Dentistry Uncensored with Howard Farran
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Is Periodontics Dead? with Charles Schlesinger, DDS : Howard Speaks Podcast #114

Is Periodontics Dead? with Charles Schlesinger, DDS : Howard Speaks Podcast #114

8/6/2015 2:00:00 AM   |   Comments: 0   |   Views: 1569

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"We should try to save teeth if we can...because no matter what we put in, they're never going to be as good as the teeth the patient has started out with."

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AUDIO - Charles Schlesinger - HSP #114

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VIDEO - Charles Schlesinger - HSP #114


Dr. Charles Schlesinger, DDS, FICOI is a dental implant educator who has been lecturing internationally for the past 10 years. He graduated with honors from The Ohio State College of Dentistry in 1996. After graduation, he completed a General Practice residency at the VAMC San Diego and then went on to become the Chief Resident at the VAMC W. Los Angeles. During his time in Los Angeles, he completed extensive training in oral surgery, implantology and advanced restorative treatment.

Once he completed his residency, Dr. Schlesinger maintained a thriving restorative and implant practice in San Diego, CA for 14 years. In 2012 he relocated to Albuquerque, NM to become the Director of Education and Clinical Affairs for OCO Biomedical. In 2013 he took over as Chief Operating Officer of OCO Biomedical. He continues to provide patient care along with his educational and R&D responsibilities.



Howard: It is a great honor today to be interviewing my buddy for a long time, Dr. Charles Schlesinger. We're talking about something that's kind of new and exciting in dentistry and the fact that when you travel around the world, you have an extensive implant background, you're leading the way at the ... What do you call it? The OCO Biomedical, but us older dentists know it from the O Company starting back in 1976 and now it's OCO Biomedical. Like I've said a million times, when you go around the world 3 out of 4 general dentists place an implant every month. They say in Korea 15,000 out of 20,000 general dentists place an implant every single month. Germany, everyone does. Brasil, I don't think I've ever met a dentist in Brazil who doesn't place implants routinely. 

Then you come to this great country of ours, 120,000 general dentists and 95 percent of them have never, ever placed a single implant in their life. We have 31 million Americans walking around with a full denture where it is really debilitating and you sell many implants. These dentists will literally get on Dentaltown and bitch about "Oh my God it's Mrs. Jones, she's 80 years old, she's always coming in for a sore spot, a denture adjustment. I charged out 1 reline for $200 a year ago and I've had to adjust this thing 10 times. She's always on my schedule, it's nonproductive." It's like "Dude you're a doctor, why didn't you just place 6 many implants, charge her 5 grand, make her happy, you make money." 

I want to open with this Charles, here's my opening question for you. When I was in college if you drink beer and whiskey and wrecked your car and got into a fist fight that was good, but if you smoked you were going to jail and kicked out of college and everything. Now pot's legal in Colorado and I've just heard that probably Nevada's next. When I was in college gay people were just born wrong and bad and now gay people can get married. I swear, I still feel that's the taboo with many implants today. You don't ever hear an oral surgeon or a periodontist talking about it. The only people that do it are a few general dentists and the oral surgeons it's like they're beating their chest like "If you're not going to make a mountain out of a mole hill ... This denture lady, this should be a 30, 50, $100,00 bone grafting, this big old dear." Here I look at America as 330 million and half of them don't have any money for that kind of stuff.

You sell many implants, what are your many implant sells compared to the big root forms?

Charles: Our many implant sales are they pale in comparison to the larger root form. We-

Howard: What does that mean? 5 percent, 10 percent?

Charles: No, I would say we're probably about 20 percent of our sales are small diameter. Even though our small diameter implants are really what brought this company to the forefront.

Howard: The O Company.

Charles: Yeah, the O Company.

Howard: Explain the O Company, explain the O Company and Dr. Dave Dalise go back to your roots. 

Charles: Sure. Sure. Go back to our roots. Dave graduated dental school back in 1967 and came out to Hobbs New Mexico, started placing dental implants because he felt there was a need. He started with subperiosteals since that what was the treatment option at that time. During that time he had developed a lot of techniques in order to refine the subperiosteal implant. It got to a point at one point where he developed a one hour refractory cast method which allowed him to do a single day subperiosteal back in the early 1970's. 

That grew the company as far as being and grew his reputation as a practitioner who was doing implants that was having doctors from all over the world coming out to visit him. He felt there was a problem with the prosthetic connection at the time. Nothing was standardized mostly everything was bars, clips and he came up with the O-Ball Overdenture connection, patented it in 1980, the rest as they say is history. It became and still is the most common overdenture connection in the world. 

Howard: He invented the ball and locator?

Charles: Not the locator but the O-Ball with the rubber O-ring housing and patented that. Got his patent in 1980, started it in 1977 and that was about the time he started the O Company. Which they were just doing attachments at that point for subperiosteal implants. Through the years then they grew and brought in Root Form implants, Blade implants, Root Form implants. 2001 was when they launched the 3.0 which was the very first one piece 3 millimeter implant on the market. From then on moved into all the other various other implants that we have within our line. 

Howard: I want to take you back down memory lane. I'm 52, do you mind saying how old you are?

Charles: I'm 48.

Howard: You kids out there that are 25 years old and just graduating dental school, take you back to memory lane. Do you realize that when I was in dental school from 83 to 87 that I was eating lunch with an oral surgeon and there was an older oral surgeon 3 tables over that started placing these subperiosteals, Ramus blades. Early implantolisgists and they called him the butcher. Then when I moved out to Arizona there was a guy across the street from me and he was doing subs. This is back in 1987 he was like 4 blocks away and people literally, they talked like these people were lunatics and needed to have their licence taken away. These were the earliest pioneers. If memory teaches anything, everything when JP Morgan wired his house for electricity everybody thought he was nuts and was going to burn the whole thing down. Yet they were lighting their homes with kerosene. 

An open flame, that's got to be good, but this electricity thing, a lot of these ... Be very careful at 25 judging some of these outliers in your class who have these radical ideas because that radical idea might be mainstream. Would you agree though in your assessment, you've placed a zillion implants. Would you agree that in 2015 Midis. You're still taboo. It's like you're not a real doctor or you're not a real implantologist. A real implantologist sink a 5.0 millimeter root form and bone graft around it and charge out a lot of money. Isn't a Midi implant just some that, I don't know ... Do you feel that way? 

Charles: I do, I think that it's the genesis of where the Midi implants came from. How they were originally marketed. I think this goes to what you said earlier regarding the fact that there are proportionately very few American dentists or US dentist that place implants compared to the rest of the world. This goes back as far as with standard size implants, the bias against general practitioners originally. Where Brånemark came into the US and basically gave the ability to place implants to 2 groups an oral surgeon or a prosthodontist. They had to include the prosthodontist only for the fact that nobody else would be able to restore implants that were placed very which way but straight. 

It wasn't until a little bit later on that the doors opened up for the periodontist and then eventually opened up to the rest of us. Now what we see is because of that historical change that occurred and more general practitioners coming into the market place to place implants. We are running into 2 situations now. One we are running into a turf war with the specialists. The turf war with the specialists is legitimate. It's cyclical, we see it in dental history over and over. I remember when I was in school we were being taught straight wire ortho and the orthodontists were very much threatened by that. 

The generation before me was molar endo and the endodontists were worried that they were going to lose all their business. There's enough out there. I think what's happened is the small diameter implants came into play. They were marketed initially as a kinder, simpler, gentler implant for the inexperienced general practitioners. The general practitioners are the ones that really decided to embrace that technology and there are some wonderful things that are being done with it. The problem I believe as you said is that the majority of specialists are not embracing the smaller diameter implants, they're very much pushing the full size diameter treatment plans as we're seeing with things like All-on-4 which do require a full size implant to do it. It's ...

Charles: Let me stop you right there. The All-on-4 not so much the brand name but that contact.

Howard: How much would that cost an American, an All-on-4? For grandma to go and get the All-on-4, how much? 

Charles: 40, 50,000 dollars per case.

Howard: You're in New Mexico and I'm in Arizona. We're both, were you born in America?

Charles: I was, I was Hollywood, California.

Howard: What percent of America's 330 million people could never afford a 45,000 dollar dental treatment?

Charles: Probably more than 90 percent of them.

Howard: Exactly. Do you ever hear the oral surgeon say, "Or if you don't want the 45,000 dollar option I can place 6 4 Midi's on the lower and 6 Midi's on the upper with balls and locators. We'll snap you back in there and that'll be, how much would some like that cost?

Charles: Generally we'd be looking at a single arch, if they have an existing denture to retro-fit anywhere between 2,500 to 3,500 total. 

Howard: If they use their existing denture. 

Charles: If they don't use it about 5. 

Howard: If a new denture 5,000, an old denture 3,500. How many implants have you placed? You've placed a gazillion.

Charles: I don't even keep track, thoudands. 

Howard: Would you treatment plan 4 in front of the metal frame in's and 6 on the maxillary in front of the sinuses?

Charles: Correct.

Howard: How much do those ... What's the name of your OCO Midi implant, is it the SDI? 

Charles: The SDI is correct.

Howard: Which was invented by Ronald Reagan, the strategic defense initiative. It's a laser implant shot from a satellite that Ronald Reagan put up in 1980?

Charles: Exactly.

Howard: Originally designed to take out nuclear weapons from Russia. Now at a denture near you. You call yours the SDI?

Charles: Correct. It's the SDI, it originally started out as the Midi, we shortened it to the SDI, since it's one part of our complete product line. 

Howard: What does SDI stand for?

Charles: Small diameter implant.

Howard: Okay. Small diameter implant. 

Charles: Real straight forward. 

Howard: Then it's really not the strategic defense initiative?

Charles: Nope. I actually like that and I like the concept of shooting up in space.

Howard: You should have the Ronald Reagan with a light saber. On the SDI, how much does a Midi implant cost? What is the diameter of that?

Charles: Our small diameter implants run either 2.2, 2.5 or 2.9 millimeters in diameter. They run in lengths from 10 millimeters out to 16. [crosstalk 00:12:35]. We are looking at a cost per implant, just the implant by itself of 55 dollars per implant, 75 dollars including housing. You're looking at ...

Howard: The whole thing would be 75 dollars. You're putting 4 on the bottom, 6 on the upper, you're looking at 10. 

Charles: Correct. 

Howard: That'd be 750 dollars. 

Charles: That's it. 750 dollars plus your time and effort. 

Howard: By the way, if anybody, you not anybody else, you should make an online CE course saying here is your solution to the 31,000,000 who don't have 50,000 bucks for All-On-4. Let me walk you through. Grandma's in here she's got sore spots, she's got loose dentures, she's complaining. You don't like her, in all honest I don't know what would be worse. To take on making a new denture for 80 year old Grandma or taking on a 3 year old kid who's been up all night with a toothache and pulpotomy. Usually the only times I want my licence taken away is after a pulpotomy or after a lower denture. Really, those are the 2 worst things. You're doing a realign and she doesn't want to be without it all day. Some of these grandma's will drop their denture off in the morning and they'll sit in my waiting room all day because they will not walk home 3 blocks because they don't want grandpa to see her without her teeth in. 

She sits there in the waiting room for 8 hours and then she'll come in everyday to have it adjusted. My assistant Jan tells me when they come in if I didn't give them big bear hugs and kisses and love on them that they might not even have a sore spot. She thinks some of them are coming back just for attention. You should make a course on how to do that. Walk through that right now. If she came in there with you. If she had an existing denture, how many appointments would this be? What would you do on the first denture? Walk us through that.

Charles: If she has an existing denture and it's serviceable in the fact that the occlusion, the teeth are in good shape. Then the first appointment we're going to treatment plan her. We may do a realign at that appointment because for a implant retained overdenture we want the best fitting lower denture that we can. We're not going to go make her a new one if everything else works out. We might do a realign appointment at first. Then we would bring her back for her second appointment. The second appointment then would be to place the 4 small diameter implants. Usually with a significant amount of primary stability we can then turn around and we can retrofit the dentures chair-side by using Cold Cure Acrylic. We're talking ...

Howard: Wait. Wait. Wait. I need more details. Would you do this with a 2-D pan or would you want a 3-D image of this?

Charles: 3-D is going to give you the most information but you can do these with a combination of a 2-D pan and mapping the bone. Since we are working anterior to the foramen. Basically if we stay within the bony envelope, there are no critical structures that we're going to run into. 2-D pan is probably the most common way that these are done. If a patient has a very atrophic mandible then a 3-D scan can give us a lot of information to find out where the bone is underneath the soft tissue that's hiding it.

Howard: I'm only starting to guess that 5,000 people listen to this on their headphones, on their iPhones, Samsung. I know what 95 percent of these dentists have never placed an implant. They're sitting there saying, "Charles, you know what if I do this I'm going to screw that Midi implant right into that mental foramen." The next thing I'm going to have is a lawyer in my waiting room wanting to know why I screwed a Midi implant from OCO right into a metal frame. How do you place 4 implants anterior to the mental foramen?

Charles: In your work up when you get ready to take your pan. What we will normally do is we will put some sort of radio opaque marker onto the existing denture. We might take their denture, drill a small little hole at the first bicuspid region. Pop a little bit of gutta-percha in there. Have the patient wear that lower denture. Shoot either the scan or the panel. Then that little gutta-percha dot will show up as a white dot on the film. We can then go back, look at the x-ray we've just taken. We can see the distance between that white dot and our metal framing. Come back to the patient at the time of surgery. Put the denture in, take a tissue marking pen, mark that dot onto the soft tissue and now we know exactly where the foramen are. We stay 5 millimeters ahead of that. That's where most distal implants are dropped. Then we drop the 2 implants in the center [crosstalk 00:17:30].

Howard: You're talking about 5 millimeters in front of that mental foramen from the interior loop? Explain what that means to our viewer. What is the interior loop? Why is that concerning?

Charles: When you look at a [panagraph 00:17:42] when you're looking at a 2-D film. You're going to see the  mental foramen which is going to be the whole, that is the emergence of the IA nerve as it turns into the mental nerve. In about 30 percent of patients there is what is called an anterior loop occurs when it's impossible for a nerve to make basically a right hand or 90 degree turn to come out of the bone. If you take a look at a pano. You can guess with pretty good success what ones are going to have an anterior loop by the fact that if the inferior alveolar nerve is running parallel or straight across to the foramen. Then it's probably going to have an anterior loop because it's not going to be able to come down, make a left hand turn and come right out the bone.

What it's going to have to do is loop forward and come back through that foramen. If you look at a pano and you see an inferior alveolar canal that has a big slope to it. Basically it starts out high in the posterior, dips down and then comes back up towards the foramen. There's a good chance that, that nerve can come straight out and not have a problem. We stay 5 millimeters ahead because from not only CT studies but categoric studies. That average distance of that loop if it does occur is about 3 millimeters and that additional 2 gives us a safety zone. 

Howard: Then let's [inaudible 00:19:05] on her head and keep talking about, how do you avoid the maxillary sinuses? 

Charles: Maxillary sinuses.

Howard: You can only place the implant down right, so you'd have to flip grandma over?

Charles: Yeah. Flip her over and go from the other end. With maxillary sinuses again it's done with our pano. We can again have a radio opaque marker that we can use to use the denture to establish a distance. Otherwise as soon as you take a denture out, you take a look at an atrophic or even an edentulous mandible or maxilla. You don't have any landmarks that you can really work with, at least that show up radiographically. We usually do the same type marking on the upper denture if we're going to do it. Stay anterior to the sinus. There is no specific distance, I like to stay about 2 millimeters in front of the anterior wall of the sinuses to make sure I don't perforate through or that there might be some irregularities. With the maxillary arch there may be some irregularities. With the maxillary arch many times a CT scan is going to give you a lot more information regarding the sinus. 

Again through a pano if you have a good one you're going to be able to use that in order to keep yourself out of trouble. The other structures we're going to be looking at, not only is the sinus but we also want to look at where the nasal floor is at because we're going to probably put 2 implants somewhere in that 8, 9 region. Grandma doesn't really like it when she has implants inside her nose. We want to make sure we're running short of the floor of the nasal cavity. Then the third thing that we're looking at really is the nasopalatine canal. We want to avoid trying to put implants into those canals too. Those are the structures that we're looking at just as we would with conventional style implants and it makes it easy with small diameter implants that are less than 3 millimeters in diameter. 

Howard: Are you going to lay a flap for these or you just going to go right to the tissue?

Charles: Not necessarily. Most of the time we're going to go directly through the tissue. The only time that we will usually reflect a flap. I don't even want to call it a flap. We usually reflect a small window is if we have a lower arch that has a knife edge to it. Basically that the bone is resorbed enough that there is not really a flat spot that we can gain a purchase point for our drill. We make a very, very small incision, it could be 5 to 7 millimeters in length just expose the top of that bone and be able to center that drill appropriately. 

Howard: You teach hands on courses with these?

Charles: Correct. 

Howard: Tell me about, where are your hands on courses?

Charles: We do these courses all over the US. We run 33 Implant one courses. Which entail not only small diameter but full diameter implants. We run 33 of those courses. We also run 12 cadaver based courses per year. We got pretty full schedule of courses where doctors can get trained on this. We have done some specific small diameter only courses that are also available. We also just work with the doctors. We'll evaluate scans for them. We'll help them treatment plan. We'll get them started. Our reps will come out to the offices, make sure that they're doing everything correct. Then there's the ability to have myself come out and work with them with cases. 

Howard: You know what I wish you would do? I really feel like, I've lectured 1,500 times in this country. I feel like I know my homies. I think you have to deconstruct the sales process. I always tell the people. The biggest asset an American will own is their home, second biggest asset is your car. An annuity, selling your home to an annuity is a good thing for grandma. Why give all your money to your ungrateful children and live like a pauper. You could give your home to a bank and they'll try to guestimate how long you're going to live. We think you'll be dead in 8 years. Your house is worth 150, we'll give you this much and if you live to be 112 we take a bath and if you die tomorrow we win.

Overall we make money. It's too big of a decision. The first commercial is just you, a guy I can trust getting to know you. All you're saying is, "Grandma just call me and get the CD and listen to it." Then when she gets the CD it's just, "Grandma, I can't tell you how much money you'll get each month. Just call me back and give me your address." I think it's a big stretch to go from. I've never done this ever. I'm 95 percent, I've never placed an implant and now you're wanting me to sign up for this course. You've got all these great programs that all my friends, a lot of my friends have taken it. My best friend Dennis lives in Albequerque, Craig Steichen he thinks you're a God that walks on water. 

You should put these online on Dentaltown because if you put that course. It's real easy for that dentist just to sit back, I watch mine on my big screen. I'm in my chair, I'm on my big screen, I'm in surround sound. I think after they watched you for an hour or 2 or an entire curriculum. Then they'd say, "You know what? I can see 10 ladies with dentures. I'm going to sign up." Obviously with implants you're going to need to go to your hands on course. I think you should deconstruct it by putting up the course of Dentaltown first. Then they get to know you. They get to trust you, like you, love you, you understand it. That's what will get them off the couch. My job is how do you get this dentist motivated and inspired to go for it? How do you get them to dive for the ball? 

How do you get them to dive into the bleachers while he throws a basketball back into his teammate and breaks his neck on the ... I'm trying to get him motivated. I think it's too far of a stretch to go from I've never placed an implant to now I'm going to go to a hands on course. The results are clear, 95 percent of the dentists have never placed an implant. I also want to apologize to you because small diameter implants are only 20 percent of your business. I spent the first 20 minutes talking about that. Let's switch gears to I don't want to have them brand you as a Midi implant guy. Now lets switch gears to Root Forms. What's the bigger market? I read things like 96 percent of crowns are placed one at a time. 96 percents of implants are placed one at a time to replace one missing tooth. Is that what you're seeing on your implant business?

Charles: Absolutely. Absolutely. Single tooth replacement is the most common replacement that's out there, I think one because its probably the largest need. 2 it's what most practitioners are comfortable with. We are seeing more and more of the larger cases that are starting to come around. We are seeing people that are raising the full arch rehabilitation on either 4 or 6 implants. That's a big step, it's a huge step to go from a single implant placement to a full arch.

Now as you know there's a lot of other factors that come into play. It's not just placing the implant. A single implant, that is a straightforward thing that any dentist out there can do with a little bit of training. You're able to use the adjacent teeth to help you guide it. You split the difference between it. It's not that difficult, it's actually more difficult in my eyes to cut a 3 in a bridge prep than it is to place a single implant [inaudible 00:26:46] space, as long as there's adequate bone. We see the single implants as the bread and butter and we see the larger cases and the cases that involve grafting as being where the next step that most practitioners go to. 

Howard: I want you to weigh in on first because these dentists, the whole motto with Dentaltown. is no dentists have to practice solo again. America could be summed up with money is the answer, what is the question? You have a lot of people trying to sell you technology and gadgets and machines that really clouds a discussion. I want you to weigh in on this debate because there's 2 camps here. This person listening to you on their headphones, they're on the treadmill. I hope they're not at Dairy Queen eating a banana split. Whoever it is, they've never placed an implant. They're hearing to place my first implant I'm supposed to buy a 150,000 dollar 3-D x-ray machine and then make a surgery guide and then snap it on those 2 teeth.

It'll have stop guides so I can't hit the mental foramen or the sinus. Then I'll just go in there like Stevie Wonder. I can't screw up and I'll place it right there and I'll be safe. I graduated 250,000 dollar student loans. Now you're talking about a 150,000 dollar 3-D machine and an implant kit. Then we're back to 95 percent of Americans have never placed an implant. The other camp says, "Dude, you're a dentist, you're a surgeon. I don't want your training wheels. You need to learn how to lay a flap." There's a tooth in front of it and behind it 96 times out of 100. You just casually said, "Dude, you split the difference." You split the difference mesial, buccolingual, mesial distal. Do you think that a 3-D, buying a 3-D x-ray machine and using it to make a surgical guide is overkill? That you really should just be able to learn how to lay a flap, look at the bone and place a single root form implant for a single missing tooth. 

Charles: I agree. I think it is overkill for a single tooth. 

Howard: That's 96 percent of the market.

Charles: That's 96 percent of them. I also think that the push towards, the problem with going in that direction and saying, "You know what? I've never placed an implant before. I'm going to do it guided, all mine are going to be guided. Is what happens when that day comes that your guide didn't show up or your guide was produced incorrectly? Now if you don't have the experience or skill to have done it by hand. Then you're stuck. I believe you should be able to do these very, very easily. We do have the skills.

As you said I'm definitely in the camp of, "That you are dentist you have the skills you can do this." Do you need to have a cone beam, absolutely not. Millions upon millions of implants have been placed without a cone beam. Where a cone beam is necessary is if there is something that you cannot see through conventional radiography. The combination of conventional radiography and ridge mapping can give you all the information you need. Go ahead and lay a flap, expose the bone, see where you are. It's not that difficult once you do it that way. I think we're running in to a situation where cone beams are becoming more common and we're getting pressure. I'm not going to stand on a soapbox and say who the pressure's coming from. 

Howard: You get on that soap box right now. I want to hear who the pressure is coming from. On Howie's podcast. 

Charles: We're feeling the pressure. I like to tell you the 2 people that tell you you should have a cone beam to do every single one of your cases is either a guy that's trying to sell you a cone beam or a guy that just bought one needs to justify that he spent 120,000 dollars. You can do it. What does a cone beam do for you? Cone beam takes away a little bit of the guessing. It does give you more information. I compare it to the difference between doing dentistry with an analog x-ray E-speed film or doing it with digital. You can do dentistry both ways and you'd probably do just as well with a conventional hard copy x-ray as you will with a digital. It's all about what you use it for. 

I think the majority of doctors out there can go in there diagnose an area that needs to have an implant, use conventional radiography. Use their eyes, use their hands, open up a flap. Drop an implant in very successfully and never look back. It's fear, it's fear that prevents everybody from getting everything started. Much of that fear is propagated by individuals that either don't want us to do implants or feel threatened that somebody else is doing implants. If you really look at the statistics and the literature, I always hear people say, "What if I run into a nerve? What if I cause a paresthesia? If you try to take a look at that and try to do a literature search in that. 

You're going to be hard pressed to find a whole lot published out there about inferior alveolar damage due to implant placement. Sure, does it happen? Yeah, absolutely it can. If you do your diagnosis and treatment planning correctly, you should be able to do it. There is no excuse why every general dentist shouldn't be able to place implants. The fact of the matter is, in the times we live in today. Now that they're teaching implantology in dental school. That guy who graduates next year, this year. Is going to be coming out hungry to place implants. If you're sitting in a practice and your not placing implants. ]

That guy's going to move in right next to you and he's going to take all your business because your patients are going to go over there for the implant and find out that they can get their [prophies 00:32:47] over there. They can get their fillings over there and their family can get treated over there and now you've lost a patient. Since we know in dentistry patients like to have a one stop shop. That's the reason why we as general practitioners have learned to do everything that we have. If we didn't then we would stick to doing fillings and placing crowns and that's all we would do. 

Howard: You said it though, you said fear. You brought up the fear word. I'm with you, since we're 2 groups are listening to us right now. 5 percent have placed implants and of those probably 5 percent of those people have done the really big aggressive stuff, like All-On-4 or something. Let's focus on the 95 percent that have never placed one and fear is the overwhelming thing. Cherry pick me my first implant case. If I am afraid, what cases would be not an entry level case. Start telling me cases that if I was going to place my first implant or my first 4 implants this summer. Tell me about those cases, what should I be looking for? Would it be, I pull the tooth and then place it or would you let it heal up? Go through 3 or 4 specific cherry picked low hanging fruit of how to get started placing an implant. 

Charles: Sure. Sure. Number one as we talked about earlier that fully edentulous patient that needs something to retain their lower denture. Those are fantastic cases to start with. Number one, you don't have any anatomical structures to deal with. 2 if your implant placement is not exactly correct, there's now an aesthetic issue to deal with at all since everything is going to be covered with plastic. That number one, 2 look for those cases that the patient has had a tooth missing somewhere within 6 months to 5 years because we're probably going to have enough bone volume there as long as there wasn't a lot to begin with.

I try to steer my docs away from immediate placement as their first cases. We always get those doctors who will call me up and say, "Hey, I have this young girl, she's 25 years old. She's absolutely beautiful. She needs to have number 8 extracted and I would like to do an extraction, immediate placement on her. That is definitely not your first case because there's a lot that can go wrong. Immediate placement is technically sensitive. Look for those cases where patients have lost the teeth already. Lower first molars are great to start with. Upper bicuspids are great to start with. Upper molars sometimes can be a challenge due to decreased vertical height. 

Howard: Meaning the sinus.

Charles: Meaning the sinus is pneumatized and they're going to be pressed a little bit for height of bone. We look for those areas that have sufficient bone, not only in the buccolingual orientation but also vertically. We're looking for areas that have a tremendous amount or a normal amount of keratinized tissue. If we can find those, those cases are really, really easy to do and if you dig into your practice, most doctors will find they have a plethora of patients that fall into that. 

The other thing is, what type of patient do you look for? I truly believe getting started, patients like to see the success of their dentists. It always amazes me how much trust a patient has in their dentist. They know that this might be the first time that you've done a procedure like this and they're all for it. They're excited because you're excited. Try to find a patient that is going to be easy to work on from a psychological point of view. I like to call them the do me patients. They basically get in the chair, they'll open their mouth as wide as they can. They've got an edentulous space and they just say, "Tell me when it's done." Those are really the ones that you want. 

Howard: Is there any profile you can say, older younger? Man or woman or rural, urban or just a personality profile? 

Charles: It's per person but I would say that the majority of the patients that fall into that are going to be somewhere in the 40 to 55 year old age. Then there's a little bit of a break and I see patients 65 and above that are pretty compliant and want to be helped. The best patient is that patient that's been wanting this type of treatment for a long time and hasn't had the opportunity to do it because either they couldn't afford it or they didn't know that it was even possible. It's just a matter of finding the right patient, not only [crosstalk 00:37:50].

Howard: You know where I found all my first implant sinus lift, everything that scared the crap out of me. I just needed some research monkeys to experiment on. Was at a [Ferrahian 00:38:04] family reunion. My first sinus lift was my mother-in-law. There's all these adorable 25 year old woman dentists that got out of school and she doesn't realize her uncles an old stand up in a row. She said, "I need a research guinea pig for an implant, a bone graft." All of her uncles are like, "Oh yeah, I don't care." Then after that then I went to failed financial arrangements.

Where I just went in and said, "Okay." They were totally prepped, they couldn't afford the root canal, build up and crown. They were going to go for the extraction. Everything was done, they paid for the extraction. Then I walked in there and said, "Hey, I've got an idea. How about the money is the same but we do this instead. We pull this, do the bone graft, implant we are." They light up the fire. The same thing about making someone happy. You lower their expectations and then you beat them. You don't sit there and tell them you're going to do a DO filling and then it turns into a root canal build up and crown because you knew it was close but you thought it would be a DO. Now you're going in and saying, "Oh by the way, that 250 dollar filling. Oh yeah now lets make it a 2,500 dollar root canal build up and crown.

What you do if it's close you tell them it's going to be a 2,500 dollar root canal build up and then you get them prepared for the worst case scenario and that happens sometimes. Then you go in there and say, "Sorry, I was wrong. I thought that was into the nerve but it's not. It's not going to be a root canal and crown. It's only going to be a filling. Now you're their hero. When you get someone and you're just totally honest, you say, "I've never done this before but you were going to pay for an extraction. I went to this course, I got these implants. I'd like to do this, are you up for it? I won't charge you a penny more." This might give you new enthusiasm to go to grandma's house on Sunday. 

Charles: Sure. Sure.

Howard: Start looking at those uncles with a different eye. What about restoring OCO Biomedical?

Charles: Really no different than any other implant out there with regard to just we use our bone level implant. It uses a universal connection that's out there. It's an internal hex with a conical seal. Many. Many companies around the world use the same connection, that makes it very familiar to a practitioner and also easy to restore from a laboratory point of view because CAD/CAM is available. They can get customized titanium or Zirconium abutments if they'd like. If they are a [Sarek 00:40:46] user or an E4D user you can drop on a scan body, scan it, build your own restoration right there in your office. It's a very, very straightforward restorative. What we do is we actually package our restorative componentry along with our implants. 

It's a single package if you would like. For example on our bone level implant you get your implant and along with that you get your analog, your impression coping, your gingiformer and your stock vinyl abutment all for a single price. That takes a lot of the guesswork out of things. If you need to go with a customized abutment then it's easy. You still take an impression. You still send it off to the lab. The only thing you don't use within the packaging would be the stock abutment. If you are a doctor that is doing only CAD/CAM abutments, only customized abutments then we have an option where you can purchase without the vinyl abutment at a lower price point and allows you to have all the flexibility that you need by doing your customization. 

Howard: Charles, I want to stop you right there. I want you to address this question. I hear this one a lot. "I just got back from the CDA or Chicago Mid-Winter or Cologne. Cologne had 225 or 275 implant companies and the dentists were just overwhelmed. They don't want to make a bad decision and they really don't have the time to figure out 275 ... That's why humans are so brand loyal. The heuristics because when you walk into a grocery store and they have 100,000 items for sale. You don't have time to go look at every single coffee known to man and look at the ingredients on it. I just go right over to Folgers, I've been drinking it for 52 years. Cut down the chase the person listening doesn't own an implant system, they're overwhelmed. They don't really want to learn 275 systems. Why should they get your system?

Charles: That's a great question. I will preface this by saying all implants work. That's anybody who tells you their implant works and another implant doesn't, that's not true. Where we feel our strong suite is, is we have a very simple surgical protocol. Basically we have what we call a 2 step protocol, which means we go from a pilot drill to a final drill. Not through intermediary steps, that makes surgery very, very simple. We have a very extensive implant line that has everything from tissue level all the way down to bone level implants and everything in between, also including small diameter. Any clinical case that comes up we can address it with our implant line which can be placed with one single surgical kit. 

Then our implant body, we have a US patent for immediate load. We're one of the only companies that does. Our implant is able to be loaded early. It's able to be loaded immediately. I would say about 85 to 90 percent of my cases both single and multi unit are being loaded immediately. In the world that we live in today where people are into immediate satisfaction and immediate gratification. That when a patient comes in with an edentulous space and leaves with a temporary on an implant. That makes them a very happy patient. 

Then finally our customer service I believe. For me when I tell doctors what do you look for, you look for a system that works within what you need. That has to be a good surgical system, a good restorative system. Accomplish what you need clinically and then have the support from your company to help you get started. Then continue and be successful because as a company we're only successful when our doctors place implants. We spend a lot on education, we spend a lot on our regional reps working with our doctors in order to make them successful. 

Howard: Do you know what? A lot of feedback I'm getting is that the reason they went to an institute or the reason they went for more training is because they spent a Saturday by their pool on their iPad watching Dentaltown online for an hour or 2. That was the closing deal that said, "I'm interested enough." I hope you do that. I hope you digitize an intermediate step between this. Especially for the 30,000,000 who only wear dentures. I really wish you'd do a Midi. Then I really wish you'd do another course on the single replacement. I want to focus in on that single replacement. You said a very controversial word, immediate load. 

Charles: Yes.

Howard: My God, there's 1,000 threads on Dentaltown arguing about that concept. What do you think about immediate load? Obviously there's probably sometimes that it's good and sometimes it's a bad idea. Let's talk about that. 

Charles: In order to be successful immediately loading an implant. You have to look at a lot of different things. You've got to have pre-requisites. You've got to have initial primary stability. Meaning the implant doesn't move. When you're placing an implant that's mechanical stability. Not every case are you able to do that. Bone quality effects it, the style of implant that you use. Do I think that it's possible? Absolutely. I do it all the time. do I think that many people get themselves into trouble with it. If you use the wrong implant with the wrong type of body style that can't give you the type of primary stability that you need. That's really the key. We feel confident with immediate load because our primary stability is so high. 

We average torque values when we place our implants anywhere between 50 and 90 newton centimeters. Most other companies will talk about not going to that 50 or 60 newton centimeter mark because of the negative consequences that can have on the bone around the implant. Our patented design negates those problems. We actually put bone in tension versus compression. Therefore we don't have those same issues. If you are a doctor and you are doing a lot of immediate load. You are practicing on the cutting edge of implant dentistry. The possibility for failure is there. 

It might be a little bit of your implants buried them for 4 months and then exposed them. The thing is, patients are reading more about immediate load, they have been exposed to it inadvertently through companies like Clear Choice that advertise teeth in a day. The only way you can have teeth in a day or a restoration in a day or restoration immediately is by immediately loading the implant. I don't believe that it's that controversial of a subject. A lot of the research out there shows that done correctly you have an equal success rate, as you do with delayed. There are all those advantages to not only promoting your practice but also providing treatment at a faster clip than you would normally. 

Howard: I want to switch gears completely. Want you to talk about this because you've  been doing this for over 2 decades. One of my pet peeves about dentists is if you listen to their conversations you'd literally think a bunch of engineers were sitting around a table that weren't even doctors. I used to always have this problem with all the filling classes that you would take. They would talk about [inaudible 00:48:52] wears at 14 microns a year and Tetric Ceram wears at 18 microns a year. Everybody would be taking notes on the wear rates of all the fillings in dentistry and memorizing it. I'm like, "Dude, that's not a problem I have. I put in a filling and it wears down." My problem isn't, oh you know all those fillings I put in? Yeah. 

They all wore down. You know what my problem is? I put in all those fillings, Billy Bob leaves and he still won't floss his teeth and he still won't brush his teeth. He's working construction in the Arizona desert so he's taking a 2 liter bottle of Mountain Dew to work with him everyday. 3, 4, 5, 6 years later he's got recurrent decaying of those fillings. I wish dentists would quit being engineers and become biologists and realize that we build these wooden barns out on the middle of the prairies and no matter what happens, termites are going to come get that. We always blame it on the patient, you should brush twice a day and you should floss before bedtime and you should use a tongue scraper and mouthwash and see your hygienist at least every 6 months.

At the end of the day 31,000,000 Americans have no teeth because the termites always come back in and eat everything down. What implants are to me is bugs can't eat them, the termites can't eat them. I think your ad should be, here's a ... I think your OCO ad, I wish I could design your marketing. I'd put a barn on the left side. I'd Google Kansas barn eaten by termites and then on the right side I'd put an aluminum barn. The barn on the left, your patient didn't brush and floss twice a day, use a tongue scraper, mouthwash and see their daily hygienist.

That's what every one your bridges looks like in 6 1/2 years. The person on the right got a titanium barn and doesn't have to brush or floss and the termites can't eat it. I really also, another pet peeve of mine is everybody talking about peri-implantitis on an implant. Dude that is not ... They're throwing up this red flag and I just don't see it like I see periodontal disease. Periodontal disease is when those Gram-negative bacilli anaerobes are in this messy, junky, cementum and it's nasty and it's bad and it's common. Then when you extract that and put in titanium, yeah you still test positive for those bugs. Yeah, you still need to clean it, but it's not nearly the disaster that we see with periodontal disease. Do you agree with that or do you think I'm wrong on that?

Charles: No. No. No. Absolutely. I think it's always in my eyes a better option to go with the implant. I know when I graduated school and you had a patient that came in with a tooth that was fractured off at the gingival level. What did we do? We tried to go ahead and do crown lengthening, post and core, endo, put a new crown on it. 3 years later the crown would break off. You'd start all over again. Nowadays we look at it. You know what? Take that tooth out, the remnants that tooth out. Put in a piece of titanium, have it last the patient the rest of their life. We're now looking at and there's so much in the literature nowadays. Looking at peri-implantitis as you said. Now the whole big buzzword is cement sepsis.

Cement has caused this, that's my pet peeve Howard. It is you're blaming the cement when really we should be blaming the practitioner because if cement was that bad we would have figured out how to screw retain crowns on natural teth a long time ago. Basically it comes down to the fact if you put the right amount of cement in and you clean the cement up there isn't a problem. What I really laugh about it is this big push towards screw retain restorations made? They cement them outside the mouth. They put them in the mouth, there's still a cement line. It's not the cement that's the problem. It's the inability to clean it up. I agree with you. I think when faced with the option of a patient with an edentulous space. 

You're either going to do a 3 in a bridge or a single implant. Single implant by far is the better treatment option. One, you're going to have a restoration that's going to last the patient the rest of their life, 2 you're not going to damage 2 potentially virgin teeth on either side. The fact of what you said, you throw a bridge on there. How many patients are actually going to floss underneath that bridge and get out their floss threader, very few of them. 3 in a bridge becomes a 4 in a bridge down the line and ends up becoming a partial. 

I think that implants are the best alternative when you have a tooth that's missing, it's the best long term alternative. When we have a patient that's fully edentulous, if they desire something that's fixed, implants are their only option. We can do very, very successful restorations that should last a patient the rest of their lives. If they don't want something that's fixed then we can take that piece of plastic that's bouncing around their mouth and driving them crazy and ruining their life and basically put few implants in. Attach that denture to it and we change the way they live on a daily basis. I'm a big believer in implants obviously. 

Howard: I'm going to do this. I built a speaking career by assuming that and we really mutually respect each other. I'm going to tell you what I think and so many people the lecturer just tells you what you want to hear. I think true friends are the ones that call you on your shit. I'm going to call Dennis on his shit, do you know why they do 3 unit bridges? Because 95 percent of them have never placed an implant. In business, money is the answer, what is the question? They're looking at this missing tooth and thinking, "Oh my God, I can bill out a 3,000 dollar bridge and I get to bill for 3 crowns even though I only prepped 2. They actually feel guilty about charging out a crown fee for a [inaudible 00:54:54] because they didn't do a damn thing. 

Then they sit there and when the tooth snaps off at the gum line they do this root canal because they can build out, they do a post build up so they can build out. Then they put on the crown and I'll call you on your deal. Here's what I did to my associates. You warranty everything for 5 years, we are a patient centered, we are not doctor centered, it's about the customer first. Yeah, you can do a root canal on a post build up and there's no [inaudible 00:55:20]. The crown's going to be as long as the root, but you're good with it. Then you do that, they come in a year later and there's their post build up and their crown.

All the money they spent on that, it didn't last 5 years is now going to be credited to how you're going to fix it and there's no money changing hands. Every endodontist needs to learn how to place implants because on the street the homies don't trust their endodontist anymore because they've seen him for 25 years. They send you a failed root canal and it's an old lady and something is wrong and the endodontist says, "Oh, I've got to give it a try." Then they bill out 1,500 bucks, redo the root canal, 6 months later it's in the trash can and they never give a penny back. The reason why they don't give it back is because if your only tool is a hammer everything looks like a nail. They just wanted the 1,500 bucks, they knew it wouldn't work.

Now the endodontists who are differentiating themselves get on the phone and say, "Look, I can make 1,500 dollars either way. I could do the retreat but I wouldn't if it was mine." I recommend. I'm going to pull it right now and place an implant. I'll send her back to you. Are you good with this implant? Can you restore this blah, blah, blah? I want an endodontist who doesn't have to feed his family by doing a 1,500 dollar retreat on a grandma when he knows in the back of the head that it's got a flying chance of success. 

I want an endodontist that's not everything ... What is it, if y9oure only tool is a hammer, everything looks like a nail. I wouldn't even refer to an endodontist who can't place an implant. The same thing with periodontists. In fact Gordon Christian said something. The most controversial podcast we've ever done, with the most views. Was when Gordon christian said, "The specialty of periodontics is done, it's over. Why are you going to do all these gum surgeries and crown lengthenings and long rooted teeth. Why are you going to go through a mountain of a mole hill when you just pull that baby and put in an implant." Do you agree with what Gordon said?

Charles: I do. I do to a certain extent. I think that what we've seen is we add to what you were talking about. I thin we're finally getting away from treatment planning according to insurance. That's where the problem really started. When I got out into practice and I was working for a big corporation when I was first started out. It was the same thing. We're going to get paid for treatment A but we will not get paid for treatment B, so guess what? You're going to do treatment A no matter what. I think that more and more dentists today, I have some hope for the profession that more and more dentists are starting to believe in treatment planning for what is correct and what is correct for that patient. 

Not necessarily what is correct for what the insurance will pay for it what the patient can afford. As far as taking teeth out. I definitely agree. If a tooth is in such a condition that it is non-restorable or you have I believe less than a 75 percent chance of recovery on it, then an implant is the best option for it. Where I don't necessarily agree with it. Is when a patient comes in has an arch full of teeth. They've got maybe a third of those teeth that have an issue and the easy way is taken out to say, let's just slick them and throw in 4 implants and a piece of plastic. That I don't necessarily agree with. I am still of the mindset that we should try to save teeth if we can if the chance of success is high enough, because no matter what we put in they're never going to be as good as the teeth that these patients have started out with. Absolutely if a patient comes in and they've got ...

Howard: Can I call you on that one?

Charles: You can. I would.

Howard: The only reason I disagree with what you just said there. You're one dentist to another, we're both men. In my 28 years Phoenix, Arizona, I don't know if Albuquerque is the same but we have a lot of retirement community. I'd say 15 percent of Phoenix is people that retired from here to Canada getting out of the cold. I just see these ladies who were 65 and the dentist tried to save the tooth like you said with the root canal, build up and crown. When she was 65 she gave someone 2,500 dollars and 10 years later full blown Alzheimer's dementia, the nursing home. Root surface decay just eats on. The average American and basically a nursing home is all women. 

There's just no men in there, if there is his name is Lucky and he only lives a week. The average person in a nursing home loses a tooth a month from root surface decay. When grandma has been in there the first year she lost 12 teeth. Those root canal build up and crowns were gone. I wouldn't have a problem if you came to me an you were 65. I don't have a problem doing a root canal build up on you because you're probably going to die. Open up the refrigerator reaching for a beer and a chunk of cheese, you'll just drop dead in your kitchen. 

Those women, the average woman lives 11 months longer than her mother. When they come in at 65 I say, "Mary, you're 65, how old was your mother when she passed away?" She goes, "My mom's still alive, she's 85." "Can she still brush and floss her teeth?" "Oh no, she's crippled, rheumatism, dementia, Alzheimer's, and I'm sitting there telling her." This s stress for me. "Man, if we pull this tooth, yeah it's an emotional loss for you and me to lose a tooth. God, if you're going to spend the last 5 years of your life not being able to brush and floss your teeth. I'd rather have titanium in there. What do you think of that rant?

Charles: I agree. I think in a geriatric population like you're talking about. Those are better options. Those teeth you're talking about that come in with enough problem to start making us think about an implant are usually in pretty bad shape. Where I'm talking about it is 40 year old women who has had issues, still has a relatively intact dentition. Absolutely take out what can't be restored. Take out what doesn't have a long term prognosis, replace it with a titanium screw and get them on their way. The problem that I have are those same 40 to 45 year old women are walking into offices, they're saying, "You know what? You're having these problems? Why don't we take everything out so you don't have to worry about it anymore?" That is an issue for me. 

Howard: Last question. We're past our hour but I've got to throw you in to one overtime question they're always asking on Dentaltown. I cement that crown on the implant or should I screw it? Cement or screw?

Charles: I'm a cement guy Howard, I'm a cement guy. Clean your cement up, you won't have any problems.

Howard: Is this a temporary cement or real cement?

Charles: I cement with permanent cement because I don't expect my crowns to fail on me. The way I look at it is if you cement with temporary cement on a single implant crown. You're not going to be able to get that off, especially if your lab did a good job of manufacturing that crown to fit that abutment with a perfect resistance form. I believe in permanently cementing. The only time that I do temporary cement is multi units. If I'm doing a full arch, now I've got enough resistance from all of my restorations in order to keep everything on.

I want to be able to have some retrievability. That's also where I think screw retain has an advantage. I also think screw retain has an advantage if you are in a situation where you have insufficient vertical height. There's no way to have restorative material and your abutment. I think that a screw retained is the way to go, but on a single straight forward unit. I'm cementing, I'm cleaning my cement up. I'm not having peri-implantitis problems and they're lasting for a long, long time. 

Howard: Last but not least, I'm driving to work, I think I'm going to place my first implant. How much is the intro starter kit with you?

Charles: We can get you into, depending on what you're doing. If you're looking at small diameter implants, we can get you into 30 small diameter implants and a surgical kit for about 1,900 dollars. Which you'll get that back twice in the first case. If you're looking at full size implants, we can get you into a kit with 10 implants for around 3,000 dollars. 

Howard: For 3,000 dollars I'd have every single thing I need, I'd have the implant drill, everything?

Charles: If you want to add the implant drill, we can get that for you it's about 6,500 to get you all set up with an implant drill, implant kit and a small variety of implants. You'll make that back.

Howard: It's how much?

Charles: About 6,500 we can do that for you.

Howard: If I've never placed an implant, I could call Charles at OCO Biomedical and I could get everything I need from A to Z to place my first, about how many implants? How many would that come with?

Charles: That would come with 10 implants. 

Howard: Hey dude, I love you to death. It was great seeing you speak at your meeting in Albuquerque. Like I said my best friend from dental school Craig Steichen, he thinks you walk on water. Everyone I know that knows you thinks you're the bomb. I'm just very fortunate that you spent an hour with me. I'm crossing my fingers that you build me 2 courses on Dentaltown. One to help the 30,000,000 Americans that don't have a tooth in their head. The small Midi implants that no surgeon will talk about. Then the other one, that 96 percent of the low hanging fruit. Just place one implant on one missing tooth at a time. 

Charles: We will work on it for you Howard.

Howard: Thank you for everything that you do for dentistry, implants and thank you very much. 

Charles: Thank you. You have a great day.

Howard: You too. Bye-bye. 

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