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VIDEO - DUwHF #912 - Arun Garg
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AUDIO - DUwHF #912 - Arun Garg
Dr. Arun K. Garg is a nationally recognized dental educator and surgeon who for over 20 years, served as a full-time professor of surgery in the division of oral and maxillofacial surgery and as director of residency training at the University of Miami Leonard M. Miller school of medicine. Frequently awarded faculty member of the year by his residents, Dr. Garg is considered the world’s preeminent authority on bone biology, bone harvesting and bone grafting for dental implant surgery and has written and published a dozen books and related surgical manuals, along with a dental implant marketing kit that has been translated in multiple languages and distributed worldwide.
He has been a featured speaker at dozens of state, national and international dental association conventions and meetings including the American Academy of Periodontology, the American College of Oral and Maxillofacial Surgeons and the International Dental implant Associations Dr. Garg earned his engineering degree from the University of Florida and completed his residency training at the University of Miami Jackson Memorial Hospital. He is also the founder of Implant Seminars, a leader in postgraduate dental implant continuing education, a company that offers a variety and hands-on and lecture-based courses.
www.implantseminars.com
Howard: It's just a huge honor for me today to be podcast interviewing a legend in implantology Arun K. Garg, and K stands for Kumar. You might have seen his movie Harold & Kumar Go to White Castle hamburger. When was that your younger brother or older brother ?
Arun: That was me in my old days.
Howard: That was you in your old days? Dr. Arun K. Garg is a nationally recognized dental educator and surgeon who for over twenty years served as a full time Professor of Surgery in the division of Oral and Maxillofacial Surgery and as director of Residency Training at the University of Miami Leonard M. Miller School of Medicine. Frequently awarded faculty member of the year by his residents, Dr. Garg is considered the world's preeminent authority on bone biology, bone harvesting, and bone grafting for dental implant surgery. And has written and published a dozen books and related surgical manuals, along with a dental implant marketing kit that has been translated in multiple languages and distributed worldwide. He has been a featured speaker at dozens of state, national, and international association conventions and meetings including the American Academy of Periodontology, the American College of Oral and Maxillofacial Surgeons, and The International Dental Implant Associations. Dr. Garg earned his engineering degree from the University of Florida, and completed his residency training at the University of Miami Jackson Memorial Hospital. He is also the founder of Implant Seminars, a leader in Postgraduate Dental Implant Continuing Education, a company that offers a variety of hands-on and lecture courses. And also I gotta do a big shout out because you just did something that I think is just amazing. If you go to amazon.com, Arun has a new book out and it is called Practical Implant Dentistry by Arun K. Garg DMD. And I've been telling you homies for years that the cheapest, fastest, highest quality, easiest way, is to just read a damn textbook. I mean this thing's only $64, all the reviews are five star. Just go there and get a book, and then when you go to Arun's lecture, you won't be sitting in the front row and he's speaking over your head. You already have read his damn book. And then when you go there, it's kind of like in college, the people who read the chapter before the lecture already knew what they were stumped on. So they could ask questions about what they are stumped on while everybody else was cramming the night before and didn't find out until eleven o'clock at night that they don't understand something on the test the next day. But my God do you ever sleep man?
Arun: I don't know man, I feel like the hardest working guy in dentistry.
Howard: Well you are and you're all around. So implants is the fastest growing sector of dentistry and podcasts are weighted towards millennials. If you go on to the sixty thousand Dentaltown app downloads, most of them were born after 1980. The people on the desktop are baby boomers, old like me. But they all come out of school, six thousand just graduated last year and they say, "Arun, we didn't do one implant in school." How did you go from zero to one implant?
Arun: You know what is first you gotta categorize it, because just like anything else you know you go from, in dental school, you go from zero fillings to graduate whatever twenty, twenty five, thirty, fifty, eighty fillings. You don't start with MODs, you don't start with pin amalgams, you start with a occlusal. You start an occlusal you do five, ten, fifteen occlusals under supervision, and then you go onto an MO five, ten, fifteen MO’s under supervision, then you do a pin, and so you graduate. And the same thing is gotta be done with implants. It's not just an implant is an implant is an implant, is we've got to categorize them, and no one's ever done that. What I did is I made a classification system, I didn't call it guard classification one two or three, I didn't do anything, it is like that. I just called green light, yellow light, red light, is categorized in the easy cases, moderate cases, and tough cases. Upper premolar with a lot of bone there is completely different than a thin missing number eight. So yeah, we're gonna have someone start with an upper premolar, tooth number four, five, twelve, or thirteen. Lower first molar number eighteen or thirty is two implant overdentures. Those are all straightforward cases. The other extreme would be something like an upper incisor. The other extreme would be next to the mental frame in tooth twenty, twenty-one, twenty-eight, twenty-nine. That takes a lot of experience, it's gonna take a lot more radiology, it's gonna take a lot more care with the flap not to jeopardize the [00:04:52] metal frame. So the first thing is we got to categorize it and I don't see anyone doing that. Is focusing them on let's start with these easy ones, let's do at least twenty-five green light, and once we've done those if you want to, some may say, "That's all I want to do and I want to refer the yellow and red lights out." Some will say, "Okay, now I'm ready to move on to yellow light," is do twenty-five of those and then maybe stop there and say, "Okay, the red lights I'm going to refer out or say “ I have an interest in that, and then move on." So it's gotta be step by step by step. I find the guys that start out just pick a random case is it doesn't go well, and then there's, "It's not for me, I don't think so. Then end up by not doing it or waiting two, three, four, five, ten years before they try again.
Howard: Alright here's another problem she has, she says I just went to the major dental meeting and my God there were four hundred different dental implant systems and they always tell me that where the city that they live in or the state that they live in or the country. Most of them continue education implant is sponsored by an implant manufacturer. So they almost feel like they have to pick their horse before they get in the cart and start learning how to place them because most of the courses are sponsored. So my question is how many different implant systems are there, and which one do you recommend?
Arun: You know in the U.S. there's about forty or so systems, worldwide, you go to Italy there's over two hundred systems. You go to Japan, over two hundred systems, Brazil, over five hundred separate systems. There's thousands of them worldwide, in the U.S. about forty, there's some clones and such. What I do in the educational process I don't pick a system, I don't get sponsorship from any company, I don't take money from them, I don't take free product from them, I don't accept free product. I talk about principles, let's talk about how to make the flap, let's talk about what drill speeds we should use, let's talk about is the different drill speed for soft bones typically on the maxilla, versus denser bone typically on the mandible. Let's discuss those, as far as putting the screw in, the concepts are relatively similar. And now what a doctor can do is go and pick whatever system they want. Now we can guide them on what to look for when they're going to pick a system is of course you want quality engineering, what kind of features you want is maybe some microthreads of the coronal portion. You want good support, you want something that's going to be around for a long time because your patients are going to be around, and you want to be able to buy prosthetic parts. We can guide them, they can use that and then go and pick their own system. I think that's what happens a lot of times is folks do the opposite, pick a system, maybe didn't have those criteria because they weren't trained on what criteria, they're trained on what would happen to me, what would happen to kind of hit it off on a personal basis. It may not have had those criteria and now they've spent $10,000, $15,000 and feel locked in.
Howard: So you know what she's asking, she says don't be a politician, what is your go-to implant system?
Arun: I really don't have a go-to implant system in my private practices. I have six practices in Miami, I have fourteen full time associates, and I let them choose from the major systems. And so we have a variety of different systems, we have ten different systems throughout the six offices and fourteen associates. I've got a facility down at the Dominican Republic, we'll go down for training. It's a twenty-six dental chair shipped in from America, two brand new CAT scanners there, we've got sixteen full time doctors at work there and use a variety of different systems there. In my training programs what I use is I use clones of the major systems, a Nobel clone, a Dentsply clone, a Zimmer clone, and a Straumann clone. Those are the four clones that I use in the training programs of the four major systems.
Howard: Nobel, Zimmer, Dentsply, what's their brand name?
Arun: The Astra.
Howard: Astra?
Arun: Well they got Astra, they've got the XiVE.
Howard: So Nobel Biocare, Dentsply, Zimmer, what was the fourth one?
Arun: Straumann.
Howard: Who makes the best clones?
Arun: I don't know who makes the best clones, there's a variety of clones out there. There's Implant Direct, there's Blue Sky Bio, there's MIS, a lot of different clones out there.
Howard: Wow,so what are my homies going to find at implantseminars.com?
Arun: If they went there, it would be a variety of implant courses. The entry level course that I started probably close to thirty years ago is at that time it was one weekend a month for a year, twelve months. I had guest speakers and I had a different speaker every month, so we had twelve different speakers each doing two days. And then we found when we got feedback, sometimes they would talk oftentimes about a particular brand for example of an implant, and another guy talks in another month on a different brand. One guy talks about mineralized freeze-dried bone, one guy talks about demineralized free-dried bone. It's good for an experienced user to have all these differences of opinion, but for the novice differences of opinion are very difficult because they know which path to go. And so what we started doing is instead of the twelve sessions, I was able to get it under four sessions. Four two-day programs, so eight days total. I do all the sessions myself so that we don't have these things. There's a continuity of thought, there's one way given to them. And so it's not like one guy says, "Well rough-surface is good," one says, "Rough-surface is bad," one says, "Tapered is good," one says, "Parallel is good." It's giving them a consistent way which saves them, it saves them eight full weekends, the travel costs associated with that, the hotels associated with that. Gives them consistency of thought, come up with a systematic way to get them trained. We've been able to lower the tuition, the tuition literally thirty years ago was 50% higher, with inflation you would expect it to be double that now and it actually is lower than that. And so that's the entry level program, and to make it convenient because as you said folks a lot of times want to go to something local. So they go to something put on by companies, for all the other training institutes you've got to go to the training institute. You've got to go to Las Vegas or to New York or to Key Biscayne, wherever the training institute is. I took my training institutes on the road, we have fifteen training institutes in every major city in America. We do that same program in Miami, in Orlando, in Tampa, Atlanta, Washington D.C. New York, Boston, Chicago, Seattle, San Francisco, Los Angeles, Houston, Dallas, and New Orleans, we do all these different cities...
Howard: Say that again, you're talking fast, name those cities again.
Arun: Okay, Miami, Orlando, Tampa, Atlanta, Washington D.C. Charlotte, North Carolina, New York, Boston, Chicago, Seattle, San Francisco, Los Angeles, Dallas, Houston and New Orleans.
Howard: Damn, and you do four two-day programs in every one of those cities every year?
Arun: Every single session myself, eight hours per day.
Howard: I noticed you only go to towns that have an NFL football team. Are you a big NFL player, is that part of you're...
Arun: I go to Dallas based on direct flights from Miami.
Howard: Wow, that's amazing cause every one of those cities has an amazing football team. I noticed that Phoenix didn't make the list, why is that, so you just go to...
Arun: There wasn't a flight, there wasn't a direct flight, that was as simple as that.
Howard: From Phoenix to Miami?
Arun: Yeah.
Howard: And so that's four two-day weekends.
Arun: Right, now you may be doing the math and say wait a minute that's more than fifty-two weekends a year. I started out doing Saturday, Sunday, of course I ran out of Saturday and Sundays. So now some cities I do Saturday, Sunday, some I'm doing Thursday, Friday.
Howard: Goddamn, have you ever thought about getting treated for being a workaholic? There might be medication available.
Arun: Yeah, I've been accused of that.
Howard: And how much is this for two-day program for, what do you call it your entry level, beginners, what do you call it?
Arun: Well we call it the Dental Implant Continuum.
Howard: It's called the Dental Implant Continuum?
Arun: Yes.
Howard: So how much is the Dental Implant Continuum?
Arun: The tuition is 9,500, we end up having a super early as 8,500, an early that's an 8,500, and a super early that's 7,865. So the majority of folks plan ahead and take advantage of the 7,865 super early pricing.
Howard: Nice, and she's driving to work right now and she says okay Arun, I do the early day, I pick my favorite NFL football team, I meet you there for four two-day weekends. At the end of four two-day weekends, what should she be able to do, and what what is the success rate? What percent of your graduate students will go on to place an implant? Because she knows a lot of people have gone through these orthodontic continuum courses, where half the class decides at the end they're not even gonna do Ortho. So what should she learn and what is the success rate that she will graduate and be able to place an implant?
Arun: Great question, the first day I go through step by step bone biology because you've got to understand the bone biology. As well as step by step as much as possible [00:14:34] treatment planning and patient evaluation. The second day I go through step by step reviewing all the different graft materials, all the different membranes, looking at advantages and disadvantages of each graft material, understanding advantages and disadvantages of each membrane and then step by step socket preservation of five-wall defects, four-wall defects, three-wall defects. And the right materials to use and to make this profitable. Once we do that the first weekend, they should be ready to do socket preservations that Monday morning. If you do the math, you ask the average person in the class how many extractions do you do per year? And they say, "Well I do two hundred extractions per year," and that's usually about the average. And if they're charging let's say $150 for a twenty minute extraction. If you intake that twenty minute extraction $150, charge it up at $295 for socket preservation and do it in three minutes, now you're taking twenty-three minutes and made it 450. You’ve tripled your hourly production. You see the key is to understand the right materials, but the key is to make this quick and efficient. If you charge another 295, roughly $300 for the socket preservation, but it took you another forty minutes, well now your hourly production remains the same. Which means either you stay late in the office, or you cancel something else and replace it with this, neither of which are good. If you had a busyness problem, doing socket preservation would solve that. But if you're taking forty minutes, then it doesn't work. If we can get you trained to do this in three minutes, you'd triple your hourly production. If you're doing two hundred extractions year, an extra $300 for each one, that's $60,000 a year, that's $5,000 a month. The class valedictorian, I always make a joke of this, the class valedictorian will pay his entire tuition within the first month by the next session. In order to pay your entire tuition $300 a month, that's what twenty-two socket preservations. Usually there's about two or three guys that pay their entire tuition before their second session of the 7,865. Everyone else in the class, their homework assignment is to completely pay off the tuition, by the fourth session they hit that. That's the return on investment, there's nothing like that, that you get it paid off by the end. And in order to make it even easier what I have folks do is I say, okay put down a small deposit, $500. You break up the rest of the payments in four payments, first session, second session, third session, fourth session. Essentially those payments should be coming out of their patient's pockets. You do the socket preservation, you make the first payment, you make the socket preservation, you make the second payment. And so nothing should have been out of pocket other than the initial deposit out of this. And after the four months, it's pure profit after that. The second session, a whole day on step by step is implant placement. What kind of anesthesia to use, what kind of drill space to use, what kind of irrigation to use, whether to place the implant sub-crest or super-crest or at the crest. What type of implant designs to look for, what kind of dammers to use where, what lens to use where, giving them formulas for all of this. What do you use for post op swelling, what kind of suturing to do. The second they're practicing all of this on a fresh frozen cadaver. Fresh frozen cadavers, this is not like we had in dental school embalmed. This is we a plastic feel and a formaldehyde smell, this is like literally a piece of meat. It was put in the freezer, taken out, it thawed, it is as realistic as you can get except for the bleeding and the movement. It feels absolutely realistic the soft tissues, the bone, practicing placing implant after implant after implant after implant, fifteen, twenty implants in that cadaver. The next session, after that session they should absolutely feel comfortable doing green light implants, upper premolars, lower first molars, two implant overdentures, some of the yellow light cases they should feel comfortable and start doing those.
The next session, a half a day step by step on soft tissue management. You do an extraction you want to get primary closure in order to keep [00:18:45] factor in with practice on pig jaws that afternoon, everyone in the room should be able to get primary closure, advancing a flap in sixty seconds or less. To advance a flap and get passive primary closure. If you get some threads exposed on implant, put in some graft material, advancing the flap to get passive primary closure, being able to do it in sixty seconds or less. The next stage, step by step prosthetics on implants. Now a lot of folks have done implant prosthetics, single tooth crowns, [00:19:25] bridges, full arches, overdentures, locators, O-rings, hybrid prosthesis step by step by step. We go through all that in detail but even folks that have done this, giving them tips and tricks to make it more efficient, lower cost. The folks that haven't done it, going through it absolutely step by step so they can incorporate it. The next session, a day on how to market implants, how to get them in, how to close them. It's a whole different thing talking to a patient about, “Ms. Jones, you need two fillings and your insurance covers it, there's a minimum copay on it and we can get you done in a half hour, during your lunch hour, before work, after work.” That's a complete different dialogue, they're essentially getting it for free because insurance is covering most of it, there's no time out of their life. Completely different dialogue versus, “Ms. Jones, this is going to cost you $2,000 $3,000 $4,000 $5,000 $8,000, it may take several months, it's going to be mostly out of pocket. It may not be able to be squeezed in during your lunch hour,” that is a completely different dialogue. And for folks that are well trained and very well and good at it, is getting case acceptance for fillings and single crowns, and root canals, and occasional bridges is a completely different conversation to talk to them about these kinds of elected dollars. So we've got to get them trained, because if you can't market it, if you can't sell it, you're not going to do it. Then spending an entire day on hygiene, half a day on hygiene maintenance and half a day on complications. Because with everything we've discussed, they should have minimal complications. By going over other complications, my past complications, other people's complications, alumni complications, now they can see what’s happened and learn not from their own complication experiences but from our experiences. So we have case after case after case after case, and showing what happened, how it was managed, how to avoid it, and that rounds it up. Absolutely the return on investment should be from socket preservations, the supplies and materials, spending $20 $30 worth of supplies and materials. Taking three, four, five minutes to do the socket preservation, tripling your extraction fee is on it. And you go well what if the patient isn't going to get the implant? Because you mentioned two hundred extractions a year but I might only be doing ten or fifteen implants a year, why would I socket preserve the other hundred and eighty extractions I do a year? Because under a flipper a big, fat, based bone is better than thinners or bridge. If they're getting a full denture, a big, fat, based bone under that denture is better than thinners or bridges. If they're getting a [00:22:03] bridge a big, fat, base under that pontic is much more aesthetic than a [00:22:10] bridge under that bridge. So it's a valuable service for the patient in all of those situations not simply for implants.
Howard: My God I could listen to you for forty days and forty nights, she's overwhelmed she’s like, “I don't know if I'm a good enough surgeon to do this.” What would be a similar skillset? Some people like you say they do two hundred extractions a year, would you say that anybody that could do two hundred extractions could place an implant?
Arun: Essentially yes, you could do...
Howard: What if she says, I refer out all my wisdom teeth, but I do simple extractions, but I refer out all my impacting wisdom teeth.
Arun: That’s fine, that’s fine if you’re doing you’re premolars, you’re doing molars, you can do implants, absolutely. And that’s not just me, you talk to guys like Gordon Christensen and such and they say the same thing. They say dentists that can do root canals and dentists that can do extractions, not impacted third molars, can place down implants. Now we’ve got to categorize it, folks may just say generically, and other folks may say, “Wait a minute, there was a number nine, there was a thin ridge, and the guy can’t do that.” No, green light and yellow light absolutely. For red light, there's additional training involved because for red light there may be bone grafting, there may be ridge splits, there may be things like that. But green light and yellow light… but the majority of cases are green and yellow light.
Howard: So Arun you’ve lectured around the world, why do we see so many cultural variances where the Koreans and the Germans and the Brazilians, three out of four general dentists place an implant every month. But in America, in the United States it's a fraction of that.
Arun: Isn’t that amazing? What happens is in Korea who places the majority of dental implants? General dentists. Who does in Brazil? General dentist. In Germany? General dentist. In every other country the exceptions have been the U.S. the United Kingdom, and Australia, those have been the three exceptions. And you know how you joked about when you did the middle name and it was just a coincidence with the movie. It’s a coincidence that the three countries where it is not that model are the three countries that speak English. It’s that kind of joke, you speak English? The GP doesn’t put the majority of the implants.
Howard. Yeah and when Straumann is a publicly traded company, and when you look at their 10-Q quarterly reports, and their [00:24:34] 10-4s they have charts of the number of implants placed per ten thousand citizens, and United States has one of the lowest penetration rates. Here’s the richest country in the world, where 5% of the people enjoy a nineteen trillion dollar economy out of a total sixty-nine trillion dollar economy. One of the richest economies in the world and its people has one of the lowest implant penetrations of implants placed for ten thousand Americans.
Arun: Absolutely, absolutely. Out of ten thousand people, it is one of the lowests here. And it is because of the way the model was created. The model was created that here is who does the majority of extractions in America? The GP and refers all the tough ones for all surgeons. Who does the majority of root canals in America? The GP and refers all the tough ones. Who does the majority of root plantings and such? The GP and refers all the tough ones. But two things were not set up like that. The model that was created in America for Ortho and for implants whereas a GP refers out 100% of it wholesale, not just the tough ones. That model was what was originally created and that’s what’s held things back. Because what happens is there's two things, with the referral pattern the prices go up and patients know that. You don’t have to tell them, they know that. They know the price goes up and so it limits the number of folks that can do affordability. The second things is, what happens is patients trust you. You’ve had patients you tried to refer you go, “Well I'm going to refer you to Dr. Jones down the road and he's a really great guy and we've referred lots of patients to him over the years, and he does all the implant surgery for us.” And oftentimes the patients says, “Oh, you mean you don't do the surgery?” “No, no we don't do surgery but you going to see Dr. Jones down the street. He’s a wonderful guy, we've worked with him for years. We're going to do the crown, we’re still going to be your dentist.” “No, but you mean you don’t do it? Oh, it’s okay then doc, if you don’t do it, I’m okay the way I am. I’m okay with this partial, I’m okay like this.” And general dentists hear that all the time, probably I would venture to guess about half the time the referral doesn't go when they find out it’s not done in your office, because they trust you. So right there we're going to have half the number of implants not even being considered, versus somewhere like Korea or Brazil, where the general dentist would have considered doing the treatment plan and doing the treatment.
Howard: Some of the biggest money I've ever seen made on dental implants was someone decides they're going to go place implants and gets good at it. And then finds some run down shack, Denture World, Denture Universe and they're doing about a half a million dollars a year doing all these dentures, they’ve got a lab tech. And they buy that $500,000 business that’s had all these old ladies in nursing homes, in trailer parks and the poor all going there for all their re alignments. Then they add the two implant snap-on, the four, the Hader bar, or maybe four to six implants and a removable bridge. And they only upsell maybe one of a hundred to All on four. But they get ten or fifteen out of a hundred to upgrade with two implants, and they'll take that $500,000 Denture World, to a 3 to 4-million-dollar business. And these are in some of the poorest areas I've ever seen in Bakersfield, California, in South Carolina, in Kentucky where all the dentists would diagnose the pocketbook and say, “Oh you can only do that if you were in Beverly Hills or Key Biscayne or Manhattan.” And they just crushed it and those little old ladies are so happy because when you're seventy-five, you're not snow skiing and jet skiing and staying out at night. You’re eating and she couldn’t eat with that loose denture. So do you teach overdenture, do you teach that too?
Arun: Yeah, and you know what, I see the same thing. I actually have folks that either will resist coming to the course, or folks that have actually already registered, they come the first day and say, “This is my population, I got a lot of denture patients and they can't afford it. I'm taking a course anyway, maybe for socket preservations. But we're not going to be doing implants and I don't think my population can even afford socket preservations.” They realize themselves one or two months into it what a gold mine they have is what happens. Folks like you said that come up with those kind of numbers, $500,000 practices a year, turning in two, three, and four million dollars a year. But more importantly what it does for us, what you said what it does for the patient. You take the lady that worked hard her whole life, she worked hard, she raised her kids, she went to church, she did all the right things. She started out life one or two years eating puree baby food, now she's seventy-five, she's got another ten, fifteen, twenty years. She shouldn't have to spend her golden years eating puree baby food for the next fifteen, twenty years. After she worked hard and did all the right things, it’s just not right. Now if she can go in and get a couple of implants, get an overdenture done on it, $1,500 per implant is $3,000. Maybe take her current denture, add the attachments to it, maybe $800 to attach the dentures, no laboratory fees. Two visits, one to place the implant, one to uncover it, add the attachments, $1,300, financing the office $250a month over fourteen or fifteen months. Wow, what an amazing service for that patient. You’ve changed their life for them and they can come up with that $250 a month for that. And they will not have to spend now twenty years of their life eating puree baby food, eating mashed potatoes. It’s this type of thing, it’s life changing for folks.
Howard: Hey don’t knock mashed potatoes, I still think mashed potatoes and gravy in Thanksgiving it’s gonna be the finest meal ever. And you know what, she lost all of her teeth and it wasn't even her fault because everyone in Phoenix tells me is when they were pregnant with her baby, the baby sucked all the calcium out their teeth. So she's a victim actually, should have her damn kids for it. I want to ask you, this is Dentistry Uncensored and I like to talk about anything anyone of you agrees with. The most controversial thing in dental implantology on Dentaltown is to use a surgical guide or not. You have all the older guys who have placed ten thousand implants, they say, “I've never used one, it's training wheels, that's bullshit. Learn how to be a real surgeon, lay a flap.” And then you have all these young millennials who say, “No, no, I use a surgical guide.” So my question is to use surgical guide, or not to surgical guide? That is your question.
Arun: I train in both, I train folks in both and there's indications. You see I think what they've done is when people chat about it, they go all this or all that. And it can’t be all this or all that. For example, let's go through a hypothetical example. There’s two implant overdenture, surgical guides on a fully [00:31:20] indented arch are tough to use. Because you don’t have teeth to snap it on to, it's not like a night guard. That lower mandible, it’s moving around like a lower denture would, so you've got to fixate it. In addition before you even drill the holes for the implants, you have to drill three holes laterally. You put in what's called pins, but they're two inches long so you and I would probably call them nails. You put these three nails in, for the novice surgeon, it's hard for them to think like that, putting in nails from the bicortical plate all the way or close to the lingual cortical plate to hold this lower guide in place. And then blindly, because you can’t make a flap now, because if you make the flap, the guide’s not going to fit on a fully dentureless case. Blindly is to punch out holes and then drilling for the two implants, blindly place the implant whether it’s sub-crestal, super-crestal. Now you should have seen all that with a CAT scan, but as accurate as a CAT scan is, you’ve got a CAT scan now you see. You look on the CAT scanner it looks like there’s no buccal bone on the facial of number eight and nine. You flop it open and this buccal bone there isn’t there, okay. So it doesn’t show that, so there’s little nuances that aren't showing in the CAT scan. So how close you are to sub-crestal, super-crestal, doesn’t always show up. Compare that to that same novice surgeon making an incision, a horizontal incision on the crest about ten to twelve millimeters long, small three to four millimeter vertical ease on the midline. Flapping open under [00:32:53] drip visualization, drilling two holes, that’s it, putting the two implants. Which is going to be easier for that person? Okay, trying to make a guide, trying to fit it on a moving lower denture ridge, trying to put the three nails in to steady it and the cost. If that person’s making that guide, that guide is probably going to run $500 to $800. Now there’s ways they can bring the cost down, they can learn how to design it themselves, they can get 3D printers, they could print in-house et cetera et cetera. But again for that novice they may or may not want to invest in that, and if they're not it's $500 to $800. Now that $3,800 hypothetical example used, a two implant overdenture becomes 4,300 or 4,500 maybe not such an easy close for that person. Now let’s contrast that with the other extreme. Number eight, she's an 18-year-old cheerleader, she had the tooth extracted by someone else and he didn't socket preserve and the ridges collapsed. It’s not collapsed enough that I need to graft the bone, so I don’t need to put it through a bone graft. I don’t probably need to, but I got to nail the position exactly in order to avoid grafting for her. And I got to nail the [00:34:03] position exactly, I don’t have room to correct with angled abutments on her, it’s got to be nailed exactly. And because it’s an [00:34:11] aesthetic zone case, mom and dad are willing to pay not 1,500 per implant, they’re willing to pay 2,500 or 2,600 or 3,000 for the implant. They’re willing to pay 800 for a custom abutment, they’re willing to pay 1,200 or 1,400 1,500 for all E-Max crown. In that case one can definitely afford to get the computer guide, and should absolutely use the computer guide there. Two complete different scenarios, right, so it’s not all yes or all no I think what happens people get caught up in that. When someone spends their money, if I'm not making a $500 to $800 guide, if I invest it to make guides in-house. Let's suppose I invested $150,000 on the CEREC machine, to scan the mouth instead of taking impressions. I invest $150,000 on a CT scanner and now I merge this, and I can get guides made at reduced cost because I’ve got some of these things in-house and maybe I can get the guide made for $250. While I’ve invested $300,000 I can get a guide made for $250 it’s a young cheerleader, definitely the computer guide we’ve got to use. Am I going to use a computer guide, I’ve invested that money for that lower denture? Even in that case probably not. It would probably be simpler and easier, more accurate to make a flap and put those two implants in, okay, two complete different scenarios.
Howard: I want to go back to your socket preservation, they’re so confused about socket preservation because for the bone grafting material, I mean there’s autografts, synthetic, xenograft, alloplastic, ceramic, polymer. What do you recommend, what is green light, yellow light bone grafting material and what is more red light bone grafting material? Then you can add in there’s some people when they’re doing a bone graft, their drawing blood from the [00:36:02] fibrin and they’re saying, oh my God am I going to have to start an IV, draw blood, get a centrifuge. So what’s the green light bone grafting versus the red light?
Arun: Okay let's go kind of where these concepts come from and then we’ll fine tune on exactly what should be used. A autogenous bone everyone says a golden standard and such but I don’t think most dentists will routinely harvest autogenous bone, nor would patients routinely want autogenous patients’ own bone harvested just for a socket preservation. No, okay. The next broad category is tissue bank bone, tissue bank bone is sort of the next best. It’s available, good quality tissue banks in this country, it works well, has lots of documentation. Tissue banks have very limited or no profit they can make, because no one… a tissue bank is donated tissues. So the government regulates it, the patient with the family donates the tissues, the government regulates what the production cost is, the processing cost is. A lot of the tissue bank they make has small profit on it. What that means is that the tissue banks rarely have sales reps. If you notice, tissue banks usually sell through a implant company, they really have their own sales rep. Tissue Banks never have sponsored speakers at national meetings. Tissue banks never have journal ads, or rarely have journal ads. Because the profit margin’s so slim that they can’t afford journal ads, they can’t afford to sponsor speakers, they can’t afford to have sales reps, they do it through implant reps. Then comes the synthetics essentially third place on that totem pole hierarchy of best to worst. Synthetics are huge profit, it is essentially all profit. If you think about cow bone, you go to the McDonald’s slaughterhouse, you get the cow bone for free essentially. Process it and sell it for $100 or $200 an ounce. The historical price of gold has been $300 an ounce, you get it for free and you sell it for the price of gold almost. You remember in the Medieval Days there were those who were called alchemists, and their job was to turn lead into gold and of course they never did it. This is modern day alchemy, you get it for almost free, yet sell it for the price of almost gold. The profit margin’s so huge, you have hundreds of graft materials and that’s where the confusion comes in. And the hundreds of graft materials can now sponsor paid speakers at national meetings, they do an infomercial from stage. With these kind of profits they’ve got one or two paid journal ads in one or all the journals, they can throw the best parties at the national meetings. They can afford a twenty, and thirty, and forty nationwide sales reps calling on the doctors, they can afford to fund research. When I was at the university, we had lots of research funded and companies would come to us and they would say, “Well we want you to use our graft material and we’d like to do a split-mouth design. One sinus you should use our graft material, one sinus you use something else. We’re going to pay you $5,000 per sinus that you do. We’re going to give you $100,000 dollars, this is an actual study, $5,000 per sinus.” It wasn’t hard to land our patients because the patients got their sinus lift for free, the company paid the $5,000 in free product. But who writes the research protocol in that situation? The company does. Who has the ability to allow us to publish it or not? They do. They had the first right to allow us to publish or not. If it’s positive, we’re allowed to publish it, if it’s negative, we’re not allowed to publish it and that has happened, that has happened to us. And then the same company comes out and says doctor, you have to look at the publications that we have and evidence based, what’s evidence based is if it’s a non-bias funding? But it’s not so evidence based when you have the right to not allow certain articles to be published. And with that kind of money, and that’s where the confusion comes in from the synthetics that have all this funding behind them. You don’t see that from freeze-dried bone and you rarely see speakers or journal ads and such, on freeze-dried bone and yet all of us know it works better than synthetics. And now what you understand is what happens, since this is uncensored, this is what’s happening. Now understanding that what are we going to use? Walk in, patients don’t want to harvest autogenous bone, you know I don’t want to harvest autogenous bones just for socket preservations. So what are we going to use routinely? Freeze-dried bone, okay we’re going to use freeze-dried bone, that’s going to get the best results. Now if we can subdivide that, it’s completely different a five-wall defect, a lower molar that’s got the buccal wall, lingo wall, [00:40:49] I might be able to get it with just PRP or some blood in there. But I could certainly just put some bone in there and no membrane because all I need is containment, and I can do primary closure of the flap or I could do other ways to get containment, that’s it. Contrast that to tooth number eight I extract and the buccal wall is missing, it’s a four-wall defect. Now you need bone and a membrane, because now we need a membrane not only for containment, we need a membrane on the buccal. Because what happens is that graft material never comes alive, even if it’s autogenous it doesn’t come alive. It’s simply a scaffolding for the bone cells in the area to grow into and have baby and grandbaby bone cells and this dissolves away the graft material. The cells come not from the periosteum, because the periosteum is the underside of the flap and oftentimes we don’t even get primary closure. Where the cells come from is something that’s similar to the periosteum. It surrounds the blood vessels and bone, it’s called the endosteum. So when the blood supply comes from bone it brings with it bone forming cells, when the blood supply comes from soft tissue it doesn’t bring with it bone forming cells. So if I’d open a membrane on that buccal missing wall that tooth number eight, the blood supply some will come from bone, from the palatal aspect of the socket and some will come from the buccal flap which won’t bring with it bone forming cells. If I put a membrane on the buccal, now all of the blood vessels that come into that graft material will come from the palatal bringing with them bone forming cells, it will form more predictable bone. And that can fold that same membrane is on to the occlusal surface for containment. So five-wall defects, just a graft material. Anything I want, a lot of different things for containment. Four-wall defects a true form membrane barrier on the missing wall plus something for containment, probably the same membrane. So in that five-wall defect, what could I use? Well I could use Bio-Guide, Biomet, Ossix, Pericardium, Ala-Derm. You see the guys in Europe, they’re putting pieces of rubber glove, they’re putting it in like a rubber damps and over the tooth in front, over the tooth in the back… just for containment and super gluing it around. You could put Coloplug, there’s a lot of different things you could do for containment, you can advance the flap. On that missing tooth number eight, there isn’t as much disagreement because we’ve got to have a membrane on the buccal aspect. And so it’s got to be a four month membrane. Now we can still subdivide that, membranes can be collagen based, there resorb, they can be polylactic acid based. The polylactic acid based like [00:43:32] GUIDOR membranes and such, they resorb through an enzymatic cleavage, and it goes from polylactic acid to lactic acid. So you have an acidic environment next to the membrane which may or may not form quite as much bone. So we prefer collagen membrane, collagen membranes are formed from Achilles tendons of cows, they’re formed from pig skin, they’re formed from human, pericardium surrounding of the heart. The synthetics just like with bone don’t work as well as tissue bank, so I prefer tissue bank collagen which is the pericardium that surrounds the heart. A tough membrane that puts up with sixty, eighty beats a minute, is pliable, is going to last for months. So now it makes sense freeze-dried bone, tissue bank in the socket. Four-wall we’re going to use pericardium, on that buccal all folded over on the crestal. Now we go to three-wall, two-wall, one-wall. You’ve got a tooth and number eight you can part with your fingers, there’s some palatal bone, there’s nothing on the mesial nothing on the apex, nothing on the buccal. What’s your socket preservation going to do there? Nothing, because you just don’t have enough walls to bring cells in, you don’t have enough of a matrix band so to speak. Because a membrane that’s malleable isn’t going to hold that out. So either you do as socket preservation just to keep the soft tissue plumped up, so that you can come back later and do bone grafting. Or what you do is you don’t do anything at all you say, “Well we’re not going to grow a bone anyway, we don’t need a bone graft, or we don’t need the socket preservation.” Or you need a very stiff membrane in that case, with tacks to hold it out, tent it out to be able to create in essence that matrix band environment, hence a different membrane. So again I think folks sometimes simplify things and go only this membrane, only this graft material. We may need a choice of three to four membranes, a stiff membrane for one or two-wall defects. A pliable form of membrane, pericardium for four-wall defects, no membrane for five-wall defects. What kind of graft material? Freeze-dried bone for five-wall, four-wall, three-wall. One and two-wall probably some autogenous bone and some bone scrapings to enhance that bone. Okay, and now it becomes very simple, so a lot of times when folks post different answers, in a way many of them are correct, but they’re just correct for a unique situation.
Howard: So what do you think, a lot of these kids are asking. They see integrated dental systems selling this smart and dental grinding that when you extract the tooth, you throw it in it’s like a garbage disposal and it purifies it and turns it to a mush. And then you have instant autogenous graft. What do you think of that technique?
Arun: Well I prefer to call it a coffee grinder than a garbage grinder, but…
Howard: A coffee grinder, I always think of that movie, what was that movie in south… Fargo, where the last scene he puts the body in the wood chipper and you see a leg sticking out. When I first saw that I thought, oh my God they should call that the Fargo Machine. And my God I always say that was one of the best movies ever, did you ever see Fargo?
Arun: Yeah I saw it.
Howard: So what do you think of the Fargo tooth grinder?
Arun: It works, it absolutely works. The tooth it doesn’t act at the level of autogenous bone but it does certainly act at the level of tissue bank freeze-dried bone. And so you can make it, it’s autogenous in that regard, acts at the level of freeze-dried and so nothing wrong with it. What a doctor has to question for himself is the work involved, because what happens is the more virgin the tooth is, the less work there is. If you took an impacted third molar, you could take that, put it in the Fargo grinder, coffee grinder, garbage grinder or whatever you want to call it, grind it up. It still needs some treatment because the pulp has to be removed, so there’s some chemicals that will remove that pulp and then [00:47:30] rinse that off, you could use it, very little treatment to it. You take out a tooth that’s got a veneer on it, well now you’ve got to take the veneer off, take some of the soft tissues off where the socket was and then put it in the grinder, a little bit more work. It’s got a MOD composite, it’s a little bit more work to take that out. It’s got a MOD composite and got a [00:47:55] and there’s a root canal. Well that’s probably not cost effective, your time is more valuable than trying to get that composite and trying to get that [00:48:01] out of there. So you’ve got to see if you’ve got lots of virgin teeth to take it out, fantastic, or minimally treated teeth. If a lot of teeth are taken out are heavily treated, it wouldn’t be the ideal graft material. So you’ve got to look at that. The second thing you’ll look at is the cost, if you can open up a bottle and spend twenty, thirty bucks of graft material, versus buying the grinder and how much the chemicals cost. You just have to look at your time and the cost, but it absolutely works.
Howard: Let’s keep it Dentistry Uncensored, the other biggest controversy ever is to cement or screw. Some people say the cement is causing the peri-implantitis some people say it’s got to be screw retained to remove and clean at the hygiene department. Are you a cementer or a screwer?
Arun: I know you're interviewing me and asking me but you do implants and you do all of these different procedures. Can I turn the question back to you just for a second or in essence to the audience okay. How often have you personally seen cement sepsis you personally, not in slides, not in lectures, in your office?
Howard: I haven’t.
Arun: Okay, and you do a lot of these cases. And I would suspect the listeners would probably give a very similar answer, now if you look at implied complications of that broad topic, how often have you seen misplaced implants in your office? It happens...
Howard: Especially from surgeons that start with oral.
Arun: Yes okay, so if you had to look at implant complications, probably the top of the list in terms of what happens most frequently that you personally have seen, would be misplaced implants. And probably would be at the very bottom, what you personally have seen with the would be cement sepsis alright? And I suspect if most of the listeners had listened to this, if they look at their personal experience, what they are personally seeing in their office. Out of all the implant complications that can happen, the top would probably be misplaced implants. They send it out, they get it back misplaced. Which is actually why a lot of folks come to for training cause they say, “Well I don’t have know if I can do any better, but I sure as hell can’t do any worse with what I’m getting.” That would be the top, and yet the bottom at the rate of never, okay is cement sepsis right. And neither of us are young guys, you’ve been around a long time, you’ve been doing implants a long time and we’ve never seen it. So can it happen? Yes, what would be maybe kind of in the middle on that spectrum, complications happen, broken screws, you’ve probably seen a couple of those in your career. An implant they didn’t take, probably seen a couple of those in your career. So all these things you’ve seen and yet cement sepsis you haven’t seen, wow. So screw retained becomes a solution without a problem. We’ve got the solution for cement sepsis but if you’re not seeing the problem, then what’s the point? Now it doesn’t mean it never happens, but we’ve got to understand the frequency of it and put it in proper perspective. You take a number eight or number nine, with a number eight or number nine to try to do it screw retained with typical implant systems the screw hole is not able to be placed on the the singularly lingually more than 12% of the time. You can only do it 12% of the time, that's why Nobel came out with their special screwdriver that you can put into curved canals. So they could make it curved canal for that number eight or number nine, that then takes it from about 12% to about 70% the time it can be screw retained. But if it’s not that Nobel system ON that curved canal and not that special screwdriver, and prior to that you almost couldn’t do a screw retained in the upper anterior. Try to do screw retained in upper anterior, that’s what you planned and that’s what you told that patient, that’s going to be a bigger problem than the cement sepsis in terms of probability.
Howard: So Dentistry Uncensored let’s keep it controversial, I’m convinced from reading Dentaltown, that at 2017 the dental profession can’t even agree on a definition and treatment plan for peri-implantitis even though a lot of research says that at five years, 20% of the implants placed in America have peri-implantitis. And I don’t even think they’ve agreed on the diagnosis and treatment plan, the categorization, or how to treat it or what to do with it. And then the hard thing in the field is perio is pain free, grandpa’s sitting there with peri-implantitis he can take that implant with threads showing and go to Burger King and eat a whopper with cheese and onion rings and you’re saying there’s a problem here. And he’s like stick your finger in there and I’ll tell if there’s a problem. So rant on peri-implantitis.
Arun: If you actually look at the data, and again there’s all kinds of hyperbole often times. But if you look at the peri-implantitis, again this is not scientific looking at Howard France’s cases necessarily or the listener’s cases necessarily. But you’ve got a lot of folks, we can begin to look at some guidelines. If you listen to Tom Albrektsson and I just heard him at the Nobel Symposium in Miami. I’ve got him coming to Miami to lecture for our little study club of ours about fifty people for the full day, is coming up next month. He says less than 1% of the time, and Tom Albrektsson for those who don’t know he was the right hand person of P-I Brånemark until P-I Brånemark passed away. He was the right hand guy, he was a co-author in all of the P-I Brånemark papers, the co-author in most of his textbooks…
Howard: How do you spell his last name?
Arun: As Albrektson A-L-B-R-E-K-T-S-O-N there’s probably a couple of letters that are in the double, either T is double or the S is double, and the first name is Tomas T-H-O-M-A-S.
Howard: And where is he… is he from Sweden?
Arun: He's from Sweden he was the right hand guy, he's a M.D. Ph.D. orthopedic surgeon, was there in the very beginning with P-I Brånemark. P-I Brånemark one of his first implants he actually placed it into Tomas Albrektson as a test into the muscle of his arm, and tested out, he had to volunteer there. This guy like I say he’s coming for a full day, I just heard him recently for an hour at the Nobel Symposium. He says less than 1% of the time is peri-implantitis it’s other things, biomechanical factors and on and on and on, it is not peri-implantitis more than about 1% of the time. And this is not hearsay, this is from probably the most published guy in dental implant in the world today.
Howard: Wow, that is amazing. Another thing that's controversial especially on Dentaltown…
Arun: Back up one second on that.
Howard: Yeah, feel free.
Arun: Now that’s he’s definition of peri-implantitis if you talk about exposed threads, that’s a whole different thing. You can have exposed threads and it’s still healthy. A lot of folks are seeing All on 4’s these days, that All on 4 concept. In the All on 4 there’s routinely exposed threads, I wouldn’t say 1% of the time, I wouldn’t say 20% of the time, it might even be much much higher than that. That’s an acceptable part of the particle, Paulo Maló from Portugal who came up with the All on 4 concept and popularized it over the last twenty years. He was also the Nobel…Symposium there, he would show case after case after case of exposed threads, intentionally being left as exposed threads on the day of surgery nine years later, and according to him that’s okay. The zygomatic implants are placed in zygoma, a few millimeters on the zygoma, forty millimeters in the sinus, exposed threads, exposed through the crestal bone on the ridge, back to the soft tissue, exposed threads, routinely. So the definition of exposed threads, for many that have been researching this for many many years and have thousands of publications they don’t consider exposed threads as a definition of peri-implantitis.
Howard: Well first of all when Per-Ingvar Brånemark died at age eighty-five, he made the New York Times and that was December 27, 2014 and then shortly after that we lost Carl Meiss. How will you remember Per-Ingvar Brånemark and Carl Meiss, and there’s another one Linkow, Linkow New York City, I’m sure you...
Arun: He passed away just a couple of months ago, yes.
Howard: Well I’m sorry I’m brain farting his first name,
Arun: Leonard, Leonard Linkow. People called him Lenny but Leonard Linkow, yeah he just passed away a couple of months ago.
Howard: Yeah, what did you think of those three guys, did they have an impact on your profession?
Arun: Well absolutely originally when I was a student and I was a resident, they were mentors and then later they became colleagues and they became close friends. We hand Linkow out many times, lecturing in Miami, Carl Meiss and I went to dinners many times. We’d sit around the two of us, kick around ideas and brainstorm et cetera. I never went private dinners like that with the Brånemark but I saw him at conferences and spoke to him at conferences, and my first conference up at the Mayo Clinic. In 1987 I got a picture with a Per-Ingvar Brånemark it was a huge scene for me, that was my first year of residency and in the Mayo Clinic in ‘87 and saw him. What happens is those guys that come along and they come and go, whether it’s the music industry, whether it’s the sports et cetera… guy like Lil Wayne, people might know his name today but they may not know it twenty years from now. Jon Secada they might have known him twenty years ago, they may not know it today. There's other names Beethoven, Mozart we know those names a hundred and two hundred years later. Einstein, you know those names a hundred years later. There’s certain guys in each industry that come along who are not just known for two years or five years or ten years, a flash in the pan, they’re known for a hundred years and beyond. These are those guys, Per-Ingvar Brånemark like you said is at the New York Times, his name in the profession, in the profession would be know a hundred years from now. Carl Misch, Lenny Linkow, these are names that would stand the test of time, that’s the difference.
Howard: Well said, so you just said that they were the Michael Jackson of dental implantology. You promised an hour of your time, we just passed an hour can I just ask one overtime question?
Arun: Of course.
Howard: One of the biggest controversies in Dentaltown is you’ve got all these people teaching sinus lifts, inferior alveolar nerve, lateralization and some of these guys are saying I’m just going to go place short, fat implants and avoid the nerve. And it seems like when we were little the implant, the longer the implant the better. And you would do anything to get that implant as long as possible. And there’s a lot of guys on Dentaltown showing successful cases with short or fat implants. And as a very short, fat guy, I want to promote short, fat implants. What do you think of short, fat implants?
Arun: They work, all of us, I started up I used to shoot for fifteen millimeters everywhere. And probably because that’s what we believe worked, and probably to impress the referring guys so they see the big fifteen millimeters of blood and say, wow my surgeon he is a good surgeon. And then we started seeing thirteen millimeters work, and eleven point five works and ten works. Now of course when you go shorter there’s other things you’ve got to think about. Because when you go short you can’t afford to have those exposed threads we just talked about. The zygomatic implant you can afford to have some threads exposed because it's forty-five millimeters long. And at that forty-five millimeters long, you’ll lose a couple of millimeters of exposed threads, it’s okay. At six millimeters long you can’t afford to have two millimeters of exposed threads. So there are other considerations we have to have, absolute predictability on it with no crestal bone loss. We’ve got to plan our prosthetics with that kind of precision so there’s no crestal bone loss. We’ve got to plan the surface of the implant, we’ve got to plan the placement position, but they absolutely work. And I think what we're going to see more and more and more is that type of scenario, we're going to see more and better and better surfaces, better types of implants, shorter implants allowing for less and less grafting. And even though I love grafting, even though I’ve published on grafting, I’ve built my career on grafting, I’m not sorry to say I would be more than happy if there's less grafting necessary. It would be a delight and what it does is it also opens up for more dentists to get involved in placing implants. Because if they can do the ones that don’t need grafting, couldn’t do the ones that didn’t need grafting, but now more and more of them are ones that don’t need grafting. Wow, it opens a lot more cases the dentist can do. So it would be a big boom for general dentist, it would be a big boom for patients. They avoid the morbidity and the cost and the time associated with grafting.
Howard: And the last thing I’m going to say you can’t see me but I’m actually on my hands and knees begging. I know my homies and my job is to get them moving along in dentistry. And if you look at big meeting attendance rate at all the major meetings, it’s been drifting down a long time. Millennials aren't really into learning in…they like the online stuff and I’d give anything if you’d put up an online course or series or whatever, because then they’re going to see you, they’re going to fall in love with you, they’re going to see how smart you are. And you might be that motivator. I remember in sports…
Arun: I’m not even worried that, I'm just happy to do it. I'm doing it if it excites them, okay, not anything for me. If it excites them, if it gives them something they can use on Monday morning one, two, three, or four things they can do to improve their lives, to improve their income, and improve the lives of the patients. That's what drives me is if they can do that, I’m happy to give that. And I’ll put that course together, and we’ll put it on there and help them improve their lives, improve their incomes, and the lives of the patients.
Howard: Well you know when I talk to my friends and say well why did you go into this sport and how did you get into basketball, football, karate, soccer or whatever. It was always some personnel, some coach. I remember when I walked into high school, first day of the year this big, old huge man walked to me and said, “How much do you weigh?” And I was like shocked like who is this guy. And I said I weighed ninety three and he goes [01:03:07] Bishop High School only has two boys that weigh under ninety eight, I don’t have a varsity ninety eight. I want you to join the wrestling team will you promise me you'll join the wrestling team? And it turned out to be the most exciting part of my whole high school deal. And you have that magical personnel, now you’re a Vince Lombardi of dental implants and you put up that online course you might be the one that inspired them to go visit that new place and…
Arun: That would be phenomenal if we can change more and more lives, that’s our mission.
Howard: Yeah and remember dental implants, the thing I don't like most about dental implants. You go to every one of these major meetings, and it's always some All on 4 case, it’s always some [01:03:49] doing these roundhouses and just like crowns and bridges. Ninety four crowns out of a hundred sent to the lab are for a single unit, and all that Clear Choice is the biggest beast in the world. They only do eighteen thousand arches a year at 25,000 a pop and eighteen thousand people in a country with three hundred and twenty-four million people, isn’t even a rounding error at .00. Implantology is not all on 4 roundhouse, implantology is two implants for that 70-year-old grandma so she can go back to the nursing home and the trailer park and eat. And replacing one tooth at a time on the vast middle class, and these meetings would do a lot better if they would focus on bread and butter, real world dentistry instead of this eccentric All on 4 stuff like that. But thank you so much for all that you do for dentistry, I am thanking you so much. I mean you posted a thousand times on Dentaltown, you have so many raving fans on Dentaltown. Just really Arun you’ve had me speak for you and then I stayed there and listened to you speak. Man it was an honor to have you on this show, thank you so much for all that you do for dentistry, Dentaltown, and dental implantology.
Arun: Thanks again.
Howard: Alright have a rocking hard day buddy.