Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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200 Restorative Dentistry with Mike DiTolla : Dentistry Uncensored with Howard Farran

200 Restorative Dentistry with Mike DiTolla : Dentistry Uncensored with Howard Farran

10/21/2015 2:00:00 AM   |   Comments: 1   |   Views: 852

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AUDIO - HSP #200 - Michael DiTolla

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VIDEO - HSP #200 - Michael DiTolla

Mike shares thoughts on single visit dentistry vs 2 visit, common dentist errors, and how quickly everything is going digital.



Dr. Michael DiTolla was in private practice for 15 years before becoming Director of Clinical Education for Glidewell Labs. In 2011 he received the "Most Effective Dentist Educator" award in a nationwide survey of dentists. From 2012-2015 he lectured on behalf of CR, presenting their iconic "Dentistry Update" lectures, the longest running CE program in dentistry.  In 2015 he became Director of Clinical Affairs for Sirona Dental, where he is also Director of SIROWORLD, Sirona's official community for owners and fans of their digital technologies.




Howard: It is a huge honor. Mike, I don't know if you remember this, you were my first podcast interview and today you're back again at number 200. You, I think I have the most views, and replies, and everything from your first time. You're just a legend. I mean, you've got a stellar career, your dad was a dentist, you grew up in dentistry. Everyone knows you, everyone loves your lecture. You've lectured for the company [Gordon Christiansen 00:00:33]. I mean, Gordon Christiansen had you lecture for his clinical mastery update annuals that he gives. 

You're the director of Glidewell, you've made so many YouTubes and podcasts. You're just a legend and now you left the largest dental lab in the world. Some people say Glidewell's about 5% of all the crowns made in the United States, and now you just went to the biggest mega-merger on earth, Sirona merged with Dentist Supply, and now it's something combined $11-$12 billion annual in sales, and who do they want? Mike, the man, DiTola, so congratulations to a stunning career. What was all that merger about? Did you even see it coming? I mean, a year ago did you see it coming?

Michael: No, no, no. I think it took everybody by surprise. I think it took everybody who even analyzes the dental industry by surprise, and I doubt there was more than maybe half a dozen people on either side who knew that this was going to happen, and so we were getting ready to put on the [SEREC 00:01:39] 30 meeting this year. It was about two days before and we were doing some rehearsals with the band, and some other stuff, and all of a sudden all of our phones started blowing up and vibrating, and everybody picked up their phones, and it was the announcement of the merger on whatever that Tuesday was at about 3 PM. 

It was initially kind of shocking because nobody knew it was coming. You had to be really, really high up in either corporate structure to have known that this was going on, but I think when you look at it, Sirona's essentially an equipment company that's got a small consumables line, and Dental Supply's a huge consumables company with a small equipment line, and so it looks like a great marriage between an equipment company and a consumable company, and I think, yeah, the market cap, like you said, something like $13.1 billion, becoming the biggest company in dentistry. 

That was a surprise to me, but it's kind of neat from the Sirona side to look at all the brands that six months from now, when this all goes through and it's Dental Supply Sirona, it's pretty exciting to look at all the brands that you might be able to interact with. Sirona, I just think is the coolest company on the planet. They put on the best meetings, do the best education, have the best products, and I was really excited to go and join with them not even knowing that the Dental Supply merger was going to happen, to be honest.

Howard: Did Jim Glidewell, did he cry? I mean, you were with him for 15 years. I know he loves you like a son. Did he take that okay or was it like a father's son where he was just proud that you were going to another chapter of an outstanding career?

Michael: Yeah, he was ... I found him and we sat down together alone in a room. He was as magnanimous and as grateful as I could have hoped, in fact, more so. When I sat down and told him, he was very understanding and he said, "The problem is you can't get promoted anymore here. You've gone as high as you can go," and he stopped short, but what he meant was without me just handing you ownership of the lab. It was as far as I could have gone there and I told him I was really proud of how the image of the lab had changed so much in the last 15 years, from just a large production lab to kind of being the technology leader in the lab industry, and I'll be always, always so proud of being part of the team that brought [inaudible 00:04:07] to the world back in 2009.

That was a big deal for us to be able to launch that and that kind of changed the lab industry. Solid zirconia has really put the PFM down to almost a niche product now for bridges, believe it or not, and it kind of changed the industry the same way that [Cerona's 00:04:29] been changing the industry with chair-side [CADCAM 00:04:33], so yeah, Jim was ... He wasn't upset. He certainly wasn't crying because he's done very well in this industry, and there's really almost no one employee who could leave that lab, and really have it just start spinning down the drain. It's so big now and the teams are so good that that could never happen, but he wished me well, and we shook hands, and he sent me on my way, and had it been me leaving to go to maybe work with Gordon up at CR to maybe take over CR, that would have been different. They probably would have thrown a party for me.

They didn't quite throw a party because it was Cerona and they do compete in a few ways, but he completely understood and I was very impressed with the nice things that he had to say to me during that last meeting. It just showed that he is always a very generous and understanding person who really is all about building the careers of his employees even if they have to leave and go somewhere else to do that.

Howard: Jim Glidewell's my idol because I'll never ... My dad told me, "God gave you two eyes. Keep one eye on the customer and one eye on cost, and if you don't use your God-given brain to drive down cost, then your customers don't have the freedom to afford what you have to sell." Back in the day, you'd go to so many of these institutes and they'd talk about A patients, B patients, C patients, D patients, and you wanted to hang around the right people. When they described the A patients I'd say, "There's not one of them at a Farran family reunion." I mean, we're a bunch of Kansas hillbillies and Jim used his amazing mind to drive down the costs and people would say, "Oh, it's cheap, it's cheap." Southwest Airline's lowest cost and it's also the only major airline that's never had a plane fall out of the sky.

I would much rather try to drive down costs to give people the freedom to save their teeth than to be some elite cosmetic dentist that works on movie stars. I mean, there's a niche for that, too, but I love Jim. I think he's the Herb [Kelliher 00:06:38] of dentistry. He's the Southwest Airlines of dentistry. I just love that guy to death and I want to score a podcast interview with him because so many people don't know there's a man named Glidewell. I mean, all the lab owners do, maybe 5% of the dentists do, but I think it'd be amazing for the place. You said that Glidewell competes with Sirona on the deal. Where do they compete?

Michael: Well, it's interesting because we embraced CADCAM as a laboratory very early on and we fell in love with it at the lab because one of the struggles for a big dental laboratory, whether it's Glidewell or any large laboratory, is it's very tough to keep the consistency across the board from crown, to crown, to crown, especially when Glidewell's doing almost 150,000 crowns a month now, but in the old days, it was more difficult because every crown was being hand-built by a different technician. A dentist would get a couple crowns that he loved, then get a couple that were so-so, and then get two that were awful, and three that were great, then four that were so-so, and two that were awful. 

That consistency drove dentists crazy because they could never predict what they were going to get from the large dental laboratory and CADCAM, instantly, Jim saw its potential to change all that, and now instead of having all the variation that you would get with human technicians, you could set parameters. The same amount of virtual die space, or the same amount of occlusal offset, the same strength of contact on every crown that you designed, and all those designs would come from software that would optimize whatever anatomy the doctor gave you room for, and because of the CADCAM design and manufacturing, all of a sudden the consistency really leveled out.

All of a sudden dentists were able to count a little more on the lab, but by the same token, Jim, by being a visionary, also saw that the future of dentistry is heading towards CADCAM in the other labs and in Glidewell it's the present, but he also saw that chair-side CADCAM was just a great idea and loved the idea of same day crowns, and so Glidewell purchased a company that made an [intra-oral 00:08:50] scanner, and then started developing their own mill, and then they decided just to partner with other companies, like the 3M True Definition that has a scanner, and so Glidewell has a mill, the TS150, that'll pair with the 3M True Definition intra-oral scanner, so they actually have a chair-side CADCAM system. 

When dentists say to me, "I don't know, labs are never going anywhere. I don't think chair-side CADCAM's going to catch on." Well, it's pretty telling when the largest lab in the industry believes so much that chair-side CADCAM's going to start to dominate the landscape that the laboratory comes out with their own chair-side CADCAM system. That's kind of where they compete is they both have a chair-side CADCAM system.

Howard: What was the name of the company Glidewell bought?

Michael: IOS, like Intra-Oral Scanners, down in San Diego. That's actually the company that makes the mill. It's a wholly owned division of Glidewell called IOS and they make that mill called he TS150.

Howard: How much is the TS150?

Michael: I don't remember, but the combination of the 3M True Definition and the TS150, I think you're looking around maybe the ... I shouldn't even give a number, but it's definitely less than other chair-side CADCAM systems that are out there.

Howard: Then you had another major move in that market where the huge [inaudible 00:10:19] plan Mecha bought Dallas, Texas [E4D 00:10:24], and so now that's a much bigger company. Do you think that's going to be a player, too?

Michael: It's hard to say. I've had a chance to play with their newer scanner, and see their equipment, and they all work. Sirona's obviously works, the SEREC machine works, the True Definition with the TS150 works, and E4D works. The question I think is more about the environment that goes around it. Sirona just has this huge head-start on everybody and they have this community. Our friend Sam [Perry 00:11:02] started, Spear out in your neck of the woods has six levels of SEREC education that they're teaching out there. There's just so much available. 

In fact, whenever I talk about the SEREC community that exists out there, there's only one other time you've seen a community like that out in dentistry and that's Dental Town. The SEREC community kind of grew up as part of Dental Town and then they started, but it's really tough to think about. I mean, look at SEREC 30. It was just last month in Vegas, Tony Robin spoke there, the band Train played there, [Amett 00:11:39] Smith, the running back ... It was just an incredible meeting there was [inaudible 00:11:43] thousand attendees. There's just no other meeting like that in dentistry, especially one that's just centered around one technology, like SEREC, and now that's going to change. 

We're actually changing the name and meaning to [Sira World 00:11:57] to reflect the inclusion of Sirona's other technologies and that, but the community around SEREC is just so huge that it seems like that's what the other companies don't have, and that's more the stumbling block is to have local mentors, and places where you can go watch videos to see how to use this technology. Everybody's technology works, all the equipment works, and it'll make crowns chair-side, but I think the distinct advantage of Sirona is kind of that environment or that ecosystem around it where there's just so many users and so many places to go get education on this equipment that you don't feel like you're going to purchase it and kind of be abandoned. 

Everybody else is trying to do that and create that same community as well. If they're successful, yeah, they'll stand a much better chance of being around for a long time because it's about more than just producing the equipment that can do this. If you go to the IDS show, you'll see 65 intra-oral scanners, another 65 mills. That part is now the easier part to produce those types of things, and they'll work together, and make crowns, but it's more about what do I do once I've invested in this, and how do I get my staff trained, and how do I get trained. That becomes, I think, the bigger part of the picture.

Howard: Can you mill chair-side [BruxZir 00:13:20]? Are you sending out the blocks to just mill BruxZir instead of the ... I mean, the market leader's obviously E-Max, correct?

Michael: E-max?

Howard: E-max.

Michael: Yeah, definitely. E-max is still the market leader in terms of block sales and that's not even combining it with the E-max that's sold to dental laboratories who are making it for their dentists. Yeah, Glidewell just released, it's called BruxZir NOW, and it's a fully centered zirconia block, and it can only be milled in that TS150, that Glidewell IOS mill, and the NOW, the N-O-W, stands for No Oven Waiting because it doesn't have to go in the oven, it's already been centered, but it takes about 50 minutes to mill it. It doesn't have to go in the oven, but it spends a lot longer being milled than other current blocks do, so so far that's been the one chair-side zirconia block that's been launched so far, but unlike E-max, which has many, many patents around it ... 

It's very difficult to try to get around what Ivoclar has wrapped up in E-max. Unlike that, solid zirconia, there's really no patients around it, and so it's kind of like the way there's now 14 different brands of solid zirconia besides BruxZir on the market. Since there really isn't a patent, I think you'll see most of the materials companies in the next ... I don't know, year or so, come out with the same type of block. Maybe not the same type of block, but at least a zirconia block that can be used to fabricate a same-day zirconia crown in office.

Howard: Now that Sirona, which was a European equipment company out of Germany, merges with Dental Supply, which is more of a consumables ... When I looked at that merger, it seemed like Dental Supply didn't really have a digital strategy. I mean, they were still selling hundreds of millions of dollars of impression materials and things like that, so it kind of gives them a digital strategy, but I was wondering, does Dental Supply have a consumable for the CADCAM SEREC machine that would be a block that could be competing with E-max?

Michael: They do. They have a block called Celtra DS.

Howard: Celtra DX?

Michael: DS, yeah.

Howard: Oh, DS.

Michael: It's interesting because ...

Howard: Which division does that?

Michael: I've just always said it was from Dental Supply, I guess. I don't know, I'd have to pull it up and look real quick. It's just always struck me as a Dental Supply product. I don't think it's coming out of [inaudible 00:16:09]. I don't know. I'd have to look. Well, that's the interesting thing about Dental Supply is that they got so many sub-divisions underneath them. It reminds me of Europe almost, how you have all these different countries underneath it, but they are all under the Dental Supply banner and Celtra is a lithium [di-silicate 00:16:27] material where you can mill it in a chair-side mill and if you want to stop right there, you can polish it, and then bond it into the mouth because it's not as strong in that state, or you have the option of putting it in an oven for 18-20 minutes where it'll achieve its final strength and then you can cement it in the mouth. Now it's about the same strength as E-max would be.

You don't have to put it in the oven, you can use it in its weaker state by just polishing it to finish it, but then you have to bond it into place because it's a weaker material, or you can put it in the oven like you would with E-max, center it, and then cement it. It kind of gives you both options there.

Howard: Is there still a fracture concern with all porcelain? I don't think there is with BruxZir. BruxZir doesn't really have any fractures to mention, does it?

Michael: No, it only fractures if you get it thinner than 6/10 of a millimeter or it only fractures as a bridge material if we don't have enough room in the contact area, like for a post area bridge to make it three millimeters tall by three millimeters wide, but it's the least fracturing material we've ever seen in the lab besides say cast gold, for example, but [inaudible 00:17:42] and Gordon are getting ready to come out with their five year data on their study comparing E-max and BruxZir, and they're stil the only two materials out of over 100 [inaudible 00:17:55] says that they've tested over the last 38 years that have not fractured. That study will be coming up on the five year mark this upcoming June.

They've both performed very, very well and the truth is nothing fractures if the dentist reduces enough. If you reduce two millimeters for a PFM, it won't break unless the patient gets hit in the face with a hockey puck, or a baseball bat, or something like that, but nothing breaks until you abuse it by making it too thin. That's the reality as we struggled as a lab and all labs struggle with this to get dentists to reduce enough tooth structure for whatever material they are prescribing. As a result, the solid zirconia ends up being a great solution because even if a doctor's trying to do an E-max crown and they give you a feather-edge margin or don't reduce enough on the lingual cusp, you can usually switch them to solid zirconia and have it work, but any material, if you prep enough for it, will work. That's the struggle. That's where the reality doesn't meet the theory of whether or not these things should fracture or not.

Howard: You're an amazing mind. In the future, when you're talking about Dental Supply [caulk 00:19:12], they have divisions like Tulsa Dental Products that was started by my friend Ben Johnson in Tulsa, Oklahoma, they sell direct. Most of their other divisions sell through dealers.

Michael: That's correct.

Howard: What did you think of Jeff [Bezos 00:19:25] last year saying dentistry by name that was going to get into the dental supply business, and they could deliver everything the next day, and they joined the American Dental Manufacturer's Trade Association. Do you think five years from now there will be dentists buying dental supplies from Sirona Dental Supply on or do you think not?

Michael: Well, two years ago at the California Dental Association here in Anaheim, I saw probably 13 different ... I'll call them kids just because they were under 30, but 13 different kids walking around with these black Amazon Dental shirts on, walking around, talking to people, and checking out what was going on. That was kind of like my first, "Oh, this is real. This is actually happening," and so I haven't really seen ... I mean, I love Amazon. I'm an Amazon Prime member. I ordered something last Saturday with same day delivery from Amazon and it showed up by 9 o'clock that night. That blows my mind. We have Amazon Fresh, we get a lot of groceries delivered to us by Amazon, but those are all things that don't need any explaining to me. I could see doctors ordering maybe a composite, or cotton rolls, or local anesthetic, things like that. 

Howard: Consumables.

Michael: What's that?

Howard: Consumables.

Michael: Well, consumables that don't need any explanation, but the more that dealers like Patterson, for example, they sell exclusively Sirona's products, and so if you're buying a 3D [Panarex 00:21:05] through Patterson or you're buying a SEREC unit through Patterson, you're going to need somebody to help you out with the education, the installation, trouble shooting when things don't go right, repairs, and stuff like that. I think that's something Amazon's never going to be able to touch. I don't know if you've ever had a rep in Phoenix for any of the dental distributors who were smarter than you were. I've been fortunate enough to have a couple reps like that, and there's nothing better than a rep who can come in and tell you when you say, "What's everyone else using to put their veneers on?" He tells you, "[inaudible 00:21:41] aesthetic and here's why. They like this shading system where instead of the [Vita 00:21:45] shades, it starts with the translucent and then you have these warm and cool shades ..." 

When you have a rep that knows that much and can help you, or when you have a rep where you can tell them that you're having problems with your class two composites with the contacts, and he can explain to you about a sectional matrix system, and which ones he thinks is the best. I mean, that's a lot of advice and I think that's what we're going to see with reps of the future is that the ones who really thrive are going to be the ones who it's more than just a job, they're very passionate about helping dentists, they want to find what you hate having on your schedule, what you hate doing on a weekly basis, and they want to teach you a way to do it better, show you a way, and know, and read journals, and be up to stuff, and know about high tech equipment, and whether or not you should switch.

I'm sure Amazon will get involved one day, but I think it's really just going to be for more commodity-type consumables. I think we're going to see that the distributors are going to almost force their reps to really become intelligent so they can offer some value to the dentists that you can't get just clicking through a website.

Howard: They always know who to talk to. I mean, my rep, I'll ask questions, sometimes she'll have a specialty rep come in. I had a guy in the other day and I was asking him about [endo-files 00:22:59]. My god, he went to my grease board and he knew every brand, every file, every shape, every ... I mean, I've never heard an [endodontist 00:23:08] lecture like this. I mean, the guy only did one thing, he did endo-files, and he was amazing. I mean, he was a freak.

Michael: You could have researched that all online, but it would have taken you ... Well, you could enough, but another dentist could have researched it online and it would have taken him five times as long, but it's just nice to be able to have somebody say that, especially when ... Like I remember placing my first implant, and that the rep was there from the implant company, and it's just ... It's nice to be able to have somebody who if you had a heart attack half way through the procedure, you know that they could finish it up and probably get a better result than you.

Howard: [inaudible 00:23:47], who you and I love, and respect, and adore, he uses the most expensive implant system out there, [inaudible 00:23:54] Biocare, and I've noticed that. The people who are just getting it done and doing lots of implants, you know, 100, 200 a year, they always use a rep. It's always a rep-based relationship and then the dentists who are always trying to save a dime in buying some implant from some country in the Eastern hemisphere to save $4, they're not placing any or they're placing 10 a year. It's a matter of the ones that are successful are just getting her done and when you're getting her done, you're using people in your backyard with reps that just know the grapevine, know who you need to talk to.

Michael: Yeah, and I actually, with the newest upgrade to the SEREC software, the 4.4 software, I kind of thought of you because I thought, "This is something Howard, I think would be really fascinated by," and the 4.4 software allows you to mill surgical guides in you office for single unit implants, so you have to combine it with a cone beam obviously, and a lot of the SEREC doctors use the [Galleleo's 00:24:56], the one from Sirona, but I've seen [T-Bone 00:25:00] do these cases where you take an intra-oral scan and you combine it with a cone beam, and it allows you to plan where the implant's going to be, where the abutment and the crown are going to be, and once you decide all that, SEREC makes a big block now that you could put in your mill, and you mill a surgical guide that's going to snap onto the adjacent teeth, and it's got that little metal sleeve to make sure that when you're doing the osteotomy the burr doesn't go too deep or off at the wrong angle.

These guys are becoming completely self-sufficient now where they can treatment plan an implant, and mill a surgical guide, place it on the second one, and then put the crown ... They can do this in three appointments now, and so this concept of a super-GP who is able to place their own implants, but not having to free-hand it. Surgical guides and implants, I think, are the only area of dentistry where as a GP, you know that you could probably do a procedure as well, if not slightly better, than a specialist because if you're going to try to do an [endodontic 00:26:00] procedure on tooth number two or tooth number fifteen, I'm going to say the endodontist is going to do a better job every single time than a GP on a really tricky endo like that. Not tooth number nine, but like tooth ...

Howard: Here's what we do, we'll film a video and we'll have you in observatory one doing a free-handed surgical placement of an implant, and then we'll have Stevie Wonder in room two using a surgical guide, and then we'll take [CBCT's 00:26:25] before and after, and see who did it better. My god, that would be worth Stevie's [inaudible 00:26:30] and I know where we could do it legally.

Michael: You know what would be even funnier is the camera pulls back to show his and he put the implant into the drywall, into the wall, like missed the patient by three feet, it was actually in the wall.

Howard: Oh, my god. Mike, you lectured to somebody that as you work with somebody ... You have access to more data than anybody that I know. What do you think are common dentist errors?

Michael: Well certainly, I'm familiar with common dentist errors when it comes to crown and bridge for two reasons. I used to make all those mistakes myself, personally, and I assumed that the labs that I was sending the work to was the reason why the crowns didn't look very good. I never looked into the mirror to look at myself, and then once I got into the laboratory and practiced there for 15 years, it kind of became clear that, "Oh, I'm not the only one struggling with these things." I always tell the story about how I was in remedial operative while I was in dental school and I always asked the crowd, I said, "Raise your hand if you were in remedial operative, or remedial crown and bridge, or endo," and no hands ever go up. I'm like, "See, you guys already have a better set of hands than I do. There's no reason why you can't get better results." 

It really comes down to laziness, Howard. I mean, it really comes down to dentists who don't see the value in placing depth cuts. Even though they know they need at least one millimeter for E-max, 1.5 would be ideal, and they won't use a depth cutter that's one millimeter or 1.5 millimeters. I remember a doctor where we didn't even have enough room for solid zirconia, and I called him up, and I said, "We need 6/10 of a millimeter for solid zirconia," and he said, "I could have swore I gave you 6/10 of a millimeter of space." I said, "How did you measure it?" He said, "Oh, I just eyeballed it." I was like, wow, good for you. You're like the terminator? You have a micrometer in your retina and you can now see tenths of a millimeter just by holding the patient's cheek back.

It's kind of laziness, but the actual mistakes are ... The first one is under-reduction. There's just never over-reduction. It's never a problem. There is under-reduction on a good probably 75% of the preparations in one area or another. You need at least one millimeter for E-max and in the old days ... The old days ... Between 2007 and 2009, if we got a prescription for an E-max crown that needs one millimeter of reduction and there is only 8/10 of a millimeter, our only choice was cast gold. The dentist was like, "Yeah, right. She's never going to do that," so we'd have to make a thinner E-max crown and they break under a millimeter.

Today we could switch that doctor to solid zirconia and they wouldn't have to worry, but you never know how much you reduce unless you place depth cuts. I mean, every time I get on a plane, Howard, I see the same thing you do. Two old dudes who flew in Vietnam with gray hair, who have taken off and landed tens of thousands of times using a checklist before they take of for the 21st thousandth time, and I can't get a dentist to use a depth cutter, let alone a checklist, and if dentists were in charge of the aviation industry, there'd be planes falling out of the sky left and right because they'd be free-handing the landings and the take offs. The reason Southwest never crashes is they never go anywhere it snows, so take that.

Howard: Is that true?

Michael: That's part of it. That's the reason their on time record's so good. They typically didn't fly a lot of places. They've expanded now, but I read an article about how most of the airports they flew in and out of in the Southwest, as they are named, didn't have the problems that they had in some of the other areas, but now they're in Chicago and lots of other areas.

Howard: Mike, what kind of prep are you? Are you a shoulder, are you a shoulder with a bevel? What kind of shoulder do you like on E-max and BruxZir, or are you an [inaudible 00:30:28] side kind of CAM?

Michael: For solid zirconia, it'll tolerate a feather-edge margin. Ideally, you'd have a [sham for 00:30:38], but it will tolerate a feather-edge margin. It'll work with almost anything, like if you have a prep that's got a sham for 2/3 of it and then a feather-edge on the lingual, solid zirconia will tolerate that feather-edge margin, but then you're milling a thinner crown, and there's always a chance it's going to chip, and it may not chip, but the sham for margin is kind of the universal margin that works for everything. A sham for works for cast gold, too. It works for everything and it's not overly aggressive.

A shoulder, we really don't need anymore. We needed it when we were doing PFM's and we wanted to make sure we had enough ceramic material to cover up that metal that was going all the way down to the margin, but E-max does not require a shoulder, just a sham for with ...

Howard: What about the chair-side CADCAM?

Michael: Well, same thing. It's the same margins whether or not you're prepping it for the lab or you're prepping it for chair-side. The only difference is if you under-prep a margin. If you do a feather-edge margin on an E-max crown chair-side, when you go to mill that, it's going to chip, and you're going to have to take that $30 E-max block that's just chipped, throw it away, take another $30 E-max block, put it in there, mill it again, it's going to chip again. You're going to have to go back and fix that margin, or fix it in a software to make it thicker, but that dentist who makes his own crown is going to become a better dentist because of that and start prepping better because he has to deal with his own circumstance.

If you do that same prep where it's an E-max crown and it's got sham for margins, but it's got a feather-edge, in the laboratory, they're probably going to press that. They're going to use E-max press in the pressing of it because you can press to a thinner margin than you can mill a thinner margin. The lab kind of has a way out, but the chair-side doctor learns very quickly that if they don't put a sham for all the way around that, since their only option's milling, that it might chip at the margin and they'll lose another $30 block.

That's why those dentists end up being so good is because they have to act as their own lab technician, and that's when you really learn what your preps and impressions are like is when you're forced or you choose to be your own lab person. The amount of growth in your clinical skills when you make your own crowns is astronomical. There's no faster way to become a better dentist than to make your own crowns.

Howard: What are your thoughts on a shoulder margin and [inaudible 00:33:04]? It was you 200 podcasts ago that told me how when you're doing an end-cutting burr that when you're doing the smoothing of a shoulder and you get a little fuzz, you know what that looks like at 40x, that little ... You know what I mean? You and I both agree that when I got my SEREC, seeing that prep 40 times larger, I mean, the first time you saw that, you're just like, "Oh, my god." Seeing is everything. In fact, when I talked to an endodontist, what is the best way to improve your endo? He just says, "Loops, microscope, just anything where you can see more. Just visualization."

Michael: Yeah, and I remember when you scanned your first prep with the SEREC because I could hear Jan laughing all the way here in California when she saw the [inaudible 00:33:51] blown up about 40 times. She's like, "See, I told you you're awful. Look at that margin." When I started doing that I saw the same thing, too. I would see that my lingual margin on my prep was here, up around the [gingival 00:34:02] level, and then the distal margin would come around, and where they would meet on the distal lingual line angle, they'd be off by ... I don't know, like an inch. Maybe not an inch. Maybe a millimeter, like two train tracks kind of missing each other and you're like, "Oh, my god." It was such a common problem, it was on every prep that I did and that's how you learn what you're doing wrong, but I've never really used an end cutting burr. I mean, the burr that I use is a 60 micron red strip 856025 burr, but it's got ...

Howard: Could you find a burr with more numbers so these listeners could memorize it easier? Say that burr number again.

Michael: All diamonds have six numbers, Howard. It's not just this one. It's an 856025.

Howard: 856025?

Michael: Your listeners could just use a three round burr if they can only memorize a single digit.

Howard: Who makes this burr?

Michael: Everybody in the world makes it. It's an 856025. It's just a shape and a diameter, and I use the one with the red stripe on it, which are the 60 micron diamond particles, which is perfect for smoothing off the margin because when you do take a digital impression and you blow it up, you see all the chips out of the margin that you could never see before just looking with your loops. By the way, I got to give a shout out to Orascoptic and their new EyeZoom loops. I don't know if you've seen these before. I was up with Gordon when we saw them for the first time, but these are loops that you actually can twist and turn them so they're a 3x loop, and then you turn it, and now they're 4x, and you turn it again, and they're 5x. 

I used to wear, and still wear, 3.2 a lot of the times, but when you start seeing things with 5x, oh, my god. It's a whole new ... Now, you couldn't prep the whole tooth like that because you'd have to hold so still it's not practical, but to do those margins with the water off, with an electric hand-piece down at 2,000 rpms, with those 5x loops on is fantastic. Then you can just switch back to 3x to do the rest of the prep, or 4x to find a canal for an endo, or whatever you want.

Howard: I have to wear a 4.5 just to go to the bathroom.

Michael: Yeah, to keep your self confidence up?

Howard: Just to find, it's a 4.5. I'm thinking about hanging a microscope above my toilet. [Cementation 00:36:13], talk about that.

Michael: Well, cementation has ... It's funny because with these new materials, like solid zirconian E-max, it's forcing us to think about cementation versus bonding in a different way. What I mean by that is for the first time ever, we have to take into consideration cutting these crowns off when we're trying to decide how to put them onto the tooth. I don't know if you've had the distinct pleasure of cutting off a solid zirconia crown, but ...

Howard: Well, what goes around comes around. Remember 25 years ago when [thermafill 00:36:47] came out, and they were going to leave a carrier, and that made everybody start thinking not every root canal lasts forever. When everybody was starting to play with this, everybody was saying, "Well, what happens in a re-treat?" Now it is, here it is 30 years later and we're talking about crown materials and cementation's gotten so good that we got to start thinking some of these crowns are going to have to be removed, and that is a bitch to remove these crowns.

Michael: All of these crowns are going to need to be removed unless the patient dies sooner than expected. I mean, unless you're working on somebody who's really old and really sick. For the most part, everything's going to have to be redone. You just have to assume it's going to have to be redone, and so when you go to cut through a solid zirconia crown, if you have the right burrs, like the ones, the Zircut burrs from Access Dental or there's ...

Howard: Z-I-R-C-U-T?

Michael: Yeah, Zircut.

Howard: From where?

Michael: Access makes those or [Cybron Endo 00:37:43], I guess they're now ... I think they're [Curr 00:37:47] Rotary. I can't keep track. It's a little difficult sometimes with the ...

Howard: Curr Rotary ...

Michael: Curr Rotery, yeah.

Howard: That's Access Dental's division of [Cybron Curr 00:37:56]?

Michael: Yeah, they've changed names and re-branded a couple times, so I think it's Curr Rotary now.

Howard: Isn't that right in your backyard?

Michael: Yeah, they're here. They're here in southern California. They're [crosstalk 00:38:07].

Howard: What's next? Glidewell going to merge with Cybron Curr and buy [Daniher 00:38:11]?

Michael: That could happen. No, we're hearing big things about a Dental Town merger.

Howard: Yup, we're going to merge with In-N-Out Burgers.

Michael: That's what I heard and that's going to be your personal sponsor from now on for all the shows. When you cut these off, if you use those burrs, and there's other companies, too, besides Access. There's Clinician's Choice has a burr for cutting through zirconia called the Predator. Probably not the best name, but still a [crosstalk 00:38:40]. Hey, doctor, your Predators are here. It tends to empties out the waiting room when they hear the Predator's finally ...

Howard: Where's Clinician's Choice? That's back east isn't it? Where's that at?

Michael: ... and north. Canadian.

Howard: It's where.

Michael: Canadian, Canadia.

Howard: Yeah, but which down in Canada.

Michael: Toronto I think.

Howard: Is it Toronto?

Michael: Yeah, I think so.

Howard: I just had dinner with ...

Michael: [Pete Jordon 00:39:03], I was guessing.

Howard: Oh, my god. George ... Freedman.

Michael: Freedman, yeah.

Howard: ... and his wife, so Clinican Choice burr to remove these zirconiums as well?

Michael: Yeah, they make one as well. A lot of people do and you'll see the word "Z" in the title, or "Zirc," or "Zud." That's your clue that it's a zirconia optimized burr. It's a very fine grit for cutting though zirconia.

Howard: You would think a big, course grit would cut through that better, but you're saying a fine. That's counter-intuitive, isn't it.

Michael: It is counter-intuitive. When I went to cut the first one off we were putting them on Glidewell patients, and I told them we were going to leave it there for two months, and I'm going to cut it off, then I'll put another one on, and leave it on, and they just shook their head, and said, "Yes, okay, okay." I realized they read this sheet telling them what we were going to do, and I thought we should probably translate this to their native language, but my Vietnamese is weak, so we left it in English, and they consented to let us do this. 

When we went to cut the first few off, I did. I used a course burr, and it just stripped the particles right off of the burr, and then I asked my assistant for a super-course, and it did the same thing. Then I asked her for a course again, and it stripped them off, and I said, "Let me see another course," and she was like, "Really?" I was like, "What else?" She goes, "Try a medium," so I tried a medium. That actually put a dent into it. Then I went to a fine-grit diamond, the one I was talking about smoothing the preps off with, and that did the best, and these are even finer grit diamonds that you'll see, like these [Zircut 00:40:27] ones from Access. 

These are the finest grit diamonds we've seen in dentistry, so I actually use these now for [occulsal 00:40:32] adjustments on enamel and it is counter-intuitive, but you use it to cut off zirconia and E-max, but even once you cut through it with a good burr, if it's bonded into place, it's really difficult. It's even more difficult to get these crowns off versus if they're cemented. Gordon and I wanted to make a recommendation for the lectures and for the newsletter, and we decided that the most reasonable position was cement everything you can and bond only when you need to, because when it comes to taking these crowns off, like when your boys all graduate from dental school and take over for you, you don't want them having to cut through these really difficult crowns to get them off. 

At least if they're cemented, they'll come off in three pieces instead of 13 or having to prep the whole lingual surface like it was some industrial strength enamel. This is the first time we've had to think about cementing versus bonding. Bonding's kind of always been better, at least with the cool kids, but today, cementation is the way I absolutely lean because when it comes to taking these crowns off, it's a bitch if they're bonded into place.

Howard: What would you cement it with?

Michael: My choices usually are ... Most any cement will work with both of these materials, but I've used a bio-active cement from a Swedish company called Doxa. It's a cement called Ceramir and it's a glass [ionimer 00:42:02] calcium illuminate cement. It's really nice, it handles well, it's got a basic pH, and it's the only cement we've tested that has a natural bond to zirconia oxide. It'll bond to a BruxZir crown without the need for a zirconia primer to be placed on the inside of it because it's a very [hydrophyllic 00:42:26] cement and zirconia oxide's very hydrophyllic as well, and because it's calcium-based, it starts to form the appetite crystals, not only on the tooth, but on the inside of the crown and it gets part of its bond strength from that.

It's kind of part of this whole brand new movement of bio-active materials in dentistry. It's the first cement of its kind, and so easy to use and clean up that I've been using that for zirconia and E-max now for the last four years, almost exclusively, except for when I have to bond something into place, then I'm going to use something like multi-link auto mix from Ivoclar, which is a self-etching resin cement. I'll tell you what, Howard, since I went to all self-etching for the most part, the only time I etch with acid anymore is on maybe no prep veneers on enamel, but ever since I stopped etching dentin, my incidents of post-operative sensitivity has gone way down. 

Remember when we went to LVI, and we were prepping veneers, and the instructors weren't happy just to have us prep into dentin, they weren't happy until we were in deep pink dentin, and they got really excited if we could bond into the pulp? This was like a whole reaction to being told in dental school that you couldn't do this. It was kind of the dirty little secret of dentistry, in fact, you had your own dirty little secret. Well, you've got several dirty little secrets, but the one I'm referring to is where you had your amalgams taken out, and had direct composites put in, and you were eating Motrin by the handful for six months. I remember you kept sending me pictures of your dark, tarry stool saying, "What's wrong with me?"

Howard: I had to make a decision. What was bothering me more, the diarrhea from the Motrin or my teeth aching. It was amazing and then 10 years later, they had all cracked, and broken, filled, and now I have all gold. What makes me mad about that error there is how many dentists were out there saying that if you had any sensitivity, it was you. You didn't have a rubber dam, you over-dry, it was too dry, it was too wet, it wasn't moist, and use [inaudible 00:44:33]. It was always you, yet when I would go in their office, and I would go up to the receptionist when they were working on a patient, and start looking at their schedule, and then say, "Here's a patient, Ms. Jones. Call Ms. Jones." "Oh, yeah. You had a bunch of composites done a week ago. Are you having any sensitivity ..." because I'm listening to their lecture that they don't get any sensitivity. "Oh, my god. I've already called for a Vicodin refill twice." 

How those guys would be calling in Vicodin for their patients, and then lecturing in front of thousands of people saying, "Well, we don't get any sensitivity." It was just like ... That just separated a lot of the ... There's nothing wrong with being humble. I mean, why not be humble? We're all humans, we're all just talking monkeys. You fall down, you make a mistake. Who was that implant guy? I was trying to think of the other name. He was a [prostodontist 00:45:22] who taught implants. In his lecture he would only show everything that failed and he went on to Green Labs in Arkansas, he was a consultant for Green Labs.

Michael: I don't know. I don't know who that is, but even Gordon put out a DVD called My Biggest Failures and then he did a part two. That's the only time we learn anything. That was one of the awesome things about Dental Town. That was one of the visions that you had that I didn't have and when you asked me to get involved with Dental Town in the beginning I had to say no because you had practically bankrupted me on our first venture together, but still, that's been one of the amazing things about Dental Town is people's willingness ... We were ahead of our time, by the way, with [crosstalk 00:46:04] and as it turns out, the Mac computers back then sucked and now they're the coolest things around. We should have been doing that now. 

Dental Town allows you to share your failures in a somewhat anonymous way or completely anonymous way if you want to, but it always seemed as judgmental as internet sniping can be sometimes that people were willing to ask for help and show what was going on, and I remember you used to talk about your vision of this happening, and I was like, "I don't think that's going to happen. I don't think that's going to happen," and I was wrong. It does happen and it's true. It's an amazing way to really help doctors, to tell doctors what you did that worked, just reinforces what common knowledge or what people already knew. It's only with our failures that we learn and we're only as sick as our secrets, and so until we start talking about these things, and start saying, "You know what, I've been doing a lot of these and I just did 10 veneers on somebody and now three of them need endo. What's going on?"

I remember at LVI, there was a checklist, you kind of referred to it, and at the top it said, "Are you experiencing post-operative sensitivity? If so, please take a look at the 21 things below," and then it listed all these things. I was like, "Why aren't we doing something?" There was a list of 21 things that can go wrong and you can end up with post-operative sensitivity. I want to do dentistry where there's a list of one thing.

Howard: The only person that was on Dental Town that listened to that was actually [inaudible 00:47:39], they were listening all the way from Japan. I remember one of those guys asking me in the earliest days of Dental Town saying to me, he goes, "It sounds like reading Dental Town that sensitivity's the issue." I said, "Yeah, absolutely." He said, "It's the chair-side chemistry set. That could be fixed." Then when everyone else was saying, "Well, we don't get any sensitivity, just you people overdrawing, under-drawing ... It's all you." Then the Japanese just slowly come with their self-etching and freaking took, what 2/3 of the whole direct bonding agency just because they were humble and listened. 

By the way, on Dental Town, a lot of dentists always say that you shouldn't be able to critique someone's work if you're anonymous and they don't like anonymous. They think everybody should say who they are. The problem with that is if I got rid of ... First of all, you all register with me, so I know who everyone is, and I ping the emails regularly, and once your email doesn't work, you no longer have access to your Dental Town. I know who every member is. I have one full-time employee that just does that, but the reason I maintain anonymous is that there has to be a place to ask a stupid question, and if we take that away from dentistry and some kid's got a question, he's like ... because you know, you've lectured a thousand times. Are there any questions? No, well let's take a break, and then 20 people run up to you and ask you this special private question that everybody in the room has. 

Then when you have a report of abuse and then we play baseball, three strikes and you're out. It's okay to say why did you do this or I would have done this, but if you make someone feel bad, and someone reports abuse, and we get three of these on you, you're out. We ban someone every week and with 204,000 members, we don't need cyber bullies. Everybody's beating us up [inaudible 00:49:28]. By the way, Sirona, if they want to be a hit, I've done my market research on Sirona. You know how they've replaced the lab man with a CADCAM. Well, as soon as they can replace the dental assistant with a droid, oh, my god. Everybody's going to buy that. They could charge $200,000 for that. Could you imagine walking in there and all your staff was droids?

Michael: Well, here's what I want to do. I want to ... This is another idea for them.

Howard: I'm just kidding.

Michael: I know your staff's going to hear that and not be happy with being replaced by droids ...

Howard: I'm throwing Jan under the bus on so many jokes for 28 years, she just rolls her eyes and laughs. She actually giggles out loud.

Michael: She knows how lucky you are to have her there, but I think that if every SEREC unit that was sold came with a dental lab technician duct taped to the side of it, somebody who is going to [zine 00:50:22] the crowns, mill the crowns, stain and glaze the crowns, that everybody would hop on this technology much sooner, because I think that's their fear is me and my staff don't know how to design, we're afraid that our crowns aren't going to look any good, and I think if you could just take lab technicians, and kidnap them from another country, and duct tape one to the side of the machine that you'd have a large, large step forward towards getting people to implement it if this thing basically just turned out a crown that was finished.

A lot of times doctors will tell me, "Well, that's why I don't want to get involved with chair-side CADCAM," but I always remind them, at Glidewell, we used to hire 15 people every Monday. Every single Monday there was a new employee orientation with 15 people. Now, half of them probably wouldn't be there in a year because they didn't like working with their hands as it turns out or whatever happened, but we would hire people off the streets who would become crown designers. They knew nothing about dentistry, they had maybe played a couple video games growing up, and within three months they would be designing 40 crowns a day, and by the 100th one that they did they would be considered to be ... Not a master, but very proficient at that skill.

It's even easier with stainers and glazers. We just hire people off the street and we can teach them. By the time they've done 50, they know how to stain and glaze crowns, and they might do 80-100 crowns a day. When a dentist tells me that his dental assistant with eight or nine years of experience can't learn how to do this, I'm like, "Are you kidding me? We used to hire people off the street who sometimes didn't even speak English and we would have them doing it ...

Howard: Sometimes ...

Michael: ... within a couple weeks. Don't tell me your assistant can't do it," but if you only have her do one a week, yes, that's going to be a very slow learning curve, but that's not how it should be.

Howard: Mike, when you got a high aesthetic case in there. We're talking a woman, high lip lining, you're doing an anterior chair-side CADCAM, and you stain and glaze that, does that stain and glaze really going to be there in five years? Is that more of a temporary solution that's going to make it look pretty for a year or two, but with Diet Coke and Dr. Pepper, is that really going to be there, that chair-side stain and glaze in five years?

Michael: It's going to be there as long as the laboratory stain and glaze is going to be there. It's not done any differently in the lab. It's stained and glazed exactly the same way.

Howard: How long is either of them?

Michael: No one knows. I've asked Gordon and [inaudible 00:52:50] that so many times, and you never know. I feel like I've seen PFMs before where the stain and glaze ... You ever see those patients who come in and the central incisor has a crown that's a B0, it looks like a toilet bowl, and they go, "This used to match 30 years ago," and you're like, "Yeah, whatever. Your vision's pretty awful. I dare you to bring me a picture of that that shows me that match," but then I started thinking that might be the stain and glaze coming off of there, but usually those are 20 years old or something like that. We haven't seen it in the E-max, that stain and glaze that we put in seven years ago, eight years ago, so I don't know. That might happen after 15 years, but I can tell you that the staining and glazing done chair-side's done exactly the same as what's done in the laboratory. 

There's a lot of dentists, though, who get SEREC units and they're afraid or don't want to do those anterior restorations. I think that's still a great time to use your lab. In fact, I think the dental lab of the future is going to look a lot like an endodontist's or an oral surgeon where a GP's going to do the easy endo, take out the easy teeth, and send the difficult ones to the specialist, and I fully see the world going to the point where dentists are making their posterior crowns in their office, which, according to Delta, are 80% of the crowns done in any given year are posterior teeth. The dentist does all the posterior crowns in the office and for the anterior ones or the bridges, scans it, sends it to the dental laboratory, and lets the experts in aesthetics make those anterior crowns for them.

I don't think the dental labs will ever go away. I just think they're going to become more like a specialist where they do the special cases.

Howard: When you say specialist, you mean all but orthodontists, because all specialists, like endodontists, they assume you're going to do the easy anteriors and send the re-treat molars, or all surgeons, they assume you're going to pull the easy gum disease and [inaudible 00:54:29], but I swear to god, orthodontists, if you do just one mild tooth movement, your orthodontist has to go to the hospital for an EKG and a stroke. The orthodontists are the only ones that are completely irrational. I mean, they don't let any non-orthodontist go to their meeting, they don't want anybody to do the most simplest, routine case. They're just freaks, aren't they?

Michael: Well, I'm in enough hot water with orthodontists for some comments I made earlier in this year in our magazine, so I'm going to let you ...

Howard: They're not moderate and what I see is ... I got four boys, 20, 22, 24, 26, and them and all their friends, at that age you see the world black, white, left, right, up, down, by [inaudible 00:55:14] thinking. Then by the time you're 50, 60, 70 all the smart people have just turned in to be really moderate, humble. It's like when you buy a chair-side CADCAM, the freaks stop using labs. The ones that are the most bizarre are the ones that are "metal-free." Do you drive metal-free cars? Do you fly metal-free airplanes? How do you place metal-free implants? 

They're literally trying to make ceramic implants of these freaks, which when they break, surgically, you have a nightmare to remove a broken glass implant. You just got to be humble, and moderate, and nothing's black and white, nothing's easy.

Michael: Now I'm embarrassed to tell you that I have a metal-free dental chair. I just have the patient sit on one of those beanbag chairs. That's pretty much what we're using, but to your point, I think it starts in dental school. At the University of the Pacific, when I went, we had a solid ortho education that lasted all of about 13 minutes and it was just too short, and so you and I had to go take [Ricklet's 00:56:21] course and [Brock Rondo's 00:56:22] course, and go get up to speed because you don't have to do many veneers before you realize that the greatest ...

When tooth position is the problem, tooth movement is the answer. Not a hand piece to remove all of somebody's enamel. It's the ultimate cosmetic treatment and that's why I like to see ... Here's another business that grew up on Dental Town is Ryan [Swane 00:56:48], although he sold it now, Six Month Smiles. I mean, the ability just to go in for an adult, and in six months with a combination of IPR and arch wires as opposed to removable liners, which would take forever and don't quite work, like putting a bracket and an arch wire on a tooth. Just taking an adult and straightening out some front teeth to give them a nicer smile.

Vince [Cochich 00:57:09], the very famous orthodontist who passed away a couple years ago used to say that in terms of orthodontics, kids should be treated idealistically and adults should be treated realistically. 

Howard: I love that, I love that.

Michael: I think Six Month Smiles is a great example of that to move around some front teeth and if somebody's asymptomatic, and they don't want to fix a cross-bite, and you don't want to fix a cross-bite, but they want their teeth straighter, it's the ultimate in aesthetics is to move the teeth instead of taking the teeth apart and then putting veneers back on to those. I know you and I are just huge believers in that, and that's really kind of why we wish more GP's were involved.

Howard: Can you email me that and any links? I always get a transcript of all my podcasts because most of my listeners are all commuting to work and they're not writing anything down, but they'd love to have that quote. I know you told me [inaudible 00:58:00] when you started you wanted a website link in that post on your [inaudible 00:58:06] was on[inaudible 00:58:11]-program.html. If you can email me those quotes and anything else you want in the notes, that'd be great.

Hey, Mike, I want to ask you a real serious question. These oral scanners, are they at a place in time right now to start replacing the good old fashioned [Impergum 00:58:28] and your [inaudible 00:58:29]. Are we there? Is it bleeding edge or leading edge, and part of the definition going from bleeding edge to leading edge is not only does it work better, faster, higher quality, lower cost, but the price of an Impergum as an oral scanner, are we there at the same price, are we there at the same quality? Where are we at on oral scanning?

Michael: Well, that's why the whole category, digital impressioning, I don't like that term very much because when you say digital impression system, it encourages the dentists to just look at a digital impression and compare it with a poly-vinyl [inaudible 00:59:08] impression, and when you compare those two today, the poly-vinyl yes, is always faster, it's always easier because you can be a little hacky-er with poly-vinyl than you could with the digital, and you have to take better care of the tissue for a digital impression, and the quality ... Well, the digital impression's a couple percent better in terms of accuracy, but it's not like [poly-ethers 00:59:30] and poly-vinyls are inaccurate, and it's more expensive with the digital.

If you just compare it impression to impression, no, you would never buy one and that's why they haven't really caught fire, but my message is if you look at the other five things that you can do with one of these units, five things that you can't do with anything else in dentistry or if you can, you can do it better with these, there's no single faster way to become a better clinical dentist than to get involved with this technology.

The first one we've kind of already mentioned, but now I'll mention it in terms of digital impressions, so even if you're not going to make crowns chair-side and you're still going to send everything to your lab, with a digital impression system, when you scan it, when it comes up on the screen, you're no longer looking at an impression. You're not looking at a hole in poly-vinyl and your brain's having to try to reconstruct what the stone model's going to look like. You're looking at the virtual model on the screen and you can blow it up as big as you want. It's like loops on steroids. Loops are a joke when you compare it to this. Nothing else allows you to do this besides a digital scanner.

The second thing you can do is for the dentist who, as I mentioned before, are too lazy or just not interested in placing depth cuts. After you scan your preparation, when you scan the bite, it'll now tell you how much room you have between your opposing tooth and your prep. If you're doing an E-max crown and there's an area where it's .85 millimeters between the prep and the opposing tooth, you need to take off another .15 millimeters somewhere, and this stops you from your assistant coming back with a crown that's almost worn through on this one spot, and goes, "Look, I can almost see through the temp," and you say, "Make another one," and all five of the next ones look the same because the tooth is under-reduced.

Another amazing thing that you can do is if you get a bubble or you have an area on a digital impression where maybe there's a little spot of blood or the tissue was touching the tooth, where ever that spot is on the tooth, you can go in and clean that up or remove the tissue with the diode laser, and then you just circle that area on the impression, and go re-scan it, and it'll merge it right in. With digital impressions we have repairable impressions for the first time in dentistry. Most of the time we see dentists take a poly-vinyl or a poly-ether get a bubble, they just squirt more material and stick it back in the mouth. It doesn't work that way. You can't just keep sticking it back in the mouth, so especially on bigger impressions if we have four or five different preps, now if we get a bubble in one area, we're kind of screwed with a poly-vinyl one, but in digital, you can re-take that one area and stitch it in.

The other amazing thing, and this is probably the most amazing thing, is that this is officially going to come out as a product from Sirona in the not too distant future, but you can do it with [Web X 01:02:09] or Go to my PC, any of these desktop sharing programs, is you could actually share your desktop with your laboratory technician who might be 2,000 miles away in another city. By sharing the desktop on the computer that's connected to the digital scanner, you can actually share the desktop, so your lab technician's sitting 2,000 miles away, and on their big screen, they're seeing exactly what you're seeing through your camera. You can go through and say, "How do these anterior preps look? Did I reduce enough for these E-max crowns?" They might say, "No, can you reduce a little on the [meseal 01:02:41] number 7, and the distal at 10, and just bring that facial incisor line angle back a little bit on 8 and 9?" 

All of a sudden when you get your laboratory technician helping you to approve your preps, you get some great results because they can always tell how much room they need for these preps, and then they can watch you do the digital impression, and they'll check off and say, "Yeah, that's great," or, "Hey, you know what, can you roll back the tooth number 8 and get just one more shot of the lingual there? Perfect, all right. Send it to me." This is a degree of teamwork with our technicians that we've only dreamed about before. In fact, you had to have an in-office technician to have this kind of cooperation between the two, so it's an amazing amount of teamwork that'll let you be able to work with your technician.

Howard: Are you talking about what Kevin [Coachmen 01:03:22] from Brazil's doing? 

Michael: Christian Coachmen?

Howard: Christian Coachmen from Brazil, his dental lab virtual world?

Michael: I don't know. I haven't seen him speak in a couple of years, so I'm not sure, but that's ... I mean, I would assume it's something along those lines. In fact, you can also have your lab design the E-max crowns for you and then they can send you a screenshot of that so you can approve it before they come. We had this happen the other day where there was a dentist who prepped E-max crowns on 8 and 9, and there was a big [inaudible 01:03:50], and the technician closed it, and they came back because it turned out the patient wanted it open a little bit, so they opened it, and sent the crowns back, and the patient said, "I want it open wider," so the crowns came back again to make another one. 

This could have all been avoided had the lab just sent a screenshot where you could email it to the patient and say, "Is this what you had in mind," so it works both ways, but having a lab tech check your preps, tell you if you're done, tell you if you need to do any other reduction is invaluable, and it leads to some incredible dentistry being done. Just to sum up, there's five or six reasons there why [crosstalk 01:04:26].

Howard: Recap the five or six reasons.

Michael: The first one would be just being able to see a virtual model instead of looking into a hole of impression, the second one would be blowing up your preps, like 35, 40x and being able to see chips out of the margins at things that need to be repaired. The third one would be being able to see how much reduction you have between the prep and the opposing tooth to see if you need to do more or possibly reduce the opposing to get enough clearance for the restoration. The fourth one would be sharing the desktop with a remote dental technician so they could tell you if your preps needed anything else done before proceeding, they also get to see your impression while you do it, and can help you with that at the same time, and so you get amazing feedback from that. Then some laboratories will give you $20 off because you save them a ton of time if you send them a digital impression instead of a poly-vinyl or poly-ether that needs to be ...

Howard: Which labs do that? Which labs give you a discount on your stuff?

Michael: Glidewell started it and now there's ... I know Dental Masters, Oral Arts, I mean, there's a bunch. There's a lot of them because you save them time.

Howard: Can I steal you for an overtime question or do you got to run?

Michael: No, go ahead.

Howard: My hour's up. Mike, this is a very serious question. I know I'm throwing you under a bus asking this because now you work for Sirona, but this is the most common question dental students ask me. They go, "Howard, I graduated with $250,000 of student loans, maybe $300,000, some $400,000. I just opened up my office. Is it smart to buy a $75,000 [bio-lace 01:05:57], a $100,000 CBCT, and $150,000 CADCAM when I'm already $400,000 in debt? I just bought a practice and I married a Catholic girl so she's already pregnant with triplets." Do you need these things that cost ... I mean, you buy a laser, a CADCAM, and a CBCT, that's more money than your dental school debt. Is it going to be an investment? Should a graduate with that much debt buy $150,000 SEREC machine or use a lab until they get some of their debt down?

Michael: Well, that's hard to say. Do you absolutely need those things? Well, no. You and I did dentistry for many years without those things and dentistry was done for generations before us without it, but when you start to see 3D radiographs, for example, it's kind of tough to go back to 2D, the ones that you and I grew up with when all of a sudden you can start to see why that patient's endo tooth is not hurting, but it's felt weird for the last seven years, and you see this little abscess over on the palate or whatever ...

Howard: My first x-ray was an Etch-a-Sketch. I just had two knobs and had to draw the tooth.

Michael: That's good. I always remember your example and I use it all the time about an x-ray showing into a patient. It's just so funny because you can always say things like, "As you can see on your root canal, I've left the [inaudible 01:07:16] six millimeters out to apex because I really wanted to anchor the tooth into the bone," and they'll go, "Oh, thank you. Could you have gone eight?" "I could have, but you don't want to push it." It doesn't matter what, you could just say anything and they have to believe you, which is the sad part of all this is that they don't know how to judge it, but no. We know you don't have to do any of these things.

It's really tough for me to say whether somebody $400,000 in debt should do that because I don't know who they owe the money to, if it's from the mob, or from their parents, or who it is, but there's such a great opportunity out there today that didn't exist when you and I graduated. You could actually go to one of the DSOs, like my favorite one, Specific Dental, just because they're from out here in southern California.

Howard: Steve Thorns, a good guy.

Michael: They've got a SEREC machine in every one of their now 520 practices. We just gave them an award last week from Sirona. They just did their 1,000,000th in office E-max crown, same day crown, so they crossed the 1,000,000 barrier for that. It's very impressive, Steve's commitment to technology in those practices. If I was graduating, I think I would go and work at Pacific Dental and get a little experience before I went out and bought a practice. I would go out and work there because they've got a ton of high tech equipment in those practices, and see if you like it or not. It's not a technology for everybody and my goal with Sirona is to make it so that when you scan a tooth for an impression, that 98% of the time the proposal that it gives you for the crown doesn't need to be touched at all.

Nothing would be better than if 30 minutes later it spit out a finished crown that looked almost as good as the lab's and was ready to go in the mouth, that kind of simplicity. It's tough to say whether a new doctor should right out of school or not. There's some who have like Neil [Pattel 01:09:09], a guy who just jumped on it early and often. He's placing tons of implants now and he's really made it work for him, but if you were going to invest in it, you would have to make sure that you're actually going to use this for all of its capabilities, so the SEREC system not only does restorations chair-side, but allows you to place your own implants, allows you to mill your own E-max custom abutments, and it allows you to mill the E-max crown that goes on top of it.

You can now do orthodontics, send it to Clear Correct or send it to Invisalign, and a few of those cases will help make the payment every month. If a dentist is going to use it, then absolutely I think it's worthwhile, but if they're not sure, if they didn't get a chance to use a CADCAM product and now there's Sirona products in I think 48 of the dental schools out there, so they might even get a chance at school to be able to use it. If they're really turned on and excited by it, then it's probably a good idea. If they're going to use it to be productive, but if they're not sure, go try it out somewhere and see. You just got to find out for yourself if that's going to be something that's going to be worth it for you.

Howard: I try to give all those dental students my advice and not very many of them take it, and that is, when they ask me that question I say, "Just don't leave dental school until you marry one of the girls in the class." Then you won't even have to work, let alone a CADCAM. I look back, it was the dumbest mistake. I had a dozen to choose from, every one of them would have been the best decision of my life, so if you got $400,000 of student loans, marry one of the girls in the class and ...

Michael: Have $800,000 in student loans. Oh, wait, no. Marry someone where their parents paid for school, that's the ...

Howard: Yeah, there you go. Find the girl in the class whose mom and dad paid for their dental school classes.

Michael: Let's look up all those dentists that you could have married on Facebook right now and see how they turned out.

Howard: They're amazing. I actually follow them on the Facebook, but hey, Mike, seriously man, you're a legend, you're an idol. I still think you're the funniest damn dentist that ever lectured. You're doing a podcast on ... What are you doing? You're doing a comedy [inaudible 01:11:09] podcast.

Michael: Well, yeah. It's not a comedy podcast. It's not really a dentistry podcast. It's just me and Josh Austin, a dentist from San Antonio who we both write for Dental Economics and we're friends, and we just started doing it. There's some dentistry in it, but a lot of times it's just about what's going on in our lives. It might be personal stuff we're struggling with or whatever. It's called Accidental Geniuses, because if we say anything intelligent it wasn't on purpose. It should be the name of your biography, actually, Howard, Accidental Genius.

Howard: That's a dental [inaudible 01:11:44]. I see your deals were you guys were laying in a bed. I thought it was a joke or ordeal.

Michael: Yeah, we actually recorded ... We were both in Chicago for a ... I was there to lecture and he was there for an ADA meeting, and so there was only one room left at the hotel, so we got the hotel and I just thought it'd be fun to ... We started off by I told him he was going to have his own room and then on the podcast I told him, "You're staying here with me and there's the one twin bed we both have to fit into," and so we just took a picture for that.

Howard: How do you spell his last name? O-S-T-E-N?

Michael: Close, A-U-S-T-I-N.

Howard: A-U-S-T-I-N, like Austin, Texas. Josh Austin. Well, is he your buddy? Tell him I want to podcast him.

Michael: All right, yeah. He'll do it. He's a good talker. He'll enjoy it. [inaudible 01:12:27] just say as we go that I always considered you the funniest dentist in dentistry and you want to talk about mentors, I realized early on that I wanted to have some of the energy, some of the passion, and some of the humor you did. I'm sure you'll remember this, but you gave me permission to do it. I followed you around to 20 of your lectures and like 20 in a row. I just bought plane tickets, and I went to you, and I watched you lecture over, and over, and over, 20 times to see what it was, and get inspired, and finally that kind of launched me on my way.

Howard: The boys want to say hi to you. Here's two of the four, here's Greg. Can you see them?

Michael: I can. Well, part of them.

Howard: Can you scoot down? You got to see for yourself right here.

Michael: There we go. Wow, so much better looking than Dad. That is fantastic. Thank you, Judith.

Howard: Luckily their mother was a very attractive woman and still is to this day. Hey, love you like a brother, man. You're my number one best friend, role model, idol in dentistry. I think you're the funniest, smartest, energetic ... I mean, I've heard you lecture more times than you've heard me. Thank you, Mike, for all that you do. Thank you for gracing me with another hour, and thanks for being my very first ... When I started my podcast, the first guy on the podcast was Mike, the man, DiTolla, and then we're coming up on 200, and we thought, "Who better for our 200th podcast than the man?"

Michael: Ryan's already booked me for 400, 600, 800, and 1,00 by the way. Just so you know, I'm slotted in already for those big anniversaries.

Howard: Are you scheduled for anymore Iron Man's?

Michael: Yeah, I am. I've got a half Iron Man next year. The California one at the beginning of the year.

Howard: A half? That don't even count.

Michael: I know, that's why I tell everybody who says I can't do an Iron Man, I'm like, "Four words: Howard Farran did two." There you go.

Howard: I got my third on in one month.

Michael: Oh, you're doing Arizona again.

Howard: I do it every year. That was my goal. I'm going to do the Arizona. I think the successful people start their day with the biggest problem they have and then they don't get to the small problems, and very unsuccessful people, they always start off with the small stuff, and emails, and they never get to the big thing, so when I turned 50 I thought the biggest problem you got, dude, is you're short, fat, bald, you eat out at restaurants, you have every vice known to man, so I, seven days a week, 5:00-7:00, 5:00-7:30, seven days a week is bike, swim, run, and I'll be doing my third Arizona Iron Man in a month. Who turned me onto Iron Man? Who turned me onto Iron Man?

Michael: Bruce Jenner.

Howard: No.

Michael: [inaudible 01:15:01].

Howard: Acutally, when you first were talking about you doing your Iron Man I just thought I've never gone wrong following Mike DiTolla. He's always ahead of his time, he's a smart man, he's everything. I said, "You know what, if Mike has got the time to ..." You're the busiest man I know. If DiTolla has the time to do this type of training, so do I, and when I first started doing it, I had the alarm going off at 4:45. You could hear the profanity at the neighbor's house.

Michael: Yeah, but the secret to getting up at 4:45 is go to bed at 8:45. It's all 8 hours of sleep still. It just matters where do you put it.

Howard: What I lost ... I didn't realize I was staying up watching Colbert Report or these late night shows, but I never stopped the 4:45 alarm for the 5:00 work out, so then after a month, or two, or three, or four, you just couldn't stay up at 11:00. You couldn't stay up until 10:00 and now at 9:00 you're just starting to get delirious and you think, "Man, that alarms going to come up fast." It's all the same, but I'll tell you what, I think faster ... You do it for mental health. It lowers your stress and what I like about it in the morning is when you're out there you get to plan your whole day. When you're swimming 157 laps, 3,850 meters in a swimming pool, which takes me about an 1:49, you clear out all your thoughts and then when you get out of the pool, you just run to your day. You say, "I want to do this, then this, then this." I just love it, man.

Michael: Yeah, in fact that's why I wear a Garmin watch, like a 920XT in the pool because I have to glance down at it every once in a while during a set because it is kind of meditative. They have those isolation tanks where you lay back into the water and they close the lid for you to meditate, but swimming's a lot like that where there's no other sounds, you might just see the hot woman in the lane next to you, and that's kind of distracting you, but otherwise, you're alone with your thoughts. I have a lot of great ideas in the pool and sometimes on those longer bike rides. I'm always in too much pain running to enjoy it, but that's running.

Howard: After three years I actually like running now. I can't believe I can say that now. I actually like running. I used to just cuss, and mad, and I hated it, but three years of running ... In fact now, when I run 13.1 miles, I don't even do a run unless it's 13.1 miles.

Michael: Wow, because I remember spending a lot of time with you before that. The only time I ever saw you run was to the fridge. In a commercial, you'd haul ass to the fridge, and then grab whatever, and junk food, and come back.

Howard: It's so beautiful when you're out there and the sun's coming up over the desert, and the mountains, and the palm trees, and you start your bike ride, or run, or whatever. No cars, no lights on, and then the city slowly comes alive. It's just the coolest damn thing in the world.

Michael: It's funny because every human craves sunsets. If they're on vacation, there's all those sunsets, sunsets, sunsets ... Sunrises are just as nice and there's no one really up to see those, and you're right. Starting your day that early, there is something special about being there as that sun's coming up, there's nobody on the road, things are just quiet. It's a great time to be up and doing that stuff.

Howard: What I also want to say that again, thank you personally because when I thought of things like that, I was a busy guy. I lectured a lot, I had a full-time practice, I had four kids, I got a Dental Town magazine, website, ortho ... I just didn't have time and then when I saw you making the time I thought, "Shit, DiTolla's busier than I am. If that guy can make the time, I can freaking make the time." It was you who made me think, "Dude, you have the time. You just got to prioritize it." For that, I thank you so much.

Michael: Congratulations, I'm incredibly proud that you did it. You did not grow up as an athlete. I mean, you wrestled, but not an aerobic type athlete like that. It is amazing and I do use you as an example when people say, "I can't do it." I'm like, "Well, Howard can, and he's running Dental Town, and he finds the time to do it, and it goes against his genetics, almost, to do it."

Howard: I want to say something else with a lot of people. Everybody always thinks they know everything, but I got two siblings that are over 350, two of them. I see families ... I was married to a family where all they ate is Butterfingers, and everybody got a six pack, and then I came from a family where everybody's been on a diet their whole life and they're huge, so genetics has some role. If someone just says there's no genetical variants, then you're an idiot. Again, I never compare myself or my Iron Man time to someone like you. I compare my Iron Man time to what mine was the year before and I know this. I know this. If I threw in the towel and completely gave up, I'd gain 100 pounds.

Michael: Really?

Howard: 100, so I love it. It works for me.

Michael: Have me back and we'll just talk Iron Man, and exercise, and nutrition, and all that fun stuff. That'd be good, too.

Howard: Okay, well you set up my son, Ryan. Ryan, he wants to come back and just do one on nutrition and what we'll do is we'll mark it. I'll do the before picture and he'll be the after picture.

Michael: You always like to say that, don't you?

Howard: All right, love you, brother. Talk to you later. By the way, one last thing. Get my cat. I'm talking to him the whole time. Bring my cat. Bring my baby over here. I'm sitting there ... Here's two bald dentists in their 50s talking to each other. I see your cat, [inaudible 01:20:22] and I figure you must have an ugly cat because I brought my cat out and your cat's so ugly I noticed you've hidden it during the whole podcast.

Michael: Why is your cat awake right now? My cat's been asleep for the past four hours and hasn't moved. You giving it caffeine? What are you giving that poor thing?

Howard: That's ... We got my Mimi and Tigger.

Michael: Where'd you get the cats from?

Howard: From Ryan. He brought them home from college.

Michael: Oh, see because we got ours from a shelter and she'd been in the shelter for five years. It took her a year to really fall in love with us, but even now she doesn't like to be picked up. She'd claw me to death if I tried to pick her up and do that. I'll sedate her first and then pick her up, like a lot of my dates. All right, Howard. Thanks so much.

Howard: Thanks buddy.

Michael: Talk to you next time, bye.

Howard: Bye-bye.

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