mean I honestly don't know.
Howard: It's probably an equal sampling for thousand. Because it just shows up looking like it's on the Northeast. It's probably an equal.
Jack: We are ... We have an outstanding seminar coordinator now. Her name is Roxanne, she is superb, talented, organized. She thinks out of the box. She is now really pushing the envelope on what she wants the company to do. We are now starting in 16, we are going to have an unofficial connection with the FDI. FDI is in Poland in September 2016. We're doing a pre-FDI trip in Poland for five days, and a post FDI trip to Israel. In 2017, the FDI is in Madrid Spain. We're doing a pre-Madrid trip for a few days, and a post Madrid FDI trip Portugal Douro River cruise and a post trip we're going to go to Lisbon for a few days.
There's the sort, we're unofficially tying up with the FDI because we're not connected with them. We'd like to be, we're making some communications. What we're doing now with the American Market is we're now polybagging the ADA news. We used to advertised two or three times in the ADA news which is how we pick up our American customers. We're now polybagging. We're putting one cage brochure for lack of a better world in I believe it's the late January edition of the polybag. The ADA news. It's going to go out to 180,000-200,000 dentist in the United States. Whoever gets the ADA news. We're going to be at the Chicago Midwinter with the booth. We're pushing the envelope.
Howard: When in Chicago midwinter? February?
Jack: Yeah, February. We're pushing the envelope. It's ... We have had customers we turn five, ten, fifteen times. Many of our trips half are returnees, multiple times and new people obviously of course. You talk to any of our customers, these are well organized, outstanding trips. The CE is top quality, we get ... We hire top quality lecturers, researchers, clinicians, and so the CE is excellent, certified by the ADA Surp. You go and interestingly enough. When we did our first trip in 1996, 100% of the dentist signed up, stayed for the lecture.
Right now over the last 20 years, our retention rate in the lecture is probably around 80-85% so what's interesting which I think is wonderful is that dentist really want to learn. When you're sitting on a boat, and you're in the Caribbean, and it's 85 degrees Fahrenheit outside, and the sun is shining and the waters are blue, and you're sitting in a lecture theater, and you're not living and I was at ... I hosted the lecture where they actually, when the lecturer quit, they actually told them to show another hours’ worth of material, when you're on a cruise ship and you're sitting on a lecture theater, you want to learn something.
It's heartwarming to see. It's been a wonderful experience, and I would encourage everybody to get onto our website and take a look www.kennedyseminars.com.
Howard: I mean I love dentist, they're a huge readers. They love to learn, no matter what country you go, they've got five, six, to, ten, twelve years of college. They're always top 5% income, it's great to hang out with dentist. What I can say is that when you go to a foreign country by yourself. You don't even know what to do, you don't know where to go. When you go on guided trips. I mean I've gotten to so many countries. When you go in on a guided trip, it's so much more for fun and rewarding.
Jack: The bond is there, because everybody is a dentist. They don't talk about teeth, but they have a commonality of interest.
Howard: I'll give you a classic example. After living in Phoenix for 20 years. One time we're staying at a resort and they always have this pink jeep tour in Sedona. All the tourist stood. We just sat there, and thought, "Well you know what? Why don't we just go on? We live here, we don't need that." My god I can't believe I miss that for 20 years. That was the coolest thing I'd ever seen in Arizona. It wasn't on a tour guide. Hey thank you so much for your time.
Jack: Thank you, thank you it's wonderful. Thank you very much enjoy talking to you, and I enjoyed your lecture yesterday. It was outstanding. People are still talking about it.
Howard: What it guess the party afterwards, and the Polar Bear Museum and the Humanoids?
Jack: The polar bear were just ... That was boy we just hit that on the nail. Watching those bears swim in the water.
Howard: All right well good to see you.
Jack: Thank you.