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AUDIO - DUwHF #290 - Stewart Rosenberg
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VIDEO - DUwHF #290 - Stewart Rosenberg
- Why every practice can benefit from owning a laser
- Lasers in hygiene
- All tissue lasers
- Diode lasers
Dr. Stewart Rosenberg is a world renowned innovator and pioneer in the use of lasers in dentistry since 1985 as well as in minimally invasive dentistry, micro air abrasion, intra oral cameras, composite dentistry and many other dental technologies and materials. He is a founder, diplomate and past president of the Academy of Laser Dentistry, founder and diplomate of the World Clinical Laser Institute and a board of director member, founder and past president , diplomate of the World Congress of Minimally Invasive Dentistry, fellow of the Academy of General Dentistry, Society Of Laser Applications, , Society of Laser Surgery in Medicine , American Academy of Cosmetic Dentistry and many other national and international organizations. He has been voted Clinician of the Year , and winner of the distinguished service award of numerous organizations. In addition to private practice , l, rated annually number one in the United States. He lectures on a weekly basis throughout the world on laser dentistry and is on the editorial boards of numerous journals. He is the founder and co director of RKN seminars and has trained many hundreds of dentists in the use of lasers. He has been selected by Dentistry Today as a top clinician in Dental Education for 12 years in a row.
Howard: It is a huge honor today to be podcast interviewing my Stewie. Doctor Stewart Rosenberg. It's so funny because so many dentists ask me, they go, "How do you release one of these everyday?" It's like, I just came home from work for lunch, I'm home for an hour. Every single day, I get to go to lunch with a buddy. You've been my buddy for ...
Stewart: A long time.
Howard: Almost thirty years. I think I've actually lectured on more programs with you, than probably anybody in dentistry.
Stewart: Same here. Well we did like a hundred a year, for almost three years.
Howard: Oh my God. We lived in airplanes.
Stewart: Didn't we? Lot of funny memories though, for sure.
Howard: Just in case there's one person left on earth, who doesn't know who you are ... What's that?
Stewart: Assure that there's a hell of a lot more than one.
Howard: Okay there's two. For the two people, one's in Nepal, and one's in China. Doctor Stewart Rosenberg, is a world renowned innovator, and pioneer, in the use of lasers and dentistry, since nineteen eighty five. As well as in minimally evasive dentistry, micro-air-abrasion, introrul cameras, composite dentistry, and many other dental technologies and materials. Is a founder, and past president, of the Academy of Laser Dentistry, founder, and diplomat of the World Clinical Laser Institute, and board of director, member, founder, past, present, diplomat of the World Congress of Minimally Evasive Dentistry. Fellow of the Academy of General Dentistry, Society of Laser Applications, Society of Laser Surgery in Medicine, American Academy of Cosmetic Dentistry, and many other national, and international organizations. He has been voted clinician of the year, and winner of the Distinguished Service Award, of murmurous organizations. In addition to private practice, rated annually, number one in the United States. He lectures on a weekly basis, throughout the world, on laser dentistry. Is on the editorial boards of numerous journals. He is the founder, and co-director of RKN seminars, and has trained many hundreds of dentists in the use of lasers. He has been selected by Dentistry Today, as a top clinician in dental education for twelve years in a row. More than all of that, he is just an amazing man. How are you doing Stewie?
Stewart: I'm doing great man. It's been too long. I miss you.
Howard: I miss you. I just read into you. We were lecturing in greater New York. We were in a bar in that over looked time.
Stewart: Yeah, Bill got us on cell phone together.
Howard: Oh was that on the cell phone?
Stewart: Yeah it was on cell phone, from the bar at the Marriott.
Howard: Well that's funny, the reason we called you is because we remembered a decade before, where we were on the Times Square monitor, where a company got us to do a commercial during the greater New York. I had taken my four boys there, and stayed in that hotel because it overlooked Times Square. It's the Times Square Marriott or whatever. The boys just thought it was so cool. They were like four, six, eight and ten. The dad was up on this big old ...
Stewart: I remember.
Howard: I brought Ryan, he was home from college, and so I took him with me and we stayed in that hotel, and that was just so fun. We'll start, you've done so many technologies. I member when you were out in the forefront, what was new. I got out of school in eighty seven. Patterson was the only one who sold it. It was like thirty-eight grand. It was the size of a refrigerator. What was it?
Stewart: It was Welsh Alan's Cameras, at the time was distributing.
Howard: Was it Omani Cam?
Stewart: I don't even member the name. I've lectured for so many camera companies, which one was which.
Howard: Then, I saw you lecture several times on Micro-air abrasion. Which I still love, and there was one by Creative. There was a little Daneville micro-etcher. What are you lecturing on mostly now? Lasers in dentistry?
Stewart: Yeah, almost exclusively, lasers.
Howard: I want to ask you, this is Dentistry Uncensored. I don't like to talk about anything that everyone agrees on. I always like to go right to the point.
Stewart: Of course.
Howard: Tell me if you agree with my thinking, or not, on this. I think sealants are a failed ideology. It seems like every single time I am on Pub Med, or NIDR, or any research. I just keep seeing that forty percent fail the first year. Probably another forty percent fail the second year. None of them last three years. When you talk to individual dentists, they have no research, they have no recal protocol. They always say, "My implants last because I use a rubber damn, and I do it right." Seems to me, that the pits and fissures are filled with all kinds of organic debris and plaque, so you're taking technology, where you acidetsing enamel, but your not acidifying enamel. You're acidetsing, Oreo cookies, and crud, and debris, and bacteria.
Then you paint this sealant on the surface, where it's occlusion, and chewing it off, and it seems like the reason I'm excited about hard tissue lasers ... I'm just going to focus on what I think is the most no brainer, a pediatric dentist, where no shots, no drill, if you were taking a hard tissue pediatric laser, or if you just took a course diamond, disposable, single use, and cleaned out those. Now your on dentin. Now you're taking acid etch on dentin, and enamel, where it was designed to be. Then you're basically building an oclusal composite, which technically could be called a preventative resin restoration. Even though, I've never cleaned out pits and fissures, that didn't have crap going all the way to the dentin.
Stewart: No question.
Howard: Do you agree with what I just said?
Stewart: Absolutely. We've known for years, that sealants don't work. You know, resin sealants don't work. Graham Millicent, in New Zealand, did incredible research on this, many years ago, and we use to lecture on it. The best way to do sealants, first of all, you've got to seal them almost before the teeth come in the mouth because by the time they're fully erupted there's usually decay in dentin. A lot of research has shown that, and we seal them with glass ionomer. I mean, we'll open the groove, check it with the diagnident, open the groove with either a laser, or if you have a burr, if you want to you can use a burr. Make sure there's nothing else in there, and we seal them with glass ionomer. We're having much better success that way, then when we used the composite resin. It just doesn't work. Especially, because most the time, we're sealing over decay.
Howard: I go into pediatric dental offices, and I look at the schedule, and it's like, no charge, repair chip sealant. Then an hour later, repair chip. I'm like, "Why are you doing all these twenty seven dollar sealants, that the research says are junk? Then I go in your office, and four-five times a day, you're repairing one, with the same crappy technique, for now charge?" Why wouldn't they do an inclusal composite?
Stewart: Good question. They should be doing an inclusal composite.
Howard: How many sealants would have to be in an inclusal composite before it made sense to buy a hard tissue laser? Or would you just go disposable diamond?
Stewart: That's a double question. As far as sealants are concerned, you can do it with a burr, you can do it with air abrasion, you can do it with whatever you want. I would not recommend buying a hard tissue laser, just to remove sealants, or do elcusal composites. That's not where the value in the laser is. If you have a laser, absolutely, you're going to do every one of them with a laser because it's totally painless, and your doubling your bond strength. It's a wow experience for patients. I would never in a million years, refer any patient to a periodontist, who didn't have a hard tissue laser. Why subject a kid to needles, and drills, and maybe make a dental phobic out of them for the rest of their young lives, if not their total lives, when it can be a pleasant experience instead.
There's so many applications, it's unbelievable. That said, for the average dentist, I think if their buying a hard tissue laser, in order to replace needles and drills, they're missing the value in the laser. It doesn't mean that, that's not the cherry on top of the whipped cream, and it certainly has value from a wow experience, but nobody got rich doing clausal composites with a laser, rather than doing them with needles and drills. The value in lasers ... and for the life, of me. You know that I speak from the heart, I don't pull punches.
Howard: Yeah, think! Yah, think!
Stewart: I think the reason why we love each other, we're both politically incorrect. We don't give a damn what anybody thinks, we say what we know, we believe in our heart is true. For the life of me, I cannot understand why every single dental office in the world, doesn't have a laser. If you're anything but an orthodontist, you should have a hard tissue laser. Without question, and my personal bias, as you know, is ordalase, by biolase. You should have one, whatever you choose, and if you're an orthodontist, you should have a dioglaser for all the things you can do with diods, which we can discuss in detail. If you practice in a state where hygenists are legally allowed to use a laser, and every hygiene room, doesn't have a diode laser in it, you're a fricken idiot. Because you're just throwing away money, and in addition to that, you are not doing your patients, the best treatment you can give them. It's a win-win for everybody. It boggles my mind, why so many offices still don't understand this.
Give you a case in point. Let's just talk hygiene okay? That's simple, that's something mostly everybody on Dental town can identify with. One of the things we do, on all our hygiene patients, is offer them laser, bacterial reduction. Laser bacterial reduction, means going into the pocket, with a soft tissue laser, preferably a diode, you could use an Ndag, but diode is the least expense, and there's a million of them on the market, and they all work. Is to go in, with a soft tissue laser, with the tip uninitiated, meaning that you're not going to be cutting anything, you're going to be killing bacteria, and do what we call laser bacterial reduction. It takes maybe, five minutes, at the most, with the slowest hygienist in the world, to do this before she goes in with her normal hygiene instruments. The idea being, to kill as much of the bacteria, and bio film as possible, before you go in with hygiene instruments, and introduce bacteria into the bloodstream. You know, the typical transient bacterium, which unfortunately, in today's world, with so many antibiotic resistant bacteria, can cause serious problems in patients.
Countries like Finland for example, where patients can buy antibiotics over the counter, without a prescription. Mom goes into the drug store to buy a pack of cigarettes, and remembers Johnny was coughing last night, and says, "Give me a pack of Marlboro, and give me a couple of those penicillin tablets, so that I can get rid of Johnny's cough." She gives him two or three penicillin tablets, and causes a worse infection, as we know. There are people that actually got deathly ill. There have actually been reported deaths, from having their teeth cleaned. What we recommend our patients, is in order to avoid the chance of introducing antibiotic resistant bacteria into the bloodstream, they allow us to do a laser bacterial reduction. We charge thirty-five dollars for it. I don't think I've had two patients say no, out of the thousands of that we've done. They appreciate it, they love it. The hygienist's appreciate it.
Howard: Is there an insurance code for that?
Stewart: No, there isn't. The patient can either pay it out of pocket, or you can do what we did, with oral cancer screening, and just up our hygiene fee, and give it to them for free. We had a thing, it's interesting. It's not on the topic of lasers, but when I first got a Velscope, to do oral cancer screening. We were charging twenty five dollars, per patient, once a year, to have the screening done. We have maybe thirty percent of our patients, agree to have the oral cancer screening, when they found out it wasn't covered by insurance. They wouldn't dream of not getting a pap smear, when they go to the gynecologist, and there are twice as many deaths a year from oral cancer, as there is from cervical cancer. Yet, patients say, "Well, it's not covered on my insurance, I don't want it." It really bothered me because I thought it was so important that they get it. That what we did, was raise our hygiene fee, fifty bucks, and give it to them for free. Now they get an oral cancer screening once a year, and we get an extra hundred dollars, of what we had before, and give it to them for free. That's what I would recommend doing with laser bacteria reduction, if you're bent that way.
Howard: I'm trying to guesstimate what thousands of dentists are questioning, as they're driving to work right now. Most people are driving to work. A lot of them are thinking, "Stewie, don't you have to have L nap for that? I thought only L nap lasers were for bacterial reduction?" That things eighty-five grand.
Stewart: It's absolute, unadulterated, hogwash. You can't do anything with a millennium laser, that you can't do with a hot paperclip, and a Bunsen burner. You can do the same procedure, with any soft tissue laser. You can do it with a twenty-five hundred dollar diode. You don't have to spend eighty-five thousand dollars for lynep. It doesn't mean it doesn't work, it does. Think for a minute, what you're doing with any soft tissue laser only. You're killing off bacteria and biofilm, which is critical, it's important, and you're removing the diseased socipathical lining, from the inside of the flap, which is also critical, and important to the success of the periodontal pocket. That's all you're doing. Do you need an eighty-five thousand dollar laser, plus another thirty some thousand dollars in training, to do that? It's ridiculous. You can do it with a twenty five hundred dollar diode.
Now you can do even better peri, and more predictable pocket reduction, and bone regeneration, using an all tissue laser. That not only does what I just said for the soft tissue, but in addition, for example biolase, with their radial firing tips. We also address the hard tissue as well, while we're in the pocket. If I'm treating the patient, a hygienist normally can't use this. They can only use the diodes, and that's enough, in the four and five milliliter pockets. When the pockets get deeper, after they do their scaling and root playing, we bring the patient to us, and we do what we call laser assisted scaling and root playing. Which is our perio procedure.
It's called repair, by biolase. It's called la-nap, by millennium. It's called probably something else, by the other companies but it's essentially the same procedure. The difference, when we're using an all tissue laser, hard tissue laser, is we're addressing the hard tissue. Which is the other part of the periodontal problem. We're removing the twenty percent of the calculus, that the best hygienist leaves on the teeth, on her best day. You don't even have to know it there. Just running the laser in the pocket, up in down, in a zig zag fashion. Up and down, in and out of the pocket. You'll see visually, see all this black crud, flying out of the pocket. Calculus and granulation tissue, and you keep lasing until no more stuff comes out.
In addition to that, we're also removing the smear layer, on the root surface, that's put on by conventional hygiene instruments. When you use conventional hygiene instruments, you create a smear layer on the cementum. Just like we create a smear layer on dentin, with a burr when we cut a cavity prep. What the laser does, is remove the smear layer, remove the endo toxins, and very lightly and atromatically, etch the roots surface, for reattachment. We've known for many, many years, that cementum surface, has to be lightly etched, lightly roughened, for asioglass, and fiber glass to attach. They won't attach to a totally smooth surface. In the old days, periodontist used citric acid, or tetracycline, until we found tetracycline actually inhibits reattachment for anywhere from a week, to a month. The laser will do all that, and the other thing it does, that a lot of people forget about. What's the biggest complaint, that patients have when they have periodontal surgery? Their damn teeth are sensitive to cold for the rest of their lives, from whatever recession they get. "I was fine until you sent me to that guy. Now, I can't eat ice cream, I can't drink a cold soda, or bla, bla, bla." How many times do we hear that? Forever?
Well the urbian lasers, will desensitize, permanently, that root surface. Without even trying to. Just as a natural part of the process, you're desensitizing the root surface at the same time. Patients will never complain of post op sensitivity to root surfaces. It's the biggest no-brainer in dentistry. If you're talking just perial alone. If a patient has, is a healthy mouth patient. Thirty five bucks, for the mouth, for laser bacterial reduction. If they have four and five millimeter pockets, the hygienist does, laser assisted scaling, and root cleaning using the diode laser, in addition to her regular instruments. Hand instruments, piso electrics, catotrons, whatever she uses. Typically, offices charge anywhere from twenty five, to fifty dollars extra per quadrant. Using the same code as you normally use for scaling, and root cleaning. You just up the fee, twenty five, or fifty bucks a quadrant. Say you do fifty bucks a quadrant, like we do, that's two hundred dollars extra, per mouth. That you're getting for scaling and root cleaning. Add up the dollars in that.
Now if the pockets are deeper, or they have redundant pockets after they see the hygienist for scaling and root cleaning, they still have a couple frications evolments that are bleeding, or they have deep pockets in the molar area, or whatever, or they have generalized sereperio, then they go to me. I do what we call the biolase, the repair protocol. That Larry Norden and Slovai Cavaski and I invented, developed, and then refined over the years, and we have a lot of research that we did in Vienna Austria, to back this up. This is not just me talking. We've got hard research, in addition to tens, of thousands of cases, but they go to us, we use the laser, in addition to conventional hygiene. We do our procedure. I can normally do an entire mouth, in an hour to an hour and a half. Depending on how severe it is, how long I have to be in pockets, or how tough the patient is to work on, or how much I have to numb, or how much I can do the topical anesthetic. It's an hour to an hour and a half. I get eight-fifty to a thousand a quadrant. Eight-fifty, if it's three teeth or less. A thousand a quadrant if it's four teeth or more. Not bad for an hour, hour and half with no lab fee, is it? You can read a book while you're doing it. That's how easy it is.
If the affiliants general practice, has one patient like this a month, just one, that's three or four thousand bucks, for that one, one hour patient, of four millimeter or greater pockets that are bleeding. The average hard tissue laser, bio lasers now, the water lase, I think the package is like twelve hundred a month or something, over five years. I don't know what the other's cost. Doctors would have to ask whichever they're interested in, but biolase are about twelve hundred a month. If you get three or four thousand, from doing one-one hour patient, that pays your laser thing for the month, plus a couple thousand profit, on one-one-hour patient. What don't people understand? This is the biggest no brainer in dentistry.
In doing so, we've cut down on the amount of osteo surgery and bone graphing we need on our patients, by pretty darn close to ninety percent. I'm zipping up. I swear to God, I've been doing it for years, six, seven, eight, nine, ten millimeter pockets, without surgery. On a routine basis. Does it work on every site? No, there's always the few that are the exception to the rule, and those we do osteo surgery and bone graphs with. We do that with a laser also, and that's easier to do in a class two composite, by a long shot, and we teach doctors how to do that during our training courses. We have one coming up, third weekend in January, in Irvine. For biolase owners, who haven't had advanced training yet. That's just one of a hundred different procedures we do with the lasers. It's mind boggling.
Howard: You know what's amazing, when I first started hearing this from you ... how many years ago was that?
Stewart: Long time ago. It was when you spelled laser L-A-Z-E-R.
Howard: At that time, the periodontists, back in the late eighties, they were saying, "This guy's crazy. No way." Now, the periodontists, in my backyard, are starting to use laser. They were very late to the party.
Stewart: No question about it. The only reason they're in the party now is because they're losing so many patients to people like me. Otherwise, they still wouldn't be. It's not because they wanted a change, it's because they thought they have to change, if they're going to keep market share, and rightfully so. I would never refer to a periodontist that doesn't have a laser.
Howard: You're saying that water lase, is an erbium laser, that works on soft tissue, and hard tissue, and you're calling it an all tissue laser?
Stewart: Right, because it's more than a hard tissue laser. The erbium yags, good as they are on hard tissue, are normally not quite as good on soft tissue, as say a diode, or an NDI. That's why most of the companies that market or sell erbium yags, also bundle it, with either and nd yag or a diode with it because it cuts soft tissue a little quicker and more effectively, and it coagulates better. The water lase, I was amazed to find, it's far and away, you know I've had every laser that there is. I've had as many as twelve lasers in my office at one time. It's the best soft tissue I've ever seen on this earth, period. It cuts the best. It doesn't cause any scarring. It doesn't cause any charring or delayed healing or adjacent tissue damage. It's the best soft tissue laser, and in my opinion also the best hard tissue laser.
Howard: Stewie, what happened to the carbon dioxide lasers? Back in the day, that was going to be ...
Stewart: That was my baby, you know I helped bring it into dentistry, and along with Bob Pick and a few others, Stew Colten, there were eight of us. We wrote the manual, on how to use it in dentistry. We actually, in Phoenix, Arizona, we went to the Point Resort, at Tapa-whatever it is Cliffs.
Howard: Yeah, I lived three miles from the point.
Stewart: Well we sat around a conference table, and hammered out, very scientifically, the manual on how to use carbon dioxide dentistry. By saying, "Well what are you doing with it?" "Well I'm doing fronectomies." "Well what setting are you using?" "I'm using, so and so." "Well how about you?" "I'm using such and such." "All right, can we agree, lets go between the two, and that's our number for fronectomies." I mean, that's literally how we did it, and then we also founded the Academy of Laser Dentistry at that meeting. It was really a landmark meeting for laser dentistry.
Howard: What was wrong with the carbon dioxide laser? Why did it get replaced?
Stewart: It died because, number one was strictly soft tissue. The big advantage to carbon dioxide in the old days, was it cut soft tissue faster, then the other soft tissue options. Which were Ndag, and argon. However, every patient had to be numb, there was post operative discomfort, and most importantly, it died because, you really couldn't use it in a periodontal pocket. Whereas the other lasers, work on solid glass fibers, or tips, so you can make them small enough, to get into a periodontal pocket. C oh two energy has to be funneled through a hollow tube, and no matter how small you make the tube, if you put it in the pocket, if its small enough to get in the pocket, the moment that you get a little bit of granulation tissue, clogging up the tube, you've got to throw it away. End of story. It's virtually impossible to do perio with it, unless you lay open a flap, and do it that way, and it's not good on hard tissue, so it kind of died. I haven't used one in, almost fifteen years.
Howard: How come when you do your laser training course, you should digitize one of those, and film it, and put it on Dental town. Stewie, we put up three hundred and fifty, one-hour courses, and they've been viewed over half a million times. You should get some of those laser guys, yourself, someone. You should put some of those on Dental Town, you already teach the course.
Stewart: I will, I'll do it. You know, I lecture every week, it's easy to do.
Howard: Why don't you film one of those?
Stewart: I'll do it. How long should they be?
Howard: They like their ATD credits, so they're usually in increments of hours. Most of them are one hour, some are two hours. A few are three. Carl Mish, his was four. It depends on the deal. I think the more, the merrier because ...
Stewart: Okay, great. I will try and record the highlights of my normal, one-day lecture, and get it to you. People really need to know about this. It is such a no brainer for every office. You talk about recession proofing practices. I don't know how it is in Arizona, but everywhere I talk to dentists, people are still not where they were in the salad days. We've got holes in our appointment books. We've got hygiene patients that don't show, or cancel last minute. It's not what it use to be, and in my office. I'm in a lower middle class, to middle class area, halfway between Baltimore and Washington. Lot of people who are on PPO's and HMO's and whatnot, or work for big corporations, or for the government, and they're hurting, and they're still hurting. Maybe starting to come back a little bit but it's not where it was back in our salad days. In my lifetime, I don't know that it will ever be. I don't know how much longer I've got. I'm seventy five now, and I'm still doing it because I love it to death, but one day, the traffic will start to bother me, and I'll say to hell with it. We have as many openings in our appointment book, as anybody has. More than I've ever had, in June will be fifty years in private practice.
Howard: Congratulations buddy. Seriously, you graduated when you were what? Twenty four?
Stewart: Sixty-six. I graduate in nineteen sixty-six.
Howard: How old were you in sixty-six?
Stewart: I don't know. I'll be seventy five in March, so what's that?
Howard: You were twenty five?
Stewart: I guess twenty four-twenty five.
Howard: Your celebrating your fifty year anniversary?
Stewart: Yeah, June we're having our fiftieth reunion.
Howard: Oh my gosh. Send me pictures, I want to put them in Dental Town Magazine. I mean that is just epic man. Congratulations on an epic career.
Stewart: Some of us are still practicing. None of us because we have to. All of us because we love it too much, and I don't want to ever stop because I'm enjoying it too much, and I mostly enjoy, changing lifestyles, and teaching dentists how to improve their practice, and their wealth and everything else, with lasers and other stuff I believe.
Howard: I want to sum you up from how I've seen you. I've only seen you for half of those fifty years. I've known you since the late eighties. If you look at all your background, it's lasers but it's minimally evasive dentistry. It's micro air abrasion. I mean, basically, I would sum up Stewie, is what you've done for me, and so many people that listen to you, is you don't like to shove a tooth in a pencil sharpener and do a crown. You like to save tooth structure. You don't like flapping tissue back and putting a bunch of stitches in.
Howard: You always try to touch the patient the least, to get your dental cure, medical outcome. Is that a fair summary?
Stewart: Yeah. Absolutely. I know you're the same way. That's the way it should be. It's easy to do. It just takes education, and a commitment.
Howard: When I was watching you teaching, you were big into, show the internal camera. These people don't know that a MO and a DO. Show them the black hole. Then take air abrasion, clean that out. No shot, no drill. You didn't make them dental phobic, you didn't hurt them, they're not numb. Then show them with the internal camera, then fill that. You've always been a hell of a guy. Don't touch them, don't hurt them. Get rid of the disease, with as few of shots, and reducing tooth structure, as you can.
Stewart: That sums it up. That's exactly what I believe in.
Howard: Then you go to the seminar, lecturing in the room next to you, and it's some practice management person, talking about crown opportunities, and every time someone comes in, you should be pointing them MOD, and there's a crown opportunity. You should be doing, four, five, six, eight crowns a day. It's just like, you didn't go to dental school to shove eight teeth a day into a pencil sharpener.
Stewart: Agreed. Agreed, one hundred percent. So many teeth that people are condemning to crowns, would be just as well off with indirect, or direct restorations. Whether it be a ceramic inlay, or on lay, or a direct composite, that don't need crowns. Not that we don't do a lot of crowns. Sometimes you don't have an option. We don't always just condemn every tooth to a crown, if it doesn't need it.
Howard: I was in a dental office yesterday, and this patient had a large, ab fraction. You know what the dentist, did? Crowned it. To treat the wear from the ab fraction, you stuck the whole tooth in a pencil sharpener. People will have worn down teeth, so what do they do? How do they treat the worn dentition? They stick all the teeth in a pencil sharpener, and build them up with PFM's.
Stewart: It's criminal.
Howard: Endo is the funniest. You'll see someone with a root canal on an incisor. "Every root canal needs a crown." Then they'll file that down, and by the time you file an incisor down, for a crown.
Stewart: Right, and then you're going to do an implant. It's ridiculous.
Howard: You've probably saved fifty tons of enamel, in your fifty years as a dentist.
Stewart: I hope so, at least I try to. You've got to do what's in the best interest of the patient, and sometimes you have to do macro dentistry, but not anymore than we absolutely have to.
Howard: I'm going to follow on that thread. What happened to air abrasion?
Stewart: Air abrasion kind of died out, I think because of the mess of the powder.
Howard: Right. I know, my assistant Jan, every time I get that thing out, she gives me the eye.
Stewart: That's what happened, it was the mess of the powder. Now with the hard tissue lasers, you don't need it anymore. I still have one, I rarely ever use it. I use it more to clean out the insides of veneers and ceramic crowns or whatever, to rebound them, than I do to do dentistry with because I use the laser for it. It's just easier for me to do them without the mess of the powder. Air abrasion certainly, still has it's place in many areas, and for sure was revolutionary when you and I started promoting it.
Howard: Is anybody still selling it?
Stewart: I don't know if anybody is anymore. I don't know who is, if anybody.
Howard: DanVille sells the micro etcher.
Stewart: I think that may be about it. I got a funny story to tell the audience about air abrasion. When you and I first became friends. Can I tell that story?
Stewart: For those of you listening. Howard, vilified me, on lasers, which he knew nothing about at the time. He spelled it L-A-Z-E-R. We had never met, but we kind of hated each other, even though we'd never met. I'm doing a seminar, I think it was the American Academy of Cosmetic Density meeting or something. On air abrasion, and Howard's sitting in the back of the room, and I see him, and he see's me, but we don't say anything to either one of us. Then he comes up to me at the end of the program. It was the first time we had actually ever physically met. You said, "This is really interesting, can you tell me more about air abrasion?" I was dumbfound, I said, "I'll tell you what I'm going to do." I said, "I'm going to fly down to Phoenix personally, and bring an air abrasion unit into your office, and show you how to use it, and tell you all about it.
All the promise I want from you is if you'll try it. If you like it, you'll buy it, and if not, send it back. No harm, no foul, at least I did my best." You said to me "Well why would you do that?" I said, "Because right or wrong, and neither of us are always right, and neither of us are always wrong but the one thing I've always loved about and respected you for, was your passion for dentistry, and doing what you honestly believe in. I know, that if you find, and hopefully you will, that you like it, you will be evangelistic, and more and more people, will start doing minimally evasive dentistry because of your passion, and the way you promote things that you believe in." Me and the rep come down to Phoenix Arizona. I bring the unit in. I do a slide presentation.
The whole staff is there. Everybody's there. Howard's in and out of the room. Eighty seven times. Answering phone calls, doing this, doing that. We leave, thinking the son of a bitch didn't even listen to one word I said. I was livid. I get a call a few days later. "I did like nine restorations yesterday, and ten today. I flat out love this thing. What can we do to promote this. Why don't we lecture together, and spread the word around the world?" I said, "Howard, deal." That's how we became friends. We lectured, literally, I think a hundred cities a year, for three years in a row. Everywhere we went, having a ball. Me in the morning. Howard in the afternoon, and just loving it, and hopefully doing dentistry some good, by promoting minimally evasive dentistry. That's how we became friends. Remember?
Howard: I do remember. God it was so long ago. The other thing I think about that, is I think of all those lectures. Half the room it was just dentists saving money coming by themselves, and then the other half the room would be one dentist with five staff members, so the left side of the room would maybe be two hundred dentists, and the right side might only ten, but a hundred staff. It was the dentist who always brought all their staff. If you got the staff behind it, it got implemented, it got done.
Stewart: Absolutely, like with everything else.
Howard: I know. Then you go look at the income of the dentist who brought all their staff, and they were making twice as much money, as the dentist on the other side all saving money, not bringing their staff. They never got that it was a team sport.
Stewart: Absolutely, and it's never changed. It's the same way now, as it always was.
Howard: I want to ask you another thing. This is dentistry uncensored. I'm going to throw my own country under a bus. How come, when I go around the world, the Americans use the least amount of glass onimer, but as you get closer to Japan, Australia, New Zealand, they use glass onimer? Who's right, Japan, or the United States? Is it Australia, New Zealand.
Stewart: I think Japan and Australia, and New Zealand are right. I'll tell you how I got involved with it. Graham Milischetch, from new Zealand, made a believer out of me. Back in the early days of world congress of minimally evasive dentistry. When he did a program on the use of glass ionomer as a sandwich technique in class two composites.
Howard: Okay, you're going to have to explain sandwich technique.
Stewart: Yeah, I will. When we use a composite, in a proximal box. If you can envision, from dental school, how the enamel rods lay in a tooth, and how the dental tubials lay in a tooth. You will see, that at the bottom of a proximal box, they're laying on their side. There's virtually, if not literally, no bond strength, to the bottom of a proximal box, in a class two composite. Virtually none, because you need mechanical retention, and you're trying to get retention, it's like spitting on the side of the wall and getting something to stick. It's not going to do it, so where do class two composites fail, most of the time? In the proximal boxes. Recurring decay in the proximal boxes because a lack of proper bond strength. Glass ionomer, in addition to the constant fluoride release, also is a chemical bond. An unbreakable, chemical bond, to dentin. You can break the composite, you can break the glass ionomer, you cannot break the bond between the glass ionomer and the composite. Glass ionomer and the dentin. Ian Node, from Australia, you know Ian.
Howard: Oh yeah.
Stewart: Brilliant, brilliant guy.
Howard: I flew him to my study club, right here in Ahwatukee, twenty years ago.
Stewart: Well then you know what he's saying exactly what I'm just saying. He did incredible SEM's to show that. The best way, in my opinion ...
Howard: He was in Adelaide wasn't he? Adelaide, Australia, originally from Vietnam?
Stewart: Exactly. He went from Vietnam, he was a Vietnam boat person, with his family. They went to New York, somewhere in the states, and then somehow immigrated to Australia. This is a Vietnamese Australian, who speaks with a New York, Vietnamese, Australian accent.
Howard: Yeah, I love him.
Stewart: Great guy, brilliant. They made a believer out of me with glass ionomer. It was Grahams work, that showed me the falacy of composite sealants, and why we should be using glass ionomer. Preferably something like fuju triage, which has seven times, or six times the fluoride release of like fuji nine, or relax, or any of the other glass ionomers. I agree one hundred percent, that we're doing it wrong. I really believe that.
Howard: Can I tell you why I think, what the difference is, if I had to explain it, you know what is the difference? I think US dentists are engineers, and Japanese, Australian, new Zealand, are biologists. Whenever you talk to an american, like the gurus, like Gordian Christian. He'll talk all day long about the wear rates, the bond strength. Is this building a house or a bridge? Then, in Australia, new Zealand and japan, they always think, okay, I don't care how you build your barn in the backyard, it's going to get eaten by termites. Dentistry is a biology problem. It's bugs eating teeth, bugs eating gums, and they always are trying to build a restoration that continues to have some type of effect, on the biological life forms. Is that a fair summary?
Stewart: I agree a hundred percent. Could not agree more.
Howard: There's a US company that's kind of got it. What is it, pulp dent?
Stewart: GC America does too.
Howard: Well GC is out of Japan.
Stewart: They get it also.
Howard: I was talking to the president of iviclear, Bob Ganley. I was asking him about that, and he said, "Yeah, Iviclear gets it, we totally get it. The holy grail, is trying to find something to put in these resins, that kill bugs. It's like these big, billion dollar companies, they totally get it but in the mean time, until the resin companies can build anything antibacterial, I don't think the US are going to go to glass onymer. Or do you see it improving?
Stewart: I haven't seen it improving, I really haven't. I think that we still do it the same way we did it thirty years ago.
Howard: The sandwich, so you would recommend to these listeners, that you think these fillings would last longer, if you did a MOD composite. To fill up the proximal boxes with glass onymer, and then to sandwich it.
Stewart: To sandwich it, with whatever composite you're using. Or do an indirect restoration, with a universal modified, resin glass onimer cement. That will accomplish the same thing. I do more indirect restorations, now than I do direct, if they're of any size at all. I just think they last longer, they're better. The contacts are better, the aesthetics are better, and I don't get the marginal leakage, that I was getting on just composites.
Howard: What are you cementing with?
Stewart: Right now, we've been using Nexus.
Stewart: Yeah. I don't know if it's any better than, any others.
Howard: I want to get clear on the sealants. Do you think sealants are a failed ideology, and it should go by the side of the road?
Stewart: I think resign sealants are for sure. I think glass ionomer sealants, are still very valuable. Depending on when they're done. Graham Millicent, use to show some amazing things, where he would show teeth that were half erupted. Still had no perculum, say a lower first molar, still had the perculum over the distal half of the tooth, that had complete eclusal decay, way before it ever fully erupted. What he recommends, is the instant a tooth starts to erupt, you etch it, and seal it. Smear on, like fuji triage all over the whole eclusal surface. Under the epurculum and everything, and then just let the tooth erupt. What the glass ionomer does, is infuse fluoride into the tooth, to help prevent the enamel from decaying and the groove from decaying.
Then, when the tooth is fully erupted, eventually, the wear, the glass ionimer off of the eclusal bearing areas, once it comes into inclusion, but it will still be in the groove, and that's the ideal, best sealant, as far as I know. Other than that, I would either explore the groove, check it with a diagnaden or something similar, to make sure there's no decay in the groove, and then seal it with glass ionomer, rather than with composite. I just think it's a better restoration. It's easier to do because you can place it in the presence of saliva or whatever in the mouth. The tooth doesn't even have to be bone dry, like it does for a composite. How hard is it for a hygienist, with no assistant, no rubber damn, to do sealants, that aren't containment.
Howard: Now Fuji's made by GC right?
Stewart: Yeah, fuji is made by GC, but there are other companies that make them too. What we always used was Fuji Triage. Down in Australia ... it was actually invented, I think by hian No and Jeffry Night, For GC. It has something like seven times the fluoride of regular glass ionomer, and that's why it was called Fuji seven. When it came to the united states, they changed the name to Fuji triage. I think that's the best one, for those situations because it has a higher fluoride release. Any of them are going to be better than regular composite.
Howard: I just want to say one other thing, you see dentists that literally brag to everybody that they're a malgum free, they're metal free. They're a malgum free, and they don't have any glass onimer, and you know, the fastest growing age group is senior citizens. We've got tons of Alzheimer, tons of dimensia. You will see them bring in an Alzheimer lady who's eighty years old, and do seven or eight root surface decays, and they will do them with resin composites. Stewie, what do you think of that?
Stewart: You're asking the wrong guy because I haven't' done a malgum in three years.
Howard: I'm talking about not just a malgum, but for root surface decay, and nursing homes. They've got their fellow ship from the academy of cosmetic dentistry, and they got these highly polished resign class fives, on a grandma with root surface decay in a nursing home. If those would have been done glass ionomer. Would they have lasted longer?
Stewart: I think so. I think that would have been best. It wouldn't be as ascetic but an eighty some year old woman, that doesn't even know she has teeth anymore. What's the difference? You just want to preserve the teeth and make her comfortable.
Howard: I think root surface decay in the nursing home, is an ... The geriatric dentists are telling me that when you're admitted to a US nursing home, you're getting one root surface cavity per month.
Stewart: I believe it because they all have dry mouth. They don't brush properly. They don't eat properly, and so it's epidemic. I would treat all of those with glass ionimer, which gives fluoride release, it's easy to place, it's inexpensive and I think that's the best treatment for them I agree you a hundred percent. Let me get back to lasers a second because I was on track with something and then we went off on another thing, which is great but I wanted to mention something about recession proofing your practice with lasers. I got as many open holes in my book today, as I've ever had in almost fifty years of practice. I could come into the office on Tuesday and have two hours open, and I could still have a ten thousand dollar day. From what I pull out of hygiene and do in between patients, during that open time with lasers. It's everything from gummy smile reductions, which take ten or fifteen minutes, at three hundred, twenty five dollars a tooth, with topical anesthetic, to biopsies of lesions, to you name it. To incisor ledge composite restoration. You talk about senior citizens, how many millions of patients do we all have in our practices, that have worn incisor ledges? That they hate, and if they bite down on a poppy seed or popcorn kernel, they shatter off the lingual plate of enamel.
I don't know about you, I've never been able to get a composite to stay there long term. It just never seems to work on my end. We end up eventually having to do a reverse veneer, or mini crown or something. You can use a laser to cut down into that dentin, two or three millimeters. Takes about ten-fifteen seconds per tooth to do. Put some composite in there, patient gets charged for two surface composite, incisor lingual and incisor facial. You can do six or eight teeth in twenty minutes, start to finish. Make your day, and then also of course you want to council them on the importance of you making them a night guard, so that they don't wear it down again. We do these on a regular basis.
How about somebody who comes in that breaks a tooth off, right near the gingiva, and need a hard and soft tissue crown lasing, because otherwise biologic width invaded. We can do the hard tissue crown lasing, without a flap, without any additional chair time. Take her and prep her tooth, take her impressions, send it to the lab, or if we have a C rack or and E4d, we do the crown lasing while the crowns being milled, and the patient goes out of the office with her crown. Same day, and they don't have to wait six, eight, ten weeks to get their crown. We do everything in one appointment, or if we're using a lab, in two appointments, and we get an extra nine hundred dollars over and above what we charge for the build up and crown.
Why would you refer somebody to a periodontist to do that? Have them use up their insurance benefits, and maybe not even be able to afford to get the crown now. The best case, wait four, six, eight, ten weeks, before you can do the crown. Sit there with a whole in your mouth, and let them make nine hundred or a thousand bucks, or whatever you want to charge. When in two minutes, literally two minutes, you can do it yourself.
How about a patient, we talk about the old class two's, somebody had a big ole class two amalgam, other times we see them where the proximal box is at or literally below the level of the bone. Now you want to try and do a cad cam onlay, or even a direct composite or even an indirect composite. You can't get a good margin. The margin's below the bone. There's no way you can get it, but you can use the laser to re contour the bone in that spot. Charge whatever you want for it. Charge them for the crown lasing. Be able to take a perfect impression, or a digital reading, and you're home free.
A patient comes in, and they have a crown or a veneer that's gorgeous. I had a patient, about two months ago had six beautiful veneers, cuspid with decuspen, and the gingival margins around the veneers, were bright red. I mean as bright red as you can get, and you just looked at them and they bled. The guy came into us for hygiene, it was his first visit, and my hygienist said look at the inflammation around these veneers, and they guy said, "Oh my dentist said I'm allergic to porcelain, and that's why they're inflamed because I'm allergic to porcelain, but what can I do?" I said, "Well, you're not allergic to porcelain, what's happened is." I explained to him what invasion of biologic width is. I scheduled him an appointment, and in fifteen minutes, we did hard tissue crown lasings, underneath the gingivia on six teeth, and a week later, the tissue, looked like the most gorgeous tissue you've ever seen in your life.
Howard: Okay, but I'm going to interrupt you because the periodontists tell me that only only twenty percent of the dentists, do crown lengthening, and get the biological minimal. They tell me in every city, in every country, that all there patients for crown lengthening, and so they go to the other dentist, that don't refer. They think well who are they referring to? Are they doing them themselves? They say, they're not referring them to anybody else, and they're not doing them. I want you to slow down spanky, and go over what is the violation of the biological minimum width? Why is crown lengthening a procedure? Explain it in a way ... First of all, do you agree that twenty percent of dentists, agree with this, and do crown lengthening, and eighty percent don't?
Stewart: I don't know the percentage, I do know, there are a lot of bad dentists out there, or dentists that just haven't been educated to do what some of the rest of us have taken continued education to learn. I don't want to knock anybody, but that's the facts.
Howard: Okay, so you've got nine minutes to explain, why four out of five dentists do not do crown lengthening, and why do I need to do crown lengthening. What is this biological minimum width? Are you telling me to buy a BMW?
Stewart: You got it. Okay. Biologic width, means you have to have three to four millimeters, from the margin of your restoration, to the beginning of the bone. If for example, I'm going to do a gummy smile reduction, because somebody's not showing enough clinical crown and I want to re contour the gingival margins. Whether I do it with a laser, a scalpel, electro surge, whatever. If once I get down, and I probe from the new gingival margin, to the crest of the bone, if I have less than three millimeters, what's going to happen? The tissues going to rebound back to where it was because I've invaded biologic width. We need that space in order to maintain biologic width, three to four millimeters. If we do a crown, and when we finish the crown, the margin of the crown is less than three millimeters, to the beginning of the bone, that tissue is going to be chronically inflamed for the rest of that patients life. We've all had patients where either we, or some other dentist have done a beautiful crown. Everything about it looks good, the margins are good, the ascetics are good, the eclusion is good, contacts.
Everything's fine, and yet that darn buckled tissue, pillow and bleed like crazy. No matter what they do, and no matter what we do, we continue to bleed. The reason is, you don't have enough space, between the margin of the crown, and the beginning of the bone. What a periodontist would do, in that situation, would be to lay a flap, take a bur, and trim the bone back, so that you then have three to four millimeters between the new height of the bone, crest of bone, and the margin of your restoration. Then sew it back up. Then you'll have to wait umpteen days, or weeks before you can do your crown. Or you can take a laser, stick it in the pocket, without a flap, touch the bone, back it off a millimeter. Sweep it side to side for thirty seconds to a minute, to a minute and a half, melting away the bone, and re contouring it, and you're done.
Why would you not do that? You're going to end up with a better restoration. One where the tissue is never going to be inflamed again. Patients going to be happier, and you're going to get the going rate, for whatever is charged by a periodontist in your area, for hard tissue crown lasing. In my neck of the woods, it's nine hundred bucks, so that's what we charge. When I'm doing a crown, if it needs a crown lathing, I got an extra nine hundred dollars for a minute and half of work. I assure the patient then, that we can get the crown the same day if we do a Syriac, or two weeks later if we are doing a lab processed crown. It just makes absolute sense. Everybody should be doing it.
Howard: I want to ask you other questions. A lot of times people are lecturing, or you see an advertisement about low level laser therapy. What is low level laser therapy?
Stewart: Low level laser therapy, is my baby. We teach it as an intrecal part of our advanced training course, and it is truly magic. To use an analogy, low level laser, God forbid, somebody you love was in a terrible automobile accident, they're laying in a hospital, tubes running everywhere, and monitors. You go in and you're mortified, and you pray to God, please do whatever is in your power to heal him, as quickly and as painlessly as possible. That's what low level laser energy does. When we shine specific wavelengths of light, delivered by the proper mechanism, with bio lasers epic X laser, has two hand pieces with it. One is one that we use also for bleaching teeth, the other is called a pain relief hand piece, that channels the energy deeper into tissue.
First of all, whenever we do any surgical procedure in the mouth, regardless of what it is, we hold the bleaching wand on there. We turn the laser on to three watts continuous power, hold it on there for thirty seconds, and the wound site will heal fifty percent faster. With no swelling, no pain, no nothing. If I have a sinus problem, I can open my sinuses. I treat carpel tunnel syndrome on my hygienist. I have bad knees from old lacrosse injuries, and when my knees act up, I have one at home, and I use it every day on me. There's nothing you can't use it on, in the body to make it heal faster. In or out of the mouth, or anywhere on the body. Other than the eye. You can't use it on the eye because, the wavelength will blind you, so you have to wear protective eyewear, when you use a diode laser. You couldn't use it on the eye. Anywhere else on the body, it is magical.
The other really cool things I've done with it, I've closed arilantual fistulas completely, in three or four sessions, just using a laser. Without a cardwell luck, without anything. I had a patient, who had an eight millimeter oralantural fistula because she'd been on these phosphonates for a rare type of cancer, that made her bones so brittle she would roll over in bed and break an arm, or a leg, or a wrist or whatever, and she was going through chemo therapy. She had this fistula, in her upper first molar. I completely closed it, in about twenty five days. With her coming in every three to five days. Completely closed it. It's unbelievable. We're also treating parastesia very effectively. I'm so far, knock on wood, ten for ten, reversing parastesia. The longest one, that was numb that I had out was three years. Somebody had a lower third molar extracted, on the lower right side, and lip was numb for three years. We reversed it in about three weeks. I've had some where they were just numb a week after extraction, or two weeks after extraction.
Then only one or two sessions, and they had their feeling back. That's something that every dentist who's interested in this stuff should look into. You can use the waterlase the urban lasers, are not good lasers for low lever laser stimulation. You need a diode laser. The best of the bunch because the wavelengths and the delivery systems are the best for this would be bio lasers. You could do it with other lasers, I could teach you how to do it with other lasers, but taking the tip off the handpeice, defocusing five millimeters, at a lower energy, about point seven watts. Not get as predictable results, but still get good results with it. Howard, it's off the charts. It's off the charts. You are my hero, running marathons and doing all the stuff you're doing. I know you've got to have aches and pains and bruises and stuff for sure. After all the abuse you put your body through. Man, you should be using a diode, when something bothers you. It will be better so much quicker it's unbelievable.
Howard: Last question, I've only got you for one more minute, you've been talking about laser's this whole time. Laser bleaching, is that marketing hype? Does that do anything, or does it not do anything? For teeth whitening?
Stewart: You know my history with teeth whitening. I was in it from the beginning, and bleach is bleach. I don't care whose it is, or what it is, it's all the same stuff. There's carbon peroxide, and there's hydrogen peroxide. One for take home, one for in office. Nobody's going to get lasting results without take home, as we all know. What is the advantage of using the laser? Time and less sensitivity. Because a laser is only on a for fifteen seconds at a time. Depending on how quickly your assistant or hygienist could put on the paint on rubber damn. You're going to get faster results. We typically bleach a patient with a laser in a half hour. There's our zoom light, which we also have, takes about an hour to an hour and a half.
The results, we're finding are pretty much identical, good or bad. Brown teeth and yellow teeth bleach well, green and gray teeth don't. That's just the facts of life, and none of them work well without the take home. I wouldn't buy a laser just to bleach teeth with, but there is an advantage in time saving, and anecdotally only. I haven't done a study on this. The patients we've done with a laser, seem to report less post op sensitivity, of their teeth after the bleaching, than people we've used the zoom light on. Because we don't generate as much heat, and you're only on a quadrant for fifteen seconds at a time. Rather than baking the teeth for an hour or so.
Howard: One last, I'm over the hour, I've got to get off, but one overtime question. Stewie, a lot of them, in business school, are always saying your business has to have a unique selling proposition. What is different about you than anyone else? I just hear a lot of dentists that will tell you, off the record that the best thing their laser was, was for marketing and advertising on their website, to be a laser dentist. Do you see any of that? Do you think there's any truth to that?
Stewart: There's no question about it. We get a ton of patients from our website, because I'm a laser dentist. No question about it. Once they come, it's what you do with it that really matters. Once you get them in the door is one thing. We get them in the door because we're laser dentists. That's the number one marketing thing for my practice. Especially the fact that I can treat periodontal disease, without having to do conventional periodontal surgeries. We get a lot of patients from that.
Howard: My podiatrist buddy, is just blowing it up in podiatry, because he's the only one with a laser. What's that?
Stewart: Treating toe nail fungus.
Howard: Well hey, go. Where are you off to now?
Stewart: I go to the Tampa Florida lecture all day tomorrow, for biolase. Then tomorrow night, fly to New York to lecture all day Saturday, too. I'm a glutton for punishment.
Howard: You're a road warrior. Buddy I love you to death, really do. Thank you so much for a twenty five year friendship. Thank you so much for what you have personally done for me, and Stewie, you've got to put an online course on Dental Town.
Stewart: I will. I promise.
Howard: You're old school where you fly around the world twenty four hours a day. You put an online course on Dental Town, people will be listening to this, in China, while you're sleeping.
Stewart: I will. I promise I will. It's so great to reconnect, thank you so much for inviting me. I hope to see you soon, man.
Howard: All right. Thanks for an hour. Thanks.
Stewart: Bye bye.